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April 15, 2025 Katie Perzel, Authorized Agent Bar None Residential Services 7625 Metro Blvd Ste 200 Minneapolis, MN 55439 License Number: 1036848 (CRF) Report Numbers: 202409503, 202405253, 202407979, 202408399, 202411025 and 202500960 CORRECTION ORDER Dear Katie Perzel: On February 10, 2025 through 13, 2025, the Department of Human Services (DHS) conducted a licensing review and investigation at your facility located at 22426 Saint Francis Blvd, Anoka, Minnesota, 55303. As a result of this visit, DHS determined that you are in violation of 24 of the children’s residential facilities rules and statutes. 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. PRACTICES 1. Violation: The license holder did not have a copy of the resident’s rights, program abuse prevention plan and the internal and external reporting policies and procedures posted on either living unit. Rule/Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), and Minnesota Rules, part 2960.0050, subpart 3, items C and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program postings meets all applicable requirements. This violation was corrected during the licensing review. No further corrective action is required. 2. Violation: The physical environment did not provide for the comfort, privacy and dignity of the residents. The physical plant was missing a bedroom door (Omegon unit) and curtains (Haven unit). Statute Violated: Minnesota Rule, part 2960.0110, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the physical environment provides privacy to the residents. Within 30 days receipt of this order, submit documentation that demonstrates compliance. 3. Violation: 2 of 13 Internal reviews (IR) of alleged maltreatment did not meet requirements. The internal reviews did not indicate the following: a. Related policies and procedures were followed (IR dated November 21, 2024); and b. The policies and procedures were adequate (IR dated April 23, 2024). Rule Violated: Minnesota Rule, section 245A.66. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all internal reviews meet applicable requirements. 4. Violation: The annual evaluation of program strengths and weaknesses for calendar year 2024 did not include the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months. Rule Violated: Minnesota Rules, part 2960.0060, subpart 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual evaluation of program strengths and weaknesses meet all applicable requirements. 5. Violation: The quarterly review of patterns of restrictive procedures dated April 15, 2023, July 1, 2023, and July 1, 2024, did not meet requirements. The review did not consider any patterns or problems indicated by similarities in: a. The day of the week; and b. The duration of the use of a procedure. Rule Violated: Minnesota Rules, part 2960.0710, subpart 11, item A. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quarterly review of restrictive procedures meets all applicable requirements. 6. Violation: The license holder did not have documentation to demonstrate that clinical supervision was provided weekly by a licensed mental health professional for two of two weeks sampled: a. December 22 through December 24, 2024; and b. February 2 through February 8, 2025. Rule Violated: Minnesota Rules, part 2960.0630, subpart 2, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of clinical supervision meets all applicable requirements. 7. Violation: 3 of 23 grievances reviewed did not meet requirements. There was no documentation to demonstrate the license holder provided a written response within five days of the resident filing a grievance on the following dates: a. June 6, 2024; b. September 13, 2024; and c. December 3, 2024 Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must provide written responses to grievances within five days and meet all applicable requirements. 8. Violation: The license holder did not ensure that hazardous chemicals were adequately stored to ensure the residents right to live in safe surroundings was protected. During the physical plant tour, it was observed by a DHS licensor that a cleaning closet was left open, allowing access to chemicals. Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item H. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure youth do not have access to cleaning chemicals. Within 30 days receipt of this order, submit documentation demonstrating that staff have been retrained on job duties related to the safe storage of cleaning supplies. 9. Violation: The license holder did not provide the commissioner with timely access to resident files required to demonstrate compliance with applicable statutes and rules. The commissioner must be given access without prior notice and as often as the commissioner considers necessary if the commissioner is conducting a licensing inspection. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the commissioner’s right of access meets all applicable requirements. PERSONNEL FILES 10. Violation: One of eight personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 4). There was no documentation of the specific medication assistance training in the staff persons file. Correction Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation training meets all applicable requirements. 11. Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: a. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 3 through 5 and 8); b. Training to the following required topics was completed late: i. Vulnerable adults maltreatment reporting requirements and definitions for calendar year (CY) 2024 (personnel file numbered 8); ii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was not completed in CY 2024 or 2025 (personnel file numbered 8); iii. The maltreatment of minors reporting requirements and definitions was completed late in CY 2024 (personnel file numbered 8); and iv. HIV Minimum Standards Training was completed late for the CY 2024 (personnel file numbered 8). c. Training on the license holders program abuse prevention plan was not completed in CY 2024 or 2025 (personnel file numbered 8); Rule/Statute Violated: Minnesota Statutes, sections 245A. 19, paragraph (a), and 245A.65, subdivision 3; and Minnesota Rules, parts 2960.0080, subpart 14 and 2960.0100, subpart 3, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance for personnel files numbered 3 through 5 and 8. 12. Violation: Three of six personnel files reviewed for requirements governing individual staff development plans did not meet requirements (personnel files numbered 6 through 8). There was no documentation that the annual individual staff development plan was developed within 90 days after the person began employment. Rule Violated: Minnesota Rules, part 2960.0660, subpart 1, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff development plans meets all applicable requirements. RESIDENT FILES 13. Violation: Four of four resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 4, 5 and 7). The file did not contain documentation that the license holder completed an inventory of the resident’s personal property, including clothing, upon admission. Rule Violated: Minnesota Rules, part 2960.0070, subpart 4. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident file demonstrating compliance. 14. Violation: One of two resident files reviewed for requirements governing HIV training in substance use disorder treatment programs did not meet requirements (resident file numbered 2). Orientation to the HIV minimum standards was not completed within 72 hours of admission. Statute Violated: Minnesota Statute, section 245A.19 (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. 15. Violation: One resident file reviewed for requirements governing vulnerable adult orientation and the individual abuse prevention plan (resident file numbered 2) did not meet requirements in the following ways: a. There was no documentation to demonstrate that the resident was oriented to the program abuse prevention plan, policies and procedures governing maltreatment of a vulnerable adult and the internal and external reporting policies including the telephone number for MAARC; b. The individual abuse prevention plan did not assess the persons susceptibility to abuse by other vulnerable adults. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult orientation and individual abuse prevention plans meet all applicable requirements. 16. Violation: Two of three resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. The health screening did not address the residents history of abuse (resident file numbered 4); b. The mental health screening, the screening for sexually abusive behavior, and vulnerability assessment were completed late (resident file numbered 4); and c. There was no documentation that a health screening was completed (resident file numbered 7). Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items A and C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission screening meet all applicable requirements. 17. Violation: Four of four resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The individual treatment plan was not completed within 10 working days of admission (resident files numbered 1 and 2); b. The license holder did not document a description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident file numbered 7); c. There was no documentation in the youth’s file describing how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youth’s siblings (resident files numbered 1 and 7); and d. The program did not identify the treatment goals the resident must meet to have access to increased freedom of movement or be placed in a less restrictive appropriate treatment setting (resident file numbered 3). Rule/Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4 (h) and Minnesota Rules, parts 2960.0490, subpart 2, 2960.0620, subpart 1, item B, 2960.600 and 2960.0700, subpart 1, item B. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022 and November 12, 2024. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days receipt of this order, submit documentation of a treatment plan to demonstrate compliance. 18. Violation: One of two resident files reviewed for requirements governing service plan reviews did not meet requirements (resident file numbered 1). The plan review was not recorded in the six dimensions. Rule Violated: Minnesota Rules, part 2960.0490, subpart 5. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that service plan reviews meet all applicable requirements. Within 30 days receipt of this order, submit documentation of a service plan review to demonstrate compliance. 19. Violation: Three of three resident files reviewed for requirements governing health care services did not meet requirements. There was no documentation of the following: a. The license holder contacted a newly admitted resident’s prescribing medically licensed person to verify information regarding prescribed medication, including the symptoms that would warrant consultation with a physician (resident file numbered 4); b. The quantity of prescription drugs initially received from the pharmacy (resident files numbered 4 and 7); c. A resident’s refusal to take prescription medication (resident file numbered 7); and d. Prescription medicine belonging to a resident must be given to the resident's parent or legal guardian upon the resident's release or must be disposed of according to a pharmacy-approved plan. The license holder must note the disposition of the resident's medicine in the resident's file (resident files numbered 1 and 4). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D, E and F. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care services meet all applicable requirements. 20. Violation: Two of three resident files reviewed for requirements governing psychotropic medication did not meet requirements (resident files numbered 2 and 7). The license holder, under the direction of a medically licensed person, must document and check for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication or a significantly increased or decreased dose of a currently used psychotropic medication, and at least quarterly thereafter. There was no documentation on medication monitoring for the following weeks: a. March 16 through 22, 2024 (resident file numbered 2); b. October 13 through 19, 2024 (resident file numbered 7); c. October 20 through 26, 2025 (resident file numbered 7); d. January 5 through 11, 2025 (resident file numbered 7); and e. January 26 through February 1, 2025 (resident file numbered 7). Rule Violated: Minnesota Rules, part 2960.0620, subpart 2 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication meets all applicable requirements. 21. Violation: Three of three resident files reviewed for requirements governing informed consent did not meet requirements in the following ways: a. The information communicated in obtaining consent did not include: i. The diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed (resident file numbered 2); ii. The expected benefits of the medication, including the level to which the medication is to change the symptoms and behavior (resident files numbered 2 and 7); iii. The pharmacological treatment option available and the course of the condition with and without the treatment options (resident files numbered 2 and 7); b. There was no documentation that demonstrated that the resident was informed or involved in the decision making process. Rule Violated: Minnesota Rules, part 2960.0620, subparts 6 and 7, items A, B and C. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022 and June 8, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that informed consent meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident that demonstrates compliance. 22. Violation: Four of four resident files reviewed for requirements governing restrictive procedures did not meet requirements in the following ways: a. The license holder did not document the time of day that a physical escort took place on September 5, 2024 (resident file numbered 1); b. The license holder utilized a room that was not approved for seclusion on September 5, 2024 (resident file numbered 1); c. The staff person who implemented the emergency use of physical holding or seclusion did not document its use immediately after the procedure on December 30, 2024 (resident files numbered 4 and 5) and January 4 and 14, 2025 (resident file numbered 7); d. Documentation did not specify why less restrictive measures failed or were found to be inappropriate on September 5, 2024 (resident file numbered 1) and December 30, 2024 (resident file numbered 5); e. There was no documentation of the time the physical hold or seclusion began and the time the resident was released on September 5, 2024 (resident file numbered 1) and December 30, 2024 (resident file numbered 5); f. The license holder used a prone restraint on a resident on August 3, 2024 (resident file numbered 7); and g. The administrative review of the use of restrictive procedures was not completed within three working days on reviews dated December 30, 2024 (resident files numbered 4 and 5) and January 4 and 14, 2025 (resident file numbered 7). Rule/Statute Violated: Minnesota Statutes, section 245A.11, subdivision 3 and Minnesota Rules, part 2960.0710, subparts 5, 6 items L, M, and K and 10. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident that demonstrates compliance. 23. Violation: Four of four resident files reviewed for requirements governing discharge procedures did not meet requirements in the following ways: a. The files did not contain documentation to demonstrate the license holder returned the residents property to the resident upon discharge (resident files numbered 1 and 3 through 5); and b. There was no documentation that demonstrated that the license holder conferred with other interested persons to review issues involved with the decision to discharge a resident, prior to discharge (resident files numbered 4 and 5). Rule Violated: Minnesota Rules, part 2960.0090, subparts 2 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meets all applicable requirements. 24. Violation: Two of three resident files reviewed for requirements governing aftercare did not meet requirements (resident files numbered 4 and 5). There was no documentation that the license holder provided monthly aftercare services to the resident after discharge, for a period of six months. Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that aftercare services meets all applicable requirements. If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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 a corrective action ordered must be sent to DHS Licensing at: 1. By secure email to: maddy.moore@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Moore 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: Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Questions If you have any further questions regarding this matter, you may contact Maddy Moore, Senior Licensor, at 651-431-4585. Sincerely, Maddy Moore, Senior Licensor
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