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November 12, 2024 Su-Fei Wong, Authorized Agent 7625 Metro Blvd Ste 200 Minneapolis, MN, 55439-3057 License Number: 1036848 (CRF) Report Numbers: 202403642 and 202404736 CORRECTION ORDER Dear Su-Fei Wong, On July 15, 16 and 17, 2024, Department of Human Services (DHS) licensors conducted a licensing investigation at your facility, Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN. This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, chapter 2960. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. PRACTICES 1. Violation: One incident report reviewed for requirements governing critical incidents did not meet requirements. An incident dated June 3, 2024, met the definition of a critical incident and was not reported to the commissioner. Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the reporting of critical incidents meets all applicable requirements. 2. Violation: Requirements governing clinical supervision were not met for one week reviewed. Seven staff persons that provided program services the week of June 23, 2024, did not attend a weekly clinical supervision meeting. Rule Violated: Minnesota Rules, part 2960.0630, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision meets all applicable requirements. RESIDENT FILES 3. Violation: One resident file reviewed for requirements governing a variance to allow a resident admission to a program when their age is below what is stated on the CRF license did not meet requirements (R1). The variance required that DHS be notified of any incident within 24 hours. Thirty-one incidents occurred between March 29, 2024, and April 30, 2024, and were not reported as required by the variance. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 9. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all conditions required by an approved variance to Minnesota Rules are met. 4. Violation: Two resident files reviewed for requirements governing standards for treatment in a locked setting did not meet requirements (R2 and R3). The individual treatment plan did not identify the following required components: a. The need for treatment in a locked setting; b. The relationship of treatment within a locked setting to the resident's overall treatment goals; c. The treatment goals the resident must meet to have access to increased freedom of movement or be placed in a less restrictive appropriate treatment setting; d. A plan for discharge from treatment in a locked setting to a less restrictive treatment environment when it is consistent with the resident's ability to be in a less restrictive environment. Rule Violated: Minnesota Rules, part 2960.0700, subpart 1, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans for treatment in a locked settings meets all applicable requirements. Within 30 days receipt of this order, submit an individual treatment plan that demonstrates compliance. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at maddy.gilbertson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Maddy Gilbertson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Questions If you have any further questions regarding this matter, you may contact me at 651-431-6259. Sincerely, Katie Leuer, Unit Supervisor Licensing Division Office of Inspector General
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