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January 24, 2025 Melissa Winkler, Authorized Agent Northwood Children’s Home Society, Inc. 714 W College Street Duluth, MN 55811 License Numbers: 801775 Northwood Children’s Services-Main Campus (CRF) 1091513 Northwood Children’s Services Inc.-Diagnostic Assessment Center (CRF) CORRECTION ORDER Dear Melissa: On December 2 through 5, 2024, Department of Human Services (DHS) licensors conducted licensing reviews at your facilities, Northwood Children’s Services-Main Campus located at 714 W College Street, Duluth, MN 55811 and Northwood Children’s Services, located at and 4000 W 9th Street, Duluth, MN 55807. These reviews were conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, shelter care services under Minnesota Rules, part 2960.0510 through 2960.0530, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, restrictive techniques standards under Minnesota Rules, part 2960.0710, residential program certification for compliance with the Family First Prevention Services Act, Minnesota Statutes, section 245A.25, and crisis stabilization services under Minnesota Statutes, section 245A.26. 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. Throughout this Correction Order, the licensed programs will be referenced as follows: · Northwood Children’s Services-Main Campus: (Main); · Northwood Children’s Services: (DAC); and · When citations are specified to all licensed programs: (ALL). LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Physical Plant 1. Violation: A copy of the resident’s basic rights was not posted in the staff work station (All). Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item D. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident rights are posted in the staff work station and meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. Policies, Procedures, and Practices 2. Violation: The license holder’s annual review of the plan for the transfer of clients and records upon closure did not meet requirements (All). A controlling individual did not annually review and sign the plan for calendar years 2022 and 2023. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. 3. Violation: Two of two internal reviews of alleged maltreatment of minors did not meet requirements (Main). The internal review did not include an evaluation of whether related policies and procedures were followed for reviews dated September 20, 2024, and November 5, 2024. Statute Violated: Minnesota Statutes, section 245A.66. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that internal reviews of alleged maltreatment meet all applicable requirements. 4. Violation: The license holder did not have documentation that they conducted an annual evaluation of the program’s strengths and weaknesses according to performance indicators identified in Minnesota Rules, part 2960.0060, subpart 3, item A, for calendar years of 2022 and 2023 (All). Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the annual evaluation of the program’s strengths and weaknesses meets all requirements. Within 60 days receipt of this order, submit the annual evaluation for the calendar year 2024 for both Main and DAC programs. 5. Violation: The license holder’s review of the use of restrictive procedures did not meet requirements (All). The license holder did not have documentation of the following: a. Quarterly reviews of the use of restrictive procedures for 2022, Quarter 4; 2023, Quarters 1 through 4; and 2024, Quarters 1 through 3. b. An annual written evaluation of the use of restrictive procedures for the years of 2022 and 2023. Rule Violated: Minnesota Rules, part 2960.0710, subparts 2, item D, and 11. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the reviews of the uses of restrictive procedures meet all requirements. Within 30 days receipt of this order, submit the 2024 Quarter 4 review for both Main and DAC programs. 6. Violation: The license holder’s staffing ratios did not meet requirements (Main). On June 17, 18, 19, and 23, 2024, documentation identified times that the Cubs unit had two staff on the schedule during normal waking hours with nine residents on the unit, the youngest being six years old. Rule Violated: Minnesota Rules, part 2960.0690, subpart 2, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff ratios meet all applicable requirements. 7. Violation: The license holder’s provision of weekly clinical supervision did not meet requirements in two of two weeks reviewed (Main). Clinical supervision documentation indicated a mental health professional did not provide at least weekly clinical supervision to staff providing program services to a resident for the following: a. For the week of June 16 through 22, 2024: i. One of thirteen staff did not attend (Evergreen); and ii. One of twelve staff did not attend (Eagles). b. For the week of November 24 through 30, 2024: i. There was no documentation that clinical supervision occurred (Cub); ii. Three of thirteen staff did not attend (Eagles); and iii. Three of nine staff did not attend (Evergreen). Rule Violated: Minnesota Rules, part 2960.0630, subpart 2. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision meets all applicable requirements. Personnel 8. Violation: One of five personnel files reviewed for staff qualifications did not meet requirements (All). The license holder did not have documentation showing that the staff’s professional licensure was current (personnel file numbered 2). Rule Violated: Minnesota Rules, part 2960.0150, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation in personnel files meets all applicable requirements. 9. Violation: One of seven personnel files reviewed for orientation did not meet requirements (All). The license holder did not orient the staff person to the required topics (personnel file numbered 1). Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivisions 1, paragraph (c), and 14, paragraph (b), 245A.25, subdivision 3, paragraph (e), and Minnesota Rules, parts 2960.0100, subparts 3, item A, and 5, 2960.0150, subpart 4, item C, and 2960.0650, subpart 1, items A, B, D, E, F, and G. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute and rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that personnel numbered 1 was oriented to emergency procedures, maltreatment of minors reporting requirements under Minnesota Statutes, section 260E, and operational policies and procedures of the license holder, including grievance procedures. 10. Violation: Three of eleven personnel files reviewed for ongoing training did not meet requirements in the following ways (All): a. The staff person did not receive annual training on the maltreatment of minors reporting requirements and definitions in chapter 260E (personnel file numbered 1); b. The emergency plan was not reviewed with staff at least once every six months (personnel files numbered 1, 6, and 8); and Statute and Rule Violated: Minnesota Statutes, section 245A.66, subdivision 4, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subparts 3, item B, and 5. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute and rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Residents 11. Violation: Five of six resident files reviewed for resident information did not meet requirements (All). Documentation in the resident’s file did not contain: a. The placing agency’s case plan goals for the resident (resident file numbered 3); and b. Contact information for all known biological family members and fictive kin of the resident (resident files numbered resident information 1, 2, 4, and 5). Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (g) and Minnesota Rules, part 2960.0070, subpart 3, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation on resident information meets all applicable requirements. 12. Violation: Five of six resident files reviewed for admission procedures did not meet requirements (All). a. The inventory of the resident’s personal property was not signed by the resident or two staff members if the resident refused to sign (resident files numbered 2 and 4); b. There was not documentation to demonstrate that the license holder informed the resident how to contact the appropriate state appointment ombudsman or that they gave the resident the name, address, and phone number of the state-appointed ombudsman (resident files numbered 2, and 4 through 6); and c. There was not documentation that within 12 hours of admission the resident’s immediate needs were assessed that included the need for connection to family and other natural supports (resident file numbered 3); and d. Admission procedures were not completed for the resident’s August 14, 2024, intake at the Main campus. The resident file contained admission documentation that was completed for a previous intake at the DAC campus (resident file numbered 2). Statute and Rule Violated: Minnesota Statutes, section 245A.26, subdivision 5, paragraph (a), and Minnesota Rules, parts 2960.0050, subpart 3, items A, B, and E, 2960.0070, subpart 4, 2960.0080, subpart 4, and 2960.0160, subpart 4, items A, B, and C. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meet all applicable requirements. 13. Violation: Five of six resident files reviewed for program services did not meet requirements (All). The license holder did not have documentation to demonstrate: a. That they contacted and facilitated outreach to the resident’s siblings (resident files numbered 1 and 2); and b. That they were offered crisis stabilization services as described in Minnesota Statutes, section 256B.0624, subdivision 7 (resident file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.25, subdivision 4, paragraph (g) and 245A.26, subdivision 4, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program services meet all applicable requirements. 14. Violation: Three of five resident files reviewed for treatment plans did not meet requirements in the following ways (All): a. Treatment plans did not include: i. The use of restrictive procedures (resident file numbered 4); ii. How the program maintains the youth’s connections to their siblings (resident files numbered 1 and 2); b. The crisis treatment plan did not include (resident file numbered 3): i. Crisis assistance strategies that have been effective in the past; ii. Measurable treatment objectives; iii. Specific interventions the license holder will use to help the resident engage in treatment; and iv. Documentation of referrals to and scheduling of services, including specific providers where applicable. Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 4, paragraph (h) and 245A.26, subdivision 5, paragraph (b), and Minnesota Rules, part 2960.0710, subpart 6, item F. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. 15. Violation: Four of six resident files reviewed for service plan reviews did not meet requirements in the following ways (All): a. The treatment team did not include and document the review of the use of time-out for the resident during the review of the resident’s treatment plan (resident files numbered 1, 2, and 5); and b. There was not documentation to demonstrate that the resident’s crisis treatment plan was reviewed each week by a mental health professional (resident file numbered 3). Statute and Rule Violated: Minnesota Statutes, section 245A.26, subdivision 5, paragraph (c) and Minnesota Rules, part 2960.0080, subpart 5, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service plan reviews meet all applicable requirements. 16. Violation: Six of six resident files reviewed for health care did not meet requirements in the following ways (All): a. There was not documentation to support that the license holder contacted the newly admitted resident’s prescribing medically licensed person to verify the following information: i. Instructions about how the medication must be administered (resident files numbered 2 through 5); ii. The symptoms that the medication will alleviate (resident files numbered 1 through 5); and iii. The symptoms that would warrant consultation with the physician (resident files numbered 1 through 5). b. The license holder did not have documentation of the disposition of the resident’s medication or that prescription medication belonging to the resident was given to the resident’s parent or legal guardian upon the resident’s discharge (resident file numbered 6). Rule Violated: 2960.0080, subpart 11, items D and F. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care meets all applicable requirements. Within 30 days receipt of this order, submit verification documentation of a newly admitted resident verifying the information in item a. 17. Violation: One of four resident files reviewed for psychotropic medication reviews did not meet requirements (Main). Psychotropic medication reviews completed on August 29, September 26, and November 21, 2024, did not include side effects observed and actions taken (resident file numbered 2). Rule Violated: Minnesota Rules, part 2960.0620, subpart 5, item C. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication reviews meet all applicable requirements. 18. Violation: Four of four resident files reviewed for informed consents did not meet requirements (Main). The information communicated in obtaining consent for psychotropic medications did not include: a. The level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed (resident files numbered 2 and 4); b. The expected benefits of the medication, including the level to which the medication is to change the symptoms and behavior and an indication of the method used to determine the expected benefits (resident file numbered 1); c. Specific information about the psychotropic medication to be used, including the rote of administration (resident file numbered 1); d. The pharmacological and nonpharmacological treatment options available and the course of the condition with and without the treatment options (resident files numbered 1, 3, 4 and 5); and e. The more frequent and less frequent or rare but serious side effects of the psychotropic medication, including how the risks and possible side effects must be managed (resident file numbered 5). Rule Violated: Minnesota Rules, part 2960.0620, subpart 7, items A, B, C, D, and E. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that informed consents meet all applicable requirements. Within 30 days receipt of this order, submit informed consent documentation for one resident to demonstrate compliance. 19. Violation: One of five resident files reviewed for time out procedures did not meet requirements (Main). In a time out utilized on September 8, 2024, documentation did not include the resident’s response to the time out or the resident’s ability to de-escalate during the time out (resident file numbered 2). Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that time out procedures meet all applicable requirements. 20. Violation: One of five resident files reviewed for restrictive procedures did not meet requirements (Main). In a physical hold that occurred on July 24, 2024, documentation did not demonstrate that the physical hold was necessary to protect the resident or others from physical harm, that it was the least intrusive intervention that would effectively react to the emergency, or a detailed description of the incident which led to the use of physical holding (resident file numbered 1). Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items A, B, and K. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures meet all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons involved in the restrictive procedure used on July 24, 2024, have been retrained in restrictive procedures policies. 21. Violation: One of four resident files reviewed for discharge procedures did not meet requirements (Main). There was not documentation that the license holder returned all of the resident’s personal property to the resident along with a signed receipt upon discharge (resident file numbered 4). Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meet all applicable requirements. 22. Violation: Three of three resident files reviewed for transition services plans did not meet requirements (All). The license holder did not have documentation to demonstrate: a. That the plan was developed with input from the resident, the resident’s family, the providing school district, and the persons who will provide support services to the resident upon release (resident files numbered 4 and 5); and b. That the plan included a budget plan and a description of the resident’s financial and employment status or transportation needs (resident file numbered 6). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B. Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plans meet 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 Hannah.Horsch@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Hannah Horsch 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 651-431-6270 or at Hannah.Horsch@state.mn.us. Sincerely, Hannah Horsch, Licensor Licensing Division Office of Inspector General
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