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February 18, 2025 Tyler Nyhus, Authorized Agent Twin Ports Children Services Inc 4905 Hermantown Road Hermantown, MN 55811 License Number: 1085851 (Home and Community-Based Services) License Numbers: 1113286 (Home and Community-Based Services-Community Residential Setting) Kirkus 1114240 (CFRS) Morgan 1090916 (CFRS) Kirkus 1116371 (CFRS) Swan Lake 1121787 (CFRS) Martin CORRECTION ORDER Dear Tyler Nyhus, On July 18, 2024, the Department of Human Services (DHS) issued an Order of Conditional License to Twin Ports Children Services Inc located at 1707 Maple Grove Road, Duluth, Minnesota. On January 14-15, 2025, DHS licensors conducted a licensing review to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D and that the terms of the Conditional License had been met. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two of four people whose records were reviewed (P2 and P4), the license holder did not meet the requirements for program abuse prevention plans as required. The license holder failed to post a current copy of the program abuse prevention plan in a prominent location in the program, CFRS license number 1121787, and be available upon request to mandated reporters, persons receiving services, and legal representatives. The license holder did have a PAPP posted at the program, however, that PAPP included information that was no longer relevant to the program. Corrective Action Ordered: The license holder corrected this onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rule, 9544.0080, subpart 1 and subpart 2. Violation: For one person whose record was reviewed (P3), the license holder did not obtain written acknowledgement of the emergency use of manual restraint policy as required. The license holder failed to obtain a written acknowledgement from P3’s legal representative of the notice of the license holders’ policy of the emergency use of manual restraint. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain a written acknowledgement from P3’s legal representative of the notice of the license holders’ policy of the emergency use of manual restraint. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For two people whose records were reviewed (P1 and P3), the license holder did not provide a written notice that identified the service recipient rights as required. a. The license holder failed to provide P1’s legal representative a written notice and explanation of the service recipient rights that identified the right to a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects. b. The license holder failed to provide P3’s legal representative with a written notice and explanation of the service recipient rights that identified the following protection-related rights within five working days of service initiation: · receive services in a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; and · receive services in a setting that is free from hazards that threaten the person’s health or safety. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 and P3’s legal representative a written notice that identifies the above-mentioned service recipient rights and an explanation of those rights; · audit all persons served records to ensure a written notice that identifies the above-mentioned service recipient rights and an explanation of those rights have been provided; and · maintain documentation of the audit. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P2), the license holder did not document the restriction of rights in the person’s support plan addendum as required. The license holder maintained documentation in P2’s support plan addendum for a restriction of P2’s right to access their cell phone at any time. The license holder failed to maintain signed and dated approval for the restriction from P2's legal representative. Additionally, the license holder was assigned a quarterly review schedule for P2’s right restriction; however, the license holder failed to review the rights restriction on a quarterly basis. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must obtain signed and dated approval for P2’s rights restriction. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For three people whose records were reviewed (P1, P2, and P4), the license holder was assigned responsibility for medication administration in the support plan addendum. The license holder did not follow medication administration procedures as required. a. P1’s December 2024 medication administration record (MAR) documented 17GM Gavilax powder in eight ounces of water daily. On December 18, 2024, P1’s Gavilax powder was changed to daily as needed. The license holder failed to discontinue the daily dose of Gavilax powder until January 8, 2025. b. During site visits that were completed during the licensing review on January 15, 2025, DHS licensors learned that P2 had continuously refused their daily scheduled 17GM Gavilax powder. Staff did not document these refusals on the MAR from July 1, 2024 through the time of the licensing review. The license holder failed to ensure notation of any occurrence of a dose of medication not being administered as prescribed, whether by error by the staff or the person or by refusal by the person. Additionally, the license holder failed to report to the prescriber a pattern of P2 refusing to take the medication as prescribed. c. August 27, 2024, P2’s Risperidone prescription was changed from one 1 milligram (mg) tablet twice daily to one 2mg tablet every evening; however, this was not transcribed accurately on P2’s MAR. P2’s MARs indicate that P2 received the incorrect dose of Risperidone from August 28, 2024 through September 30, 2024. The license holder failed to administer medications as prescribed. d. P4 was prescribed Lorazepam tab 1mg take one tablet by mouth every evening with a sticker on the bubble pack indicating this was to be administered at bedtime and a highlighted time of 4PM; however, this was documented on P4’s MAR as Lorazepam tab 1mg take one tablet by mouth every evening, with a 4PM hour administration time. The license holder failed to implement medication administration procedures for P4. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must report P2’s medication refusals to P2’s prescriber. Within 30 days of receiving this order you must document the above mentioned information in P4’s MAR. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For two people whose records were reviewed (P1 and P2), the license holder did not review and report medication and treatment issues as required. a. The license holder maintained a document in P2’s record titled “Medication Administration Review Record” that was dated October 3, 2024. The document indicated that medication administration errors were discovered during the review and that a pattern of medication administration errors were identified. The license holder failed to develop and implement a plan to correct patterns of medication administration errors when identified. b. The license holder failed to report medication errors or refusals to P2’s and P4’s legal representative and case manager as they occurred. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must: · report P1 and P2’s medication errors to their legal representatives and case managers; and · maintain documentation of the notifications regarding medication errors in P1 and P2’s record. Within 30 days of receiving this order, you must: · review the MARs for all persons served by your program to ensure the information maintained in the medication administration record is current and to identify medication administration errors; · maintain documentation of the MAR reviews you complete, including the date(s) of completion, and the name of the person(s) who completed the MAR reviews; Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b), clause 1. Violation: For two people whose records were reviewed (P1 and P3), the license holder did not meet the requirements for psychotropic medication use and monitoring as required. Target symptoms refer to any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. The license holder was assigned responsibility of administering P1 and P3’s psychotropic medications in their support plan addendums. The license holder failed to maintain documentation with the description of the target symptoms that P1 and P3’s psychotropic medications were intended to alleviate in their support plan addendums. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on January 23, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation with the description of the target symptoms that P1 and P3’s psychotropic medications are to alleviate in P1 and P3’s support plan addendums. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not survey preferences for itemized statements as required. The license holder was assigned the responsibility of assisting P3 with safekeeping of funds. The license holder failed to obtain written authorization from P3’s case manager within five working days of service initiation. Additionally, the license holder failed to survey, document, and implement the preferences of P3’s case manager for frequency of receiving a statement that itemizes receipts and disbursements of P3’s funds. Repeat Violation: In a correction order that DHS issued on January 23, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P3’s case manager to assist P3 with safekeeping of funds; and · survey, document and implement the preferences of P3’s case manager for frequency of receiving a statement that itemizes receipts and disbursements of P3’s funds. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.06, subdivision 8. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements of a positive support transition plan as required. P1’s positive support transition plan required the expanded support team to review the effectiveness of the plan no less than every quarter (three months) or 90 days. The license holder failed to develop a positive support transition plan for P1 in the manner prescribed by the commissioner when the license holder failed to review P1’s positive support transition plan every quarter. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review the effectiveness of the positive support transition plan for P1 with P1’s expanded support team; · if the incidence of targeted interventions has not decreased within the past six months, the license holder must submit a request to P1’s case manager or directly request the help of an external qualified professional; and · maintain this documentation in P1’s record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.07, subdivision 1 Violation: For two persons whose records were reviewed (P2 and P4) the license holder did not comply with the requirements of the federal waiver plan. The license holder maintained audio monitoring equipment throughout the program, CFRS license number 1121787 where P2 and P4 resided and received services. The license holder failed to receive approval for the use of monitoring technology from the lead agency.
Corrective Action Ordered: Within 30 days of receiving this order, you must either remove or receive consent for all monitoring technology being used at the program site. If you choose to receive consent and continue the use of monitoring technology, use of the monitoring technology must meet the requirements of the federal waiver plan. The lead agency approves and oversees the use of all monitoring technology so you must consult with the case managers for P2 and P4. Additionally, the same consultation must occur for all service recipient receiving services where monitoring technology is being utilized. You must inform your licensor, in writing, of your decision and submit completed DHS-6789B or DHS-6789C forms for all service recipients. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not complete assessments for intensive service planning as required. The license holder failed to complete assessments for P2 that produced information about the person that described the person’s overall strengths, functional skills and abilities. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on January 23, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must complete the required assessments in this subdivision for P2 that produce information about the person that describes their overall strengths, functional skills, and abilities. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two people whose records were reviewed (P1 and P2), the license holder did not meet the requirements for service plan review and evaluation as required. a. P1’s support plan addendum required quarterly service planning and support team meetings and quarterly progress reports; however, the license holder failed to provide progress reports or participate in service planning and review meetings on a quarterly basis. b. P2’s support plan addendum required semi-annual service planning and support team meetings; however, the license holder failed to hold a semi-annual meeting in 2024. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: On an ongoing basis, you must participate in service planning and support team meetings and complete and provide progress reports according to the timelines stated in the person’s support plan or support plan addendum. The progress report must summarize the person's status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate with P2 the identified positive support strategies at least every six months. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P2 whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. Additionally, you must maintain documentation of compliance with these requirements as required in Minnesota Rules, part 9544.0100. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.061. Violation: For two people whose records were reviewed (P1 and P2), the license holder did not ensure that emergency use of manual restraints complied with the requirements of this chapter. P1 and P2 were involved in several incidents that resulted in the emergency use of manual restraint. The license holder failed to: · within three calendar days after an emergency use of manual restraint, ensure the staff person who implemented the emergency use reported in writing to the designated coordinator the following information about the emergency use: o the staff and persons receiving services who were involved in the incident leading up to the emergency use of manual restraint; o a description of the physical and social environment, including who was present before and during the incident leading up to the emergency use of manual restraint; o a description of what less restrictive alternative measures were attempted to de-escalate the incident and maintain safety before the manual restraint was implemented that identifies when, how, and how long the alternative measures were attempted before manual restraint was implemented; o a description of the mental, physical, and emotional condition of the person who was restrained, and other persons involved in the incident leading up to, during, and following the manual restraint; o whether there was any injury to the person who was restrained or other persons involved in the incident, including staff, before or as a result of the use of manual restraint; and o whether there was a debriefing with the staff, and, if not contraindicated, with the person who was restrained and other persons who were involved in or who witnessed the restraint, following the incident and the outcome of the debriefing; · within five working days of the emergency use of manual restraint, complete internal reviews of the emergency use of manual restraints that includes an evaluation of whether: o the person's service and support strategies developed according to sections 245D.07 and 245D.071 need to be revised; o related policies and procedures were followed; o the policies and procedures were adequate; o there is a need for additional staff training; o the reported event is similar to past events with the persons, staff, or the services involved; o is there a need for corrective action by the license holder to protect the health and welfare of persons; o based on the results of the internal review, the license holder must develop, document, and implement a corrective action plan for the program designed to correct current lapses and prevent future lapses in performances by individuals or the license holder, if any; · consult with the expanded support team within five working days after the completion of the internal review to: o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identified the perceived function the behavior served; and o determine whether the person's support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint. Corrective Action Ordered: Within 30 days of receiving this order, you must complete the above mentioned items for P1 and P2 and maintain documentation of what was completed in P1 and P2’s service recipient records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two of four staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation training as required. a. The license holder failed to ensure SP2 received instruction on medication administration procedures that incorporated an observed skill assessment conducted by the trainer to ensure unlicensed staff demonstrate the ability to safely and correctly follow medication procedures. b. The license holder failed to provide SP3 with orientation training on the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04 within 60 days of hire. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP2 and SP3 with the above-mentioned training; · audit all staff training records to ensure the above orientation training has been provided and provide the training to any staff person who has not received training on any of the above mentioned topics; and · maintain documentation of the audit results in your program records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP4), the license holder did not provide annual training as required. a. The license holder failed to provide SP1 with the following annual trainings in 2024: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. b. The license holder failed to provide SP2 with the following annual trainings in 2024: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; and · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04. c. The license holder failed to provide SP4 with annual training on the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04 in 2024. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1, SP2, and SP4 with the above mentioned annual trainings; · audit all staff training records to ensure the above annual training has been provided and provide the training to any staff person who has not received training on any of the above mentioned topics; and · maintain documentation of the audit results in your program records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.11, subdivision 2, paragraph (3). Violation: For one person whose record was reviewed (P2), the license holder did not implement the program’s safe medication assistance and administration policy as written. The program’s policy on safe medication assistance and administration stated that “medications that are discontinued, outdated, or have been prepared and not administered are to be collected by the company nurse and returned to the pharmacy to be destroyed. The company nurse will document when medications are destroyed.” P2’s medication box contained expired medications. The license holder failed to dispose of medications as required. Corrective Action Ordered: Within 30 days of receiving this order you must: · review the medications for all persons served by your program to ensure medications are current and any expired or discontinued medications are disposed of; and · maintain documentation of the medication reviews you complete, including the date(s) of completion, and the name of the person(s) who completed the reviews. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245C.07, paragraph (f). Violation: For one staff person whose record was reviewed (SP4), the license holder did not affiliate staff to all rosters as required.
A background study for SP4 was submitted under license number 1090916, however, SP4 also worked under license numbers 1085851 (HCBS), 1114240 (CFRS), 1116371 (CFRS), and 1121787 (CFRS). The license holder failed to affiliate SP4 to all required rosters. Corrective Action Ordered: SP4 was affiliated to all required rosters on January 22, 2025. On an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Nicole Riley, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-3657
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