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June 11, 2025 Stephen W. Williams, Authorized Agent Kadiri House 2907 Newton Avenue North Minneapolis, MN 55411 License Number: 1095378 CRF Investigation Report No.: 202410086 Dear Stephen W. Williams: On April 24, 2025, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of the citation in the Correction Order issued to you by the Department of Human Services on April 21, 2025.
Violation: The license holder utilized a restrictive procedure with a resident and the license holder was not certified to use restrictive procedures. An incident report dated November 20, 2024, documented that a staff person (SP1) utilized a restrictive procedure on resident (R1) by guiding R1 “to the ground.” Although documentation suggested the presence of imminent risk, the facility was not certified to utilize restrictive procedures, the license holder did not have a restrictive procedures plan approved by the commissioner, and staff persons were not trained on the use of physical holding. Request for Reconsideration. You submitted a letter in which you indicated SP1’s actions were intended to be a spontaneous emergency intervention to prevent imminent harm to R1 rather than a restrictive procedure. You indicated SP1 acted in good faith under the facility’s general crisis response policy, which authorizes emergency de-escalation techniques and emphasizes client safety. You also stated the program had no pattern of using restrictive procedures and there was no plan or policy that permitted unauthorized restraint, and SP1 was trained in de-escalation, emergency interventions and maintaining client safety. You acknowledged that SP1 had not yet completed the certification process specific to restrictive procedures under Minnesota Rules, part 2960.0080. Finally, you indicated immediate corrective action including additional training, policy review and implementation of additional safeguards was taken following the incident. You also noted that R1 had a known violent criminal history and had assaulted another staff member the previous day, and you noted that the program remains committed to providing safe, high-quality care to the residents. You referenced the incident report, updated training and policy documents, and an affidavit from a staff person, but those documents were not included with your reconsideration request.
Reconsideration Determination. Under Minnesota Rules, part 2960.0080, subpart 5, item E, the license holder must be certified to use restrictive procedures according to parts 2960.0710 to 2960.0750 before using a restrictive procedure wit a resident. Under Minnesota Rules, part 2960.0020, subpart 63, item A, “restrictive procedure” means: for a facility licensed by the commissioner of human services, a procedure used by the license holder to limit the movement of a resident, including mechanical restraint, physical escort, physical holding and seclusion. The incident report was reviewed and considered during the licensing investigation along with information about an additional incident involving R1. You acknowledged in the reconsideration request that the staff person had not yet completed the certification process specific to restrictive procedures, and the internal review indicates you acknowledged during the review that the program was not licensed for restrictive procedures. You also acknowledged during an interview with the DHS licensor that staff were not trained on restrictive procedures. You indicated in the reconsideration request that SP1’s intent was to prevent imminent harm rather than to implement a restrictive procedure. However, information obtained during the licensing investigation indicated that while R1 was escalated and aggressive during the incident, SP1 had the option to walk away. You acknowledged that SP1 grabbed and physically held him/her, thereby restricting R1’s movement. SP1’s actions therefore met the definition of a restrictive procedure under the applicable rule. Because the available information indicates a restrictive procedure was used when the license holder did not have certification to do so, there is sufficient evidence to support the citation. Disposition: The Commissioner has reviewed your request for reconsideration and all the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the citation, and it is affirmed. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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