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January 10, 2025 Michelle Murray, Authorized Agent Nexus Family Healing 505 Highway 169 N Ste 500 Plymouth, MN 55441 License Number: 1119782 Report Numbers: 202406274 202406452 202407219 202407402 CORRECTION ORDER Dear Michelle Murray: On September 12, 2024 a Department of Human Services (DHS) licensor conducted a licensing investigation of your facility, Nexus East Bethel Family Healing located at 900 189th Ave NE, East Bethel, MN 55011. This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of Psychiatric Residential Treatment Facilities (PRTF) under the PRTF Variance to 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. Personnel 1. Violation: The licensor holder did not follow through with correction action steps as described in their internal reviews dated May 7, 2024 and May 8, 2024. Staff persons were not retrained on the following: a. Approved TCI techniques (SP 3, 5, 7, 12, 17, 20, and 21); b. Trauma informed care practices (SP 1 through 7, and 9 through 22); and c. Maltreatment reporting (SP 1 through 22). Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a corrective action plan is completed as determined. Within 30 days of receipt of this order, submit documentation staff persons have been trained according to the corrective action plan. Client Files 1. Violation: Four of four resident files reviewed for requirements governing 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 of admission (R2); b. The plan of care was not individualized and appropriate to the resident’s changing condition. The plan of care did not address the resident’s self-injurious behaviors, including ingestion of inedible objects (R1); c. Plan of care with the following effective dates were not signed every 30 days: 1) May 27, 2024 (R1); 2) July 18, 2024 (R3); and d. Plan of care with effective dates of June 26, 2024 (R1) and July 10, 2024 (R4) did not include the following: 1) The resident and legal guardian’s signature to acknowledge his/her participation in the development and revisions of the plan of care; and 2) The signature(s) and title(s) of the multidisciplinary team who completed or updated the plan of care and the signature of the mental health professional who approved the plan of care. Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, items A and B. Repeat Violation: In a Correction Order that DHS issued on July 26, 2024, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual plan of care meets compliance. Within 30 days of receipt of this correction order, submit a plan of care for one resident that demonstrates compliance. 2. Violation: Two of two resident files reviewed for requirements governing discharge planning did not meet requirements. The aftercare plan did not include the following: a. Medical needs, including allergies (R1); b. Clinical rationale for medications (R1 and 2); c. Discharge diagnosis and treatment summary (R1 and 2); and d. Prevention plan to address symptoms of harm to self or others (R1). Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, item B. Repeat Violation: In a Correction Order that DHS issued on July 26, 2024, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge planning meets requirements. Within 30 days of receipt of this order, submit one aftercare 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. If submissions are required as part of the corrective action ordered they must be sent to your licensor by email at ginny.benson@state.mn.us or by mail at: Commissioner, Department of Human Services ATTN: Ginny Benson 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 violation(s). 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 651-431-6957 or at ginny.benson@state.mn.us Sincerely, Ginny Benson, Senior Licensor Licensing Division Office of Inspector General
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