December 13, 2024

Tricia Johnson, Authorized Agent

Hoffmann Center

PO BOX 60

Saint Peter, MN 56082

License Number: 801377 (PRTF)

Report Numbers: 202402067

     202402781

CORRECTION ORDER

Dear Tricia Johnson:

On September 23 through 29, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Hoffmann Center, located at 1715 Sheppard Dr., St. Peter, MN 56082. This review was conducted to determine compliance with state and federal laws and rules governing the provision of psychiatric residential treatment facilities under the variance to Minnesota Rules, Chapter 2960; R2960V. 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.

Postings, Physical Plant, Policies, and Practices

1. Violation: The license holder did not comply with maltreatment of vulnerable adult requirements in the following ways:

a. The program abuse prevention plan (PAPP) was not posted in a prominent location in the program on the Wolves unit;

b. The copy of the internal and external reporting policies and procedures posted did not include the internal reporting components;

c. The license holder’s governing body did not review the PAPP at least annually using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review for the annual calendar year 2023; and

d. The license holder’s PAPP did not meet requirements in the following ways:

i. The population assessment did not include:

1) The need for specialized programs of care for clients; and

2) The need for staff training to meet the identified individual needs of the clients; and

i. The physical plant assessment did not include the existence of areas which are difficult to supervise.

Statute Violated: Minnesota Statutes, section 245A.65, subdivisions 1, paragraph (d), and 2, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure postings and the program abuse prevention plan meets all applicable requirements.

2. Violation: The license holder did not ensure that housekeeping and maintenance services were operated on a consistent and healthy basis to ensure the facility was kept clean and in good repair. During the onsite licensing review, DHS licensors observed the following:

a. A dark stained couch and stained toilets in the resident bathrooms;

b. A dining room with food and garbage remnants on the tables, floors, and walls;

c. Seclusion rooms with stained walls, torn and ripped wall paddings, and torn floor tiles; and

d. An outer recreation building with a strong odor similar to mold and mildew.

Rule Violated: Minnesota Variance, section R2960V.20, subparts 2 through 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of housekeeping and maintenance meets all applicable requirements.

3. Violation: The license holder did not develop and monitor the implementation of program policies and procedures as necessary to maintain compliance with licensing requirements under Minnesota Statutes and Rules, for the following areas:

a. Statement of intended use, including a current description of the services to be offered and the target population to be served;

b. Admission criteria, including:

i. How the program considers the program’s staffing patterns and competencies of staff when making a determination concerning whether the program is able to meet the needs of a person seeking admission;

ii. A resident must meet the eligibility criteria outlined in Minnesota Statutes, section 256B.0941, subdivision 1, including being younger than the age of 21 upon admission; and

iii. When a continued stay at the facility is needed, it is the responsibility of the resident’s multidisciplinary treatment team and the clinical director to establish that the requirements for a continued stay have been met;

c. Program rules, including consequences that are in accordance with positive support strategies and evidence-based practices;

d. Restraint and seclusion, including what debriefing documentation must include;

e. Maltreatment reporting, including both the maltreatment of vulnerable adults and the maltreatment of minors. The license holder maintained two policies for the maltreatment of vulnerable adults and two policies for the maltreatment of minors that were duplicative and contradictory; and

f. The Positive Support Rule (PSR), including:

i. A procedure to screen and assess for and determine who qualifies for the PSR; and

ii. Policies and procedures in accordance with Minnesota Rules, chapter 9544, parts 9544.0020 through 9544.0120, that are not duplicative and contradictive.

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 14; 245A.65, subdivision 1; 245A.66; and Minnesota Variance, sections R2960V.04, subpart 1; R2960.10; R2960V.11, subpart 3; R2960V.12, items A through E; R2960V.18, subpart 1, items A and B, and 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program rules meet all applicable requirements. Within 14 days receipt of this order, the license holder must contact their DHS Licensor to discuss compliance requirements pertaining to the areas identified above. Within 45 days thereafter, the license holder must submit revised policies and procedures and a resident handbook to demonstrate compliance for the areas identified above.

4. Violation: The license holder’s internal reviews of alleged or suspected maltreatment of minors did not meet requirements. There was no documentation of an internal review completed for a report of alleged or suspected maltreatment made on March 5, 2024.

Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the internal reviews of alleged or suspected maltreatment meet all applicable requirements.

5. Violation: The license holder failed to ensure the resident’s right to not perform labor or services for the facility was protected. DHS Licensors observed a “chore list” displayed on each living unit identifying that residents were responsible to clean staff bathrooms, seclusion rooms, etc., and the Client and Parent Manual included a list of resident “housekeeping chores”. There was no documentation to demonstrate this was therapeutic or consistent with residents’ treatment plans. Minnesota Statutes, section 144.651, subdivision 23, prohibits residents from performing labor or services for the facility unless those activities are included for therapeutic purposes and appropriately goal-related in the residents’ treatment plan.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item O.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident rights are protected and meet all applicable requirements.

6. Violation: The license holder did not meet requirements governing clinical supervision in the following ways:

a. For two of two weeks reviewed, the license holder did not ensure all treatment team members participated either in clinical supervision or an ancillary meeting for each calendar week they worked, for the weeks of:

i. February 25, 2024, when 23 staff persons did not attend; and

ii. July 21, 2024, when 47 staff persons did not attend; and

b. For the week of February 25, 2024, there was no documentation demonstrating a clinical supervision meeting was held for the Wolves unit.

Rule Violated: Minnesota Variance, section R2960V.13.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision for program staff meets all applicable requirements.

7. Violation: The license holder did not meet requirements governing staff ratios in the following ways:

a. The required ratio of one staff to every three residents during awake hours within each living unit was not met for the following dates and living units:

i. February 12, 2024 (Falcons);

ii. March 29, 2024 (Falcons);

iii. March 31, 2024 (Falcons);

iv. July 5, 2024 (Phoenix);

v. July 12, 2024 (Phoenix);

vi. July 15, 2024 (Knights);

vii. July 19, 2024 (Knights, Falcons, and Wolves); and

b. The required ratio of one staff to every six residents during sleeping hours within each living unit was not met for the following dates and living units:

i. February 21, 2024 (Falcons);

ii. February 22, 2024 (Falcons); and

iii. July 24, 2024 (Phoenix).

Rule Violated: Minnesota Variance, section R2960V.14, subparts 1 through 3.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff ratios meet all applicable requirements. Within 60 days receipt of this order, submit two consecutive weeks of unit staff schedules and the corresponding daily resident census per each living unit to demonstrate compliance.

8. Violation: The license holder did not meet quality assurance and improvement requirements in the following ways:

a. The license holder did not complete a review of the data or information related to the following required components every three months/quarterly:

i. Resident outcomes, including identifying ways to improve effectiveness of the services provided to residents and to improve resident outcomes (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarters 1 and 2 of 2024);

ii. Restraint data, according to part R2960V.11 (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024);

iii. Serious occurrences and other significant incidents, including (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024):

1) Determining whether policies and procedures were followed;

2) Evaluating the staff’s response to the serious occurrence and other significant incidents;

3) Assessing what could have prevented the serious occurrence and other significant incidents from occurring; and

4) Modifying policies, procedures, training plans, or resident’s ITPs in response to the findings of the review; and

iv. Self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF Variance, R2960V, and demonstrating action to improve the program’s compliance with the requirements (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarters 1 and 2 of 2024);

b. The license holder did not at least annually review, evaluate, and update the quality assurance and improvement plan for 2022 and 2023; and

c. The license holder did not at least annually meet with community leaders representing the area where the facility is located to advise them about the nature of the programs, types of residents served, the results of the services the program provided to the residents, the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months for the annual years 2022 and 2023.

Rule Violated: Minnesota Variance, section R2960V.17

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quality assurance and improvement plan meets all applicable requirements.

9. Violation: The license holder did not complete a quarterly review of the patterns of the use of restraint and seclusion procedures (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024) that considered the following:

a. Any patterns or problems indicated by similarities in the time of day, day of the week, duration of the use of a procedure, individuals involved, or other factors associated with the use of restraint and seclusion procedures;

b. Any injuries resulting from the use of restraint and seclusion procedures;

c. Actions needed to correct deficiencies in the program's implementation of restraint and seclusion procedures;

d. An assessment of opportunities missed to avoid the use of restraint and seclusion procedures; and

e. Proposed actions to be taken to minimize the use of restraint and seclusion.

Rule Violated: Minnesota Variance, section R2960V.11, subpart 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the review of the patterns of the use of restraint procedures meet all applicable requirements.

10. Violation: The license holder did not establish a mechanism or procedure to ensure that their use of electronic record keeping, including electronic signatures, did not compromise the security of the residents records. DHS Licensors observed that the electronic record system did not lock or secure the document from further alteration once it was electronically signed by the writer and/or the mental health professional and medical director for final approval and completion.

Statute Violated: Minnesota Statutes, section 245A.041, subdivision 4 paragraph (4).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the use of electronic record keeping meets all applicable requirements.

Personnel Files

11. Violation: Eight of eight personnel files reviewed for requirements governing training for staff providing services to individuals who qualify for the Positive Support Rule (PSR) did not meet requirements in the following ways:

a. At least eight hours of core training was not completed for staff persons responsible for developing, implementing, monitoring, supervising, and/or evaluating positive support strategies, a positive support transition plan, and/or the emergency use of manual restraint prior to the staff person assuming responsibilities (personnel files numbered 1, 5, 6, and 13);

b. Staff persons were not trained to the following required core training topics:

i. What constitutes the use of restraint, including mechanical restraint, time-out, and seclusion (personnel file numbered 1);

ii. Staff responsibilities related to prohibited procedures; why the procedures are not effective for reducing or eliminating symptoms or interfering behavior; and why the procedures are not safe (personnel file numbered 1);

iii. Staff responsibilities related to restricted and permitted actions and procedures (personnel file numbered 1);

iv. The situations in which staff must contact 911 services in response to an imminent risk of harm to the person or others (personnel file numbered 1);

v. The procedures and forms staff must use to monitor and report use of restrictive interventions that are part of a positive support transition plan (personnel file numbered 1);

vi. The procedures and requirements for notifying members of the person’s expanded support team after the use of a restrictive intervention (personnel file numbered 1);

vii. Understanding of the person as a unique individual and how to implement treatment plans and responsibilities assigned to the license holder (personnel file numbered 9);

viii. Cultural competence (personnel file numbered 1); and

ix. Personal staff accountability and staff self-care after emergencies (personnel files numbered 1, 2, 5, 6, 9, and 12 through 14);

c. An additional four hours of function-specific training based upon the level of responsibility and qualifications, prior to assuming responsibilities, for staff persons who develop positive support strategies and program managers, was not completed on the following required topics (personnel file numbered 1):

i. Functional behavior assessments;

ii. How to apply person-centered planning;

iii. How to design and use data systems to measure effectiveness of care; and

iv. Supervision, including how to train, coach, and evaluate staff and encourage effective communication with the resident and the resident’s support team;

d. A minimum of an additional two hours of function-specific training for staff persons in manager positions was not completed on the following required topics (personnel file numbered 1):

i. How to include staff in organizational decisions;

ii. Management of the organization based upon person-centered thinking and practices and how to address person centered thinking and practices in the organization; and

iii. Evaluation of organizational training as it applies to the measurement of behavior change and improved outcomes for persons receiving services; and

e. Four hours of refresher training covering each of the core training topics and the function-specific training topics applicable to the staff and their responsibilities was not completed on an annual basis, for 2023 and 2024 (personnel files numbered 1, 2, 5, 6, 9, and 12 through 14).

Rule Violated: Minnesota Rules, part 9544.0090, subparts 1 through 5; and Minnesota Variance, section R2960V.02, subpart 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff training for the PSR meets all applicable requirements.

12. Violation: Eleven of twelve personnel files reviewed for requirements governing background study subjects and staff files did not meet requirements. The files did not include:

a. An application for employment or resume (personnel files numbered 3, 7, 9, and 10);

b. Verification of the staff persons qualifications specific to the position including required credentials and/or professional licensure (personnel files numbered 3 and 10);

c. The date of hire (personnel file numbered 1);

d. Job description (personnel file numbered 1);

e. Documentation of orientation (personnel file numbered 12);

f. The first date the background study subject/staff person began working in the license holder’s facility (personnel file numbered 1);

g. The first date the background study subject/staff person had direct contact with persons served by the license holder’s program (personnel files numbered 1, 3, 5, and 12);

h. An annual job performance evaluation (personnel files numbered 1 and 5); and

i. An annual development and training plan (personnel files numbered 1, 2, 4, 6, and 11).

Statute and Rule Violated: Minnesota Statutes, section 245A.041, subdivision 6, and Minnesota Variance, section R2960V.15, subpart 5.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the inclusion of background study requirements and staff files meet all applicable requirements.

13. Violation: Two of four personnel files reviewed for requirements governing orientation training did not meet requirements. The staff person did not receive orientation to the following prior to direct contact:

a. Resiliency and recovery concepts and principles (personnel files numbered 4 and 8); and

b. Gender based needs (personnel file numbered 4).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 2, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of orientation training meets all applicable requirements.

14. Violation: Three of seven personnel files reviewed for requirements governing annual training did not meet requirements. The staff person did not receive annual training to the following:

a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, section 245A.65, subdivision 3, and 626.557 and 626.5572, and the license holder’s program abuse prevention plan (PAPP) (personnel files numbered 1 and 5); and

b. Resident rights as identified in part R2960V.04 (personnel files numbered 1, 5, and 12);

c. Emergency procedures (personnel files numbered 1 and 12);

d. Treatment services for residents with co-occurring disorders (personnel files numbered 1, 5 and 12) and

e. A minimum of four additional training subjects identified in R2960V.16, subpart 3, for a staff who is not a licensed mental health professional or licensed independent practitioner (personnel file numbered 12).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of annual training meets all applicable requirements.

15. Violation: Twelve of twelve personnel files reviewed for requirements governing documentation of orientation and training did not meet requirements. The documentation did not include:

a. The amount of time the training was provided (personnel file numbered 11 and 12); and

b. The names and credentials of the people who certified the completion of the training (personnel files numbered 1 through 12).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 6.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of orientation and training meet all applicable requirements.

Resident Files

16. Violation: One resident file reviewed for requirements governing the Positive Support Rule (resident file numbered 5) did not meet requirements in the following ways:

a. The license holder utilized a prohibited action and/or procedure for a behavioral or therapeutic program to reduce or eliminate a behavior. The use of time-out was implemented on April 27, 2023; and

b. The license holder did not provide written notice to the resident and their legal representative, at the time-of-service initiation, of the license holder’s policy on the emergency use of restraints that included the person’s rights under the PSR and Minnesota Statues 245D.04.

Rule Violated: Minnesota Rules, parts 9544.0030, subpart 1, 9544.0040, subparts 2 and 3, 9544.0080, subparts 1 and 2, 9544.0070, subpart 3, and 9544.0110; and Minnesota Variance, section R2960V.02, subpart 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of PSR meets all applicable requirements.

17. Violation: One resident file reviewed for requirements governing individual abuse prevention plan (resident file numbered 4) did not meet requirements in the following ways:

a. An individual abuse prevention plan (IAPP) was not developed as part of the initial service plan;

b. The IAPP did not contain an individualized assessment of the person’s susceptibility to abuse by others, including other vulnerable adults;

c. The IAPP did not include detailed measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility, if unsupervised, for a vulnerable adult who was known by the facility to have committed acts of physical aggression towards others; and

d. Documentation did not demonstrate that the resident participated in the development of the IAPP.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 11 paragraph (c), 245A.65, subdivision 2, paragraph (b).

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 30 days receipt of this order, submit an IAPP template that meets all applicable requirements to demonstrate compliance.

18. Violation: Three of three resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways:

a. The immediate needs assessment and preliminary plan of care was not completed within 24 hours (resident files numbered 1 and 3);

b. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize safety risks (resident files numbered 1 through 3);

c. Documentation in the plan of care could not demonstrate if the plan was updated to reflect the resident’s changing condition. The plan contained contradictory information, indicating significant treatment disruptions were occurring and that the resident was improving and no changes were needed for plans dated December 10, 2023 and January 10, 2024. (resident file numbered 1);

d. The plan of care was not reviewed at least every 30 days. The plan was reviewed late on July 15, 2024, when it was due by July 12, 2024 (resident file numbered 3);

e. Treatment objectives were not measurable and did not include target dates for achievement (resident files numbered 1 through 3);

f. Strategy interventions were not specific to reach each objective (resident files numbered 1 and 2);

g. Strategy interventions did not identify the frequency they were to be implemented (resident files numbered 1 and 2);

h. The medication management treatment goal did not identify specific interventions and associated frequencies that the medication prescriber was to be responsible for (resident files numbered 1 through 3);

i. There was no documentation to demonstrate an individual support plan was developed for individuals that displayed behaviors that might require the use of restraint or seclusion (resident files numbered 1 through 3); and

j. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (resident file numbered 1).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, items A and B.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 30 days receipt of this order, submit an Individual Plan of Care and Individual Support Plan for one resident that meets all applicable requirements to demonstrate compliance.

19. Violation: Three of three resident files reviewed for requirements governing treatment services did not meet requirements in the following ways:

a. There was no documentation to demonstrate that individual therapy was provided a minimum of twice per week for treatment weeks:

i. February 11, 2024 (resident file numbered 1); and

ii. February 20, 2024 (resident file numbered 2);

b. There was no documentation to demonstrate that family engagement activities were provided a minimum of one time per week for weeks:

i. February 11 and March 3, 2024 (resident file numbered 1);

ii. February 20 and 26, 2024 (resident file numbered 2); and

iii. June 18 and September 17, 2024 (resident file numbered 3); and

c. Documentation didn’t demonstrate that supportive services for daily living and safety were provided as required (resident files numbered 1 and 2).

Rule Violated: Minnesota Variance, section R2960V.06, subparts 1, and 4, item C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment services meets all applicable requirements.

20. Violation: Four of four resident files reviewed for requirements governing health care services and medication, medication reconciliation, and medication administration did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the health needs of the resident were addressed and monitored on an on-going basis when resident had an asthma attack during a manual restraint (resident file numbered 3);

b. Medication reconciliation was not completed upon admission (resident files numbered 1 through 3) and upon discharge (resident file numbered 2); and

c. Prescription medicine belonging to a resident was not documented to have been either given to the resident’s legal guardian or to the resident who was 18 years of age upon their discharge (resident files numbered 2 and 4);

Rule Violated: Minnesota Variance, section R2960V.08, subpart 2, item B, subpart 3, and subpart 4, item D.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure healthcare and medication meets all applicable requirements.

21. Violation: Three of three resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways (resident files numbered 1 through 3):

a. The prescribing practitioner did not document the following required information:

i. A description in observable and measurable terms of the symptoms and behaviors the psychotropic medication is to alleviate;

ii. Data collection methods the license holder must use to monitor and measure changes in symptoms and behaviors that are to be alleviated by the psychotropic medication; and

iii. A psychotropic medication review was completed at least weekly for the first month and every month thereafter; and

b. Resident file documentation did not demonstrate that the license holder considered the following for each psychotropic medication review conducted by the prescribing practitioner:

i. Targeted symptoms and behaviors of concern;

ii. Data collected since the last review; and

iii. Side effects observed and actions taken.

Rule Violated: Minnesota Variance, section R2960V.08, subpart 6, items B and C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure psychotropic medication reviews meet all applicable requirements.

22. Violation: Three of three resident files reviewed for requirements governing medication side effect monitoring did not meet requirements in the following ways:

a. The license holder did not document and monitor for side effects within 24 hours of admission (resident files numbered 1 and 3);

b. Documentation did not demonstrate that the nurse determined and documented the frequency of side effect monitoring within the resident file (resident files numbered 1 through 3); and

c. Documentation did not demonstrate that the license holder monitored for side effects as determined by the prescribing practitioner when the following occurred (resident files numbered 1 through 3):

i. A new psychotropic medication was ordered for the resident; and

ii. A psychotropic medication had been discontinued.

Rule Violated: Minnesota Variance, section R2960V.08, subpart 10.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of medication side effects meet all applicable requirements.

23. Violation: Three of three resident files reviewed for requirements governing documentation standards for the use of restraint and seclusion did not meet requirements in the following ways:

a. Documentation did not include why less restrictive interventions attempted had failed or were found to be inappropriate (resident files numbered 1 and 2); and

b. There was no documentation for the use of a restraint that had occurred on August 22, 2024 (resident file numbered 3).

Rule Violated: Minnesota Variance, section R2960V.11, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident file documentation meet all applicable requirements.

24. Violation: Three of three resident files reviewed for requirements governing debriefings for the use of restraint and seclusion did not meet requirements. The debriefing following the use of restraint and seclusion did not meet requirements in the following ways:

a. Documentation did not demonstrate whether additional staff training resulted from the debriefings (resident files numbered 1 and 2);

b. Documentation did not demonstrate whether the license holder provided the resident with an opportunity to have a legal representative or advocate participate in the debriefing on the following dates the use of restraint or seclusion occurred:

i. February 2, 2024 (resident file numbered 1); and

ii. February 28, 2024 (resident file numbered 2);

c. The license holder did not document a response and rationale when the license holder’s documentation indicated they were unable to accommodate participation of the resident’s legal representative or advocate for the use of restraint or seclusion on February 18, 2024 (resident file numbered 2);

d. Precipitating factors and alternative techniques that might have prevented the use of restraint or seclusion were not incorporated into the resident’s individual support plan to prevent future use (resident files numbered 1 through 3); and

e. Documentation did not include the evaluation of the circumstances that caused an injury during a safety intervention nor the plan that must be developed to prevent future injuries (resident file numbered 2).

Rule Violated: Minnesota Variance, section R2960V.11, subpart 3, items A through D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of debriefings meet all applicable requirements.

25. Violation: Two of two resident files reviewed for requirements governing discharge and aftercare plans did not meet requirements in the following ways:

a. Documentation did not demonstrate that the discharge plan was developed at least 10 days before discharge (resident file numbered 4);

b. The aftercare plan did not include the following:

i. Medical needs including allergies (resident file numbered 4);

ii. Medication, dosage, clinical rationale, and name of the prescriber (resident file numbered 2 and 4);

iii. Discharge diagnosis and treatment summary (resident file numbered 4);

iv. Prevention plan to address symptoms of harm to self or others (resident files numbered 2 and 4); and

v. Contact information for the PRTF educational provider (resident files numbered 2 and 4); and

c. There was no documentation to demonstrate the license holder shared documents related to the resident’s care in their facility to any mental health providers who will be providing aftercare services (resident file numbered 2).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, items B and C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge documentation and aftercare plans meet all applicable requirements.

26. Violation: Two of two resident files reviewed for requirements governing documentation standards did not meet requirements in the following ways:

a. Documentation in the resident’s file did not include direct care and nursing staff person’s titles (resident files numbered 1 through 3);

b. A mental health professional did not co-sign and date required treatment service notes for a clinical trainee who provided treatment services to a resident on February 8 and 21, 2024 and March 6, 7, and 8, 2024 (resident file numbered 2);

c. A daily summary was not completed for each day sampled:

i. February 22, 2024, and March 3, 4, 5, and 9, 2024 (resident file numbered 1); and

ii. December 12, 2023, and January 4, 5, 14, 17, and 19, 2024 (resident file numbered 3); and

d. Documentation did not demonstrate case coordination activities occurred with other professionals, including case managers and community-based mental health providers, or others (resident files numbered 1 and 2).

Rule Violated: Minnesota Variance, section R2960V.06, subpart 1, item C, and R2960V.19, subparts 2 through 4.

Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident file documentation meet all applicable requirements.

27. Violation: Two of two resident files reviewed for requirements governing the no eject policy (resident files numbered 1 and 2) did not meet requirements. Documentation did not demonstrate:

a. Whether the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder; and

b. The reasons that the decision to discharge was warranted and any alternatives considered or attempted.

Rule Violated: Minnesota Variance, section R2960V.07, subpart 4.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure no-eject documentation meets all applicable requirements.

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 tina.christensen@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Tina Christensen

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:

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 - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6610 or at tina.christensen@state.mn.us .

Sincerely,

Tina Christensen, Senior Licensor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/