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April 9, 2025 Marshall Smith, Authorized Agent Commissioner of Department of Human Services 444 Lafayette Road North Saint Paul, MN 55164 License Numbers: 801558 1083681 Report Numbers: 202404703 202407323 202409528 CORRECTION ORDER Dear Marshall Smith: On March 3 through 6, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigation of your facilities, Minnesota Security Hospital dba Forensic Mental Health Program, located at 100 Freeman Drive, Saint Peter, MN 56082, and the Forensic Mental Health Program, located at 1703 County Road 15, Saint Peter, MN 56082. This review and investigation were conducted to determine compliance with state and federal laws and rules governing the provision of secure mental health treatment services under MSH Variance to Minnesota Rules, parts 9520.0500 to 9520.0690 (Rule 36) and the Positive Supports Rule under Minnesota Rules, parts 9544.0050 through 9544.0140. 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. Practice 1. Violation: Prior to the Review Board meeting the license holder did not post a notice of the meeting giving the date and the process the individual shall use to arrange a meeting with the Review Board on the following units: a. Forest View North; b. Forest View South; c. Prairie View North; and d. Prairie View South. Rule Violated: Minnesota Variance, part MSH.0011, subpart 4, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a posting of a notice of the Review Board. 2. Violation: Thirteen of two hundred six grievances reviewed did not meet requirements. The following grievances were not responded to within ten days: a. August 15, 2024; b. August 16, 2024; c. August 16, 2024 (second grievance); d. August 18, 2024; e. October 9, 2024; f. December 4, 2024; g. December 17, 2024; h. December 17, 2024 (second grievance); i. December 21, 2024; j. December 21, 2024 (second grievance); k. December 21, 2024 (third grievance); l. December 22, 2024; and m. December 31, 2024. Rule Violated: Minnesota Variance, part MSH.0011, subpart 3. Repeat Violation: In a Correction Order that DHS issued on March 13, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance practice meets all applicable requirements. Personnel Files 3. Violation: Eight of nine personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. The staff person was not orientated to the following required topics before providing direct individual care: 1. Job duties, including documentation (personnel files numbered 13 and 14); and 2. Emergency procedures (personnel file numbered 20). b. Orientation to the following was not completed within the first 30 days of employment: 1. Treatment needs of individuals (personnel files numbered 7, 8, 10, and 20 through 22). Rule Violated: Minnesota Variance, part MSH.0015, subpart 2, items A and C. Repeat Violation: In a Correction Order that DHS issued on March 13, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation personnel files numbered 13, 14, 20, and 22 have been trained on all required orientation topics. 4. Violation: Fourteen of twenty-one personnel files reviewed for requirements governing annual training did not meet requirements. The file did not contain documentation the following training was completed annually: a. Training identified by the license holder’s training plan as meeting the annual requirements of Minnesota Rules, chapter 9544 in calendar years 2023 (personnel files numbered 1, 3, 9, 17, and 18), 2024 (personnel files numbered 1, 5, 9, 11, 13, 16, 18, and 20 through 22), and 2025 (personnel files numbered 5, 8, 10, and 16); b. Vulnerable adult maltreatment reporting requirements in calendar years 2023 (personnel file numbered 19), 2024 (personnel files numbered 2, 3, 14, and 19) and 2025 (personnel file numbered 10); c. Maltreatment of minors reporting requirements in calendar years 2024 (personnel files numbered 2, 3, 14, and 19), and 2025 (personnel files numbered 10); d. The program abuse prevention plan in calendar years 2024 (personnel file numbered 2) and 2025 (personnel filed numbered 10); e. Patient rights in calendar years 2023 (personnel file numbered 19), 2024 (personnel file numbered 2), and 2025 (personnel files numbered 8 and 10); and f. Suicide assessment and risk management in calendar years 2023 (personnel files numbered 3 and 18), 2024 (personnel file numbered 16), and 2025 (personnel files numbered 8 and 10). Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3; Minnesota Variance, part MSH.0015, subpart 2, item D; and Minnesota Rules, part 9544.0090, subpart 3. Repeat Violation: In a Correction Order that DHS issued on March 13, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure annual training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation personnel files numbered 1, 9, 13, 16, 18, and 20 have been trained on all required annual training topics. Individual Files 5. Violation: One of six individual files reviewed for requirements governing compliance with health care bill of rights (individual file numbered 12) did not meet requirements. The file did not contain documentation the individual was orientated to individual rights upon transfer to Ceder unit on October 31, 2024. Rule Violated: Minnesota Variance, part MSH.0011, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure compliance with health care bill of rights meets all applicable requirements. 6. Violation: Four of eleven individual files reviewed for requirements governing admission assessments did not meet requirements in the following ways: a. The nursing assessment was not completed within eight hours of admission (individual file numbered 5); and b. The following assessments were not completed within 24 hours of admission: 1. History and physical (individual files numbered 6 and 17); and 2. An initial psychiatric (individual file numbered 5). c. The initial social work documentation did not gather information from family, significant others, legal system and other parties as applicable to present legal situation, known family and support systems, cultural influences and their impact on the individual and recommendations for treatment (individual file numbered 9). Rule Violated: Minnesota Variance, part MSH.0004, subpart 3, items A, B, C, and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission assessments meet all applicable requirements. 7. Violation: Four of twelve individual files reviewed for requirements governing treatment planning did not meet requirements in the following ways: a. The initial treatment plan was not completed within 24 hours of the individual’s admission to the facility (individual file numbered 5); b. The initial treatment plan did not include initial treatment objectives and interventions for the services to be provided (individual file numbered 5); and c. The individual treatment plan (ITP) did not include the following: 1. Identification of referrals and resources needed to assure the individual’s health and safety needs are met and the staff who are responsible to assure that appropriate follow-up occurs (individual files numbered 5 and 6); and 2. Frequency of interventions (individual file numbered 18). a. An assessment was not completed as part of the treatment planning process to determine risk, need and prioritization of treatment for individual treatment plan dated April 30, 2024 (individual file numbered 9). Rule Violated: Minnesota Variance, part MSH.0011, subpart 8, items A and B. Repeat Violation: In a Correction Order that DHS issued on March 13, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment planning meets all applicable requirements. 8. Violation: One of twelve individual files reviewed for requirements governing level of care determination (individual file numbered 7) did not meet requirements. The license holder did not assess the individual’s level of care minimally every 90 days in December 2024. Rule Violated: Minnesota Variance, part MSH.0004, subpart 9, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure level of care determination meets all applicable requirements. 9. Violation: Twelve of twelve individual files reviewed for requirements governing documentation of services (individual files numbered 1, 5 through 9, 11 through 15, and 17) did not meet requirements. The file did not contain documentation of the type of treatment and hours received monthly as indicated per the individual treatment plan. Rule Violated: Minnesota Variance, part MSH.0006, subpart 3, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements for governing services meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for two individuals that demonstrates compliance. 10. Violation: One of fourteen individual files reviewed for requirements governing required services (individual file numbered 16) did not meet requirements. Services were not delivered with consideration of cultural influences and the impact of such on the individual. A language interpreter was not available for a medical appointment on August 21, 2024. Rule Violated: Minnesota Variance, part MSH.0004, subpart 1, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure required services meet all applicable requirements. 11. Violation: Nine of fourteen individual files reviewed for requirements governing documentation of treatment services did not meet requirement. Staff members did not document treatment services and observations as follows: a. Within the first eight weeks of admission: 1. Direct care staff daily (individual files numbered 7, 11, 12, 14, 17, and 18); 2. Psychiatric practitioner weekly (individual file numbered 5); and 3. Other staff listed on the treatment plan weekly (individual files numbered 9, 13, 14, and 18); b. Level B of care: 1. Psychiatric practitioner minimally every 90 days (individual file numbered 14); and 2. Other staff listed on the treatment plan monthly (individual file numbered 14); c. Level C of care: 1. Other staff listed on the treatment plan monthly (individual file numbered 13). Rule Violated: Minnesota Variance, part MSH.0006, subpart 13. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of treatment services meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for one individual for the first four weeks of admission that demonstrates compliance. 12. Violation: Two of nine individual files reviewed for requirements governing use of restraint during transport did not meet requirements in the following ways: a. An assessment was not completed upon admission to determine the individual’s risk to the public (individual file numbered 14); and b. The continued need for the use of restraints outside the secure perimeter was not reviewed at least quarterly and a new request was not submitted annually in calendar year May 2024 (individual file numbered 15). Rule Violated: Minnesota Variance, part MSH. 0009, subpart 1, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure use of restraint during transport meets all applicable requirements. 13. Violation: Two of five individual files reviewed for requirements governing when notice is required (individual files numbered 5 and 17) did not meet requirements. The file did not include documentation at the time of service initiation the license holder provided notice to the person receiving services of the license holder policy on the emergency use of manual restraint. Rule Violated: Minnesota Rule, part 9544.0080, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure when notice is required 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. 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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