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July 2, 2025 CERTIFIED MAIL Noor Yussuf, Authorized Agent Bestwood Agency LLC 1506 33RD AVE N Saint Cloud, MN 56303-1525 License Number: 1119102 (IRTS) ORDER OF LICENSE REVOCATION Dear Noor: The Department of Human Services (DHS) is revoking your license to provide at Bestwood Agency LLC, 1506 33rd Ave N, Saint Cloud, MN, 56303-1525. This revocation is based on your noncompliance with licensing laws and rules governing the provision of Intensive Residential Treatment Services (IRTS), and the Commissioner’s evaluation of the program. Details of our findings are also provided below. Our next steps and your options are also detailed. The revocation goes into effect on July 15, 2025, at 5:00 PM, to allow time for delivery of this order, and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. REASON FOR THE LICENSE REVOCATION 1. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of individuals served by your program, the qualifications of staff persons working in your program, and the ability to demonstrate competent knowledge of applicable laws and rules. DHS has determined that revocation of your license is appropriate based on the violations identified below and the program evaluation. DHS is concerned about the programs operation because since it was licensed in 2024, twenty-six licensing violations were determined in a June 2024 licensing review, and forty-seven violations were determined during the April 2025 licensing review. A significant portion of the violations determined pose risks to the health and safety of individuals served. An increase in the number of licensing violations and the determination of numerous repeat licensing violations demonstrates that you failed to adequately oversee your responsibilities as a License Holder and Compliance Officer to ensure compliance and maintain competent knowledge of applicable regulations. You lack the requisite knowledge of applicable statutes. While license holders providing Intensive Residential Treatment Services (IRTS) are required to maintain a treatment director who qualifies as a mental health professional to oversee treatment services for clients and treatment supervision for staff, your organization is structured in such a way that key positions, like the treatment director, report to you as the owner; in addition to you being the authorized agent and compliance officer. Throughout the licensing review, you ascribed the responsibility to ensure compliance with applicable requirements to individual staff persons other than yourself; when, as the owner of a program providing intensive services to individuals with serious and persistent mental illness, this is ultimately your responsibility. DHS is not confident in your ability to develop and maintain the competent knowledge required to ensure compliance with applicable statutes. Based on the Commissioner’s evaluation of the program, revocation is warranted. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. 2. Noncompliance with licensing laws and rules On April 21, 2025, through April 24, 2025, DHS licensors conducted a licensing review and investigation at your facility located at 1506 33rd Ave N, Saint Cloud, MN 56303. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed IRTS programs, citing 47 violations. The Commissioner has considered the nature, chronicity, or severity of the violation(s) of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a revocation order is appropriate. Nature and severity of licensing violations determined Many of the violations cited in the Order of Revocation are violations impacting the health, safety, or rights of individuals served by the program. The violations include: § Seven violations related to health services and medication administration were determined (violations numbered 1, 2, 11, 28, and 30 through 32), which could affect the health and safety of IRTS clients. Policies and procedures for administering, storing, and accounting for medications, and for medication orders, did not meet requirements. When you first received your license to provide IRTS, these policies were in compliance, but were subsequently revised. Clients were not adequately screened for health issues, and documentation did not demonstrate if appropriate monitoring and coordination of health needs and medical services was provided. Staff persons were not adequately trained to administer medications, and documentation of medication administration contained many errors. Failing to ensure clients receive medications accurately, by appropriately trained staff, could result in significant health implications by those who depend on the competent assistance of the license holder. These violations put the IRTS clients health at risk. § Three violations related to provider qualifications, scope of practice, and treatment supervision were determined (violations 14, 24, and 38). Staff providing intensive residential treatment services must be qualified to do so, and you failed to verify that staff were appropriately qualified. You allowed unqualified staff to provide treatment services and failed to ensure that a mental health professional provided staff with adequate treatment supervision. These violations are significant because IRTS clients have the right to receive appropriate mental health care. When basic staffing requirements are not met, your ability to ensure clients receive appropriate mental health care is in question. § One violation related to background study requirements was determined (violation numbered 3). Noncompliance with background study requirements is a serious violation and independent basis to revoke a license. Allowing an individual to work without a background study puts those served at risk of harm because DHS is not able to evaluate their criminal history. Further, the inability to submit a required background study calls into question the program’s ability to follow the applicable laws and rules; to be able to operate a program; and to ensure the well-being of clients served. § Four violations related to assessment of the client’s condition and needs were determined (violations numbered 7, 10, 19, and 22). Completion of the required assessments is a critical component of treatment, so that services provided are individualized to the client and address their specific needs. Violations were determined in all client files reviewed for diagnostic assessments, functional assessments, and substance use assessments. In addition, level of care assessments completed were finalized in a way that made it look like IRTS, an intensive service, was medically necessary, when smaller components of the assessment demonstrated it was not. It is significant that client file documentation contained false and misleading information in determining level of care required, and that basic assessments in a treatment program were missing so many required components. § Three violations related to the development and review of individual treatment plans were determined (violations numbered 4, 6, and 8). These violations were found in all client files reviewed. Intensive Residential Treatment Services (IRTS) is an intensive level of care for individuals with serious mental illness, and multiple individual treatment plans (ITP’s) did not have measurable treatment objectives. Updates to ITP’s were not made when clients were not engaging in or attending required treatment services, and you couldn’t demonstrate that ITP’s were reviewed weekly. § Two violations related to the provision and documentation of required treatment services were determined (violations 9 and 12). As an IRTS license holder, you are required and paid to provide intensive services. Client files failed to demonstrate that all required services were provided, and documentation did not identify the goals and objectives from the client’s ITP that the treatment service was intended to address, or what interventions staff persons provided. § Three violations related to staff orientation and training were determined (violations numbered 15, 16, and 23). These violations were found in all personnel files reviewed. IRTS clients are vulnerable adults who may not be able to report maltreatment and failing to ensure staff are trained on reporting maltreatment jeopardizes client safety. Additional risk to the health and safety of your clients is imposed when staff are not trained on emergency procedures, professional boundaries, and ways the program plans to reduce risks of abuse (program abuse prevention plan). § Eighteen violations related to maintaining compliant policies and procedures were determined (violations numbered 29 through 37, and 39 through 47). Multiple policies that were approved prior to issuing the license on January 17, 2024,were revised and no longer met requirements. Not being able to maintain compliance policies and procedures presents a significant safety risk, because policies and procedures direct staff how to operate the program. Noncompliant policies and procedures also demonstrate the license holder’s lack of competent knowledge related to Minnesota Statutes, chapters 245A, 245C and 245I. § One violation related to the electronic health records was determined (violation numbered 5). The license holder failed to ensure their electronic record keeping systems were secure and protected. Multiple client files, personnel files, and policies were deleted or lost. This is concerning regarding the rights of data privacy, along with storage of confidential information for both your staff and clients at the facility. Noncompliance with storage of data puts both clients and personnel at risk. Chronicity of licensing violations determined Your program received its license to provide Intensive Residential Treatment Services on January 16, 2024. An initial licensing review was conducted on June 24, 2024, through June 26, 2024, and determined 26 licensing violations. The licensing review conducted from April 21 through 24, 2025, determined a total of forty-seven violations, eighteen of which are repeat violations and were previously cited in a correction order dated August 19, 2024. This demonstrates a history of significant noncompliance with licensing rules and statutes in a short period of time. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1). Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of individuals served in your care, your license to provide Intensive Residential Treatment Services (IRTS) is revoked. LICENSING VIOLATIONS DETERMINED ON APRIL 21 – 24, 2025 DHS determined that your program did not follow licensing rules and statutes, as described below. 1. Violation: Seven of seven client files reviewed for medication administration did not meet requirements in the following ways: a. There was no documentation to demonstrate the license holder monitored the following (client files numbered 1 through 4 and 9): 1. The effectiveness of the client's medications; 2. The side effects of the client's medications; and 3. Adverse reactions the client had to their medications; b. The license holder did not document the following: 1. Medication errors, when there was no documentation in the medication administration record to indicate if the medication was given, refused, omitted, or another error occurred: i. For February 2025, 13 of 13 medications had undocumented medication errors for the dates of February 1, 5, 6, 8, 14, 15, 16, 21 – 23, and 25 – 28, 2025 (client file numbered 1) ii. For March 2025, 15 of 15 medications had undocumented medication errors for the dates of March 1, 2, 4 – 9, 13, 15 – 31, 2025 (client file numbered 1) iii. For February 2025, one medication had undocumented medication errors for the dates of February 6, 7, 9, 22 and 28, 2025 (client file numbered 2); iv. For March 2025, one medication had undocumented medication errors for the dates of March 2, 3, 8, 9, 12 and 19, 2025 (client file numbered 2); v. For December 2024, two out of two medications had undocumented medication errors for the dates of December 5 and 27, 2024 (client file numbered 4); vi. For December 2024, nine out of nine medications had undocumented medication errors for the dates of December 5 – 7, 10, 11, 14, 15, 20 – 22, 28 – 31, 2024 (client file numbered 7); vii. For January 2025, nine out of nine medications had undocumented medication errors for the dates of January 1 – 8, 10, 11, 14 – 18, 20 – 22, 24, 26, and 27, 2025 client file numbered 7); viii. For November 2024, six out of nine medications had undocumented medication errors for the dates of November 11, 21, 22, 25, 29 and 30, 2024 (client file numbered 11); ix. For January 2025, 11 out of 11 medications had undocumented medication errors for the dates of January 1 – 3, 6, 13, 14, 24 and 29, 2025 (client file numbered 11). Statute Violated: Minnesota Statutes, sections 245I.11, subdivision 5, clauses (1), (2), and (5), and 245I.08, subdivision 5 2. Violation: Six of six personnel files reviewed for requirements governing medication administration training did not meet requirements in the following ways: a. Documentation did not demonstrate the staff person received training on the following required topics prior to administering medications or observing a client self-administer medications: 1. Psychotropic medications (personnel files numbered 1 through 6); 2. Side effects (personnel files numbered 1 through 6); and 3. Medication management (personnel files numbered 1, 2, and 5); and b. Documentation did not demonstrate that medication administration training was provided by an accredited Minnesota postsecondary education institute or by a formalized training program taught by a registered nurse or licensed prescriber that is offered by the license holder (personnel files numbered 1, 2, 5 and 6). Statute Violated: Minnesota Statutes, section 245I.05, subdivision 5, paragraphs (a) and (b) 3. Violation: The license holder did not initiate a background study on one staff person (personnel file numbered 4) before they began a position allowing direct contact with individuals served by the program. The staff person (personnel file numbered 4) was hired and began working in a position allowing direct contact with persons served by the program on July 8, 2024; however, the license holder did not initiate a background study to DHS until August 25, 2024. You did not initiate background study requests on staff persons before they begin positions allowing direct contact with persons served by the program is a violation of background study requirements. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g) 4. Violation: Six of six client files reviewed did not meet the following individual treatment plan (ITP) requirements: a. The client file did not contain an ITP (client file numbered 5); b. The individual treatment plan was not completed within 10 days of admission, it was completed late (client file numbered 12); c. The ITP was not based on the client's diagnostic assessment and baseline measurements (client file numbered 3); d. The client did not approve the ITP (client files numbered 1 through 4, and 12); e. The individual treatment plan was not updated within 40 days of admission (client files numbered 1 and 2); f. The individual treatment plan was not updated within 70 days of admission (client file numbered 1); g. The ITP was not updated when client was struggling with group attendance, hygiene, lack of motivation, and negative social interactions (client file numbered 3); h. For an adult client, the license holder did not use a planning process that allows the client's family and other natural supports to observe and participate in the client's treatment services, assessments, and treatment planning (client files numbered 1 through 3, and 12): i. The ITP did not include the following: 1. The client's treatment goals (client file numbered 3); 2. Measurable treatment objectives (client files numbered 1 through 4, and 12); 3. A schedule for accomplishing goals and objectives (client files numbered 1, 2, 4, and 12); 4. The individuals responsible for providing treatment services and supports to the client (client files numbered 1 through 4, and 12); 5. Strategies to engage the client if they have a history of not engaging in treatment (client files numbered 3, 4, and 12); and 6. Strategies to engage the client if they are court ordered to participate in treatment services (client file numbered 3). j. The ITP did not identify that the client or other participants were involved in the clients treatment planning (client files numbered 1 through 4, and 12); and k. The ITP did not document the reason that the license holder did not involve the client's family or other natural supports (client files numbered 1 through 4, and 12). Statute Violated: Minnesota Statutes, sections 245I.10, subdivision 8, paragraph (a); and 245I.23, subdivision 7, paragraph (f) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 5. Violation: The license holder's use of electronic record keeping did not meet requirements: a. Electronic records were not maintained in a form capable of being retained and accurately reproduced; b. Through staff interviews during the on-site licensing review, DHS received information indicating staff persons were able to delete electronic records and templates. There were no protections enabled in the electronic record keeping system and the security of the records were compromised; and c. Personnel files were not readily accessible for the commissioner's review. The license holder did not maintain personnel files for each staff person (personnel files numbered 1 through 4, 6 and 7). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 4; 245I.09, subdivision 1, paragraph (a); and 245I.07, subdivision (b) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 6. Violation: Four of four client files reviewed for the initial treatment plan did not meet requirements in the following ways: a. The client file did not contain an initial treatment plan (client file numbered 5); b. The plan was not completed within 24 hours of admission (client file numbered 1); c. The plan did not consider crisis assistance strategies that have been effective for the client in the past (client files numbered 1, 2, and 12); and d. The initial treatment plan did not identify the following required components: 1. Measurable treatment objectives (client files numbered 2 and 12); and 2. Participants involved in the client's treatment planning (client files numbered 1, 2, and 12). Statute Violated: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (b) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 7. Violation: Five of six client files reviewed did not meet level of care assessment requirements in the following ways: a. The level of care assessment determined that the client did not meet a medically monitored level of service and the treatment supervisor did not document how the client's admission (client files numbered 2 and 3) and continued treatment (client file numbered 2) was medically necessary; b. The assessment was not completed within five days of admission (client file numbered 10); c. The assessment was not updated within 60 days of admission (client files numbered 1 and 2); and d. The level of care assessment, completed by a mental health practitioner, was not approved by the treatment supervisor within ten business days of completion (client files numbered 2 through 4). Statute Violated: Minnesota Statutes, sections 245I.23, subdivision 7, paragraph (d); and 245I.08, subdivision 3 Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 8. Violation: Three of three client files reviewed for requirements governing weekly reviews did not meet requirements. The client file did not contain documentation demonstrating the treatment plan or the individual abuse prevention plan was reviewed weekly, for all weeks the client was at the program (client files numbered 1, 2, and 4). Statute Violated: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (i) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 9. Violation: Four of four client files reviewed did not meet requirements for required treatment services. The license holder’s documentation template listed all possible treatment services for the writer to choose from. Documentation of treatment services did not identify a specific treatment service that was provided, so there was no way for DHS to verify that the following required treatment services were provided throughout the clients treatment episode: a. Co-occurring substance use disorder treatment (client files numbered 4 and 10); and b. Illness Management and Recovery (IMR) or Enhanced Illness Management and Recovery (E- IMR) (client files numbered 4, 10 and 12). Statute Violated: Minnesota Statutes, section 245I.23, subdivision 4, paragraph (b) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 10. Violation: Six of six client files reviewed did not meet standard diagnostic assessment (DA) requirements in the following ways: a. The file did not contain a DA (client file numbered 5); b. The DA was not completed within 10 days of admission (client file numbered 4) c. The DA did not identify recommended mental health services to develop the client's mental health services and treatment plan (client file numbered 2); d. The assessor did not consult with the client's family about which services they prefer when completing the DA (client files numbered 1 through 4, and 10); e. The DA did not include the required information about the client's current life situation: 1. The client's current living situation, including the client's housing status and household members (client file numbered 4); 2. The status of the client's basic needs (client files numbered 1, 2, and 4); 3. The client's employment status (client files numbered 3 and 10); 4. The client's current medications (client files numbered 1 through 4); 5. Any immediate risks to the client's health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotional symptoms (client files numbered 2 and 4); 6. The client's perception of their condition (client file numbered 3); 7. The client's history of substance use disorder treatment (client file numbered 4); and 8. Substance use history, if applicable, including: i. Amounts and types of substances (client files numbered 1, 3, and 4); ii. Frequency and duration of use (client files numbered 1, 3 and 4); iii. Route of administration (client file numbered 4); iv. Periods of abstinence and circumstances of relapse (client files numbered 3, 4 and 10); and v. The impact to functioning when under the influence of substances, including legal interventions (client files numbered 1, 3, 4 and 10); f. The DA did not document information related to the following required topics: 1. The client's relationship with family and other significant personal relationships, including the client's evaluation of the quality of each relationship (client file numbered 3); 2. The client's strengths and resources, including the extent and quality of the client's social networks (client files numbered 1 through 4); 3. Maltreatment, trauma, potential brain injuries, and abuse that the client has suffered (client files numbered 1 and 4); 4. The client's history of or exposure to alcohol and drug usage (client file numbered 2) or treatment (client file numbered 4); 5. The client's physical health history (client files numbered 3 and 10) and family health history (client file numbered 10); and g. The DA did not include the following required components of the assessment: 1. The client's mental status examination (client file numbered 4); 2. The client's baseline measurements (client files numbered 2 and 4); 3. The client's behavior (client file numbered 1); 4. The client's skills and abilities (client files numbered 1 through 4, and 10); 5. The client's resources (client files numbered 1 through 4); 6. The client's vulnerabilities (client files numbered 2, 4, and 10); 7. The client's safety needs (client files numbered 2 and 4); and 8. An explanation of: i. How the assessor diagnosed the client using the information from the client's interview, assessment, psychological testing, and collateral information about the client (client file numbered 4); ii. The client's needs and risk factors (client file numbered 2); iii. The client's strengths (client files numbered 1 through 3); and iv. The client’s responsivity factors (client files numbered 1, 2 and 10). Statute Violated: Minnesota Statutes, section 245I.10, subdivisions 2, paragraph (g); 4; and 6, paragraphs (b) through (e) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 11. Violation: Four of seven client files reviewed did not meet health services requirements in the following ways: a. The client was not screened for health issues within 72 hours of admission (client files numbered 1 through 3); b. There was no documentation to demonstrate the license holder monitored the physical health needs of the client on an ongoing basis (client files numbered 3 and 4); and c. There was no documentation to demonstrate the license holder coordinated the client's psychiatric (client files numbered 2 and 3) or medical services (client file numbered 3). Statute Violated: Minnesota Statutes, section 245I.11, subdivision 2 12. Violation: Four of four client files reviewed did not meet progress note requirements. The progress note did not include the following required components: a. Documentation of the scope of the service, including the following required components: 1. The targeted goal and objective; i. For all progress notes dated December 19 – 25, 2024, and January 16 – 22, 2025 (client file numbered 1); ii. For all progress notes dated February 13 – 19, 2025, and March 20 – 26, 2025 (client file numbered 2); iii. For all progress notes dated February 21, 22 – 25, 26, 2025; and March 3 – 6, 10 – 21 (client file numbered 3); iv. For all progress notes dated December 4, 2024, to January 7, 2025 (client file numbered 4); 2. The intervention the staff provided to the client; i. For all progress notes dated December 19 – 25, 2024, and January 16 – 22, 2025 (client file numbered 1); ii. For all progress notes dated from February 13 – 19, and March 20 – 26, 2025 (client file numbered 2); iii. For all progress notes dated February 21 – 26, and March 3 – 6, and 10 – 21, 2025 (client file numbered 3); iv. For all progress notes dated December 4, 2024, through January 7, 2025 (client file numbered 4); 3. The methods the staff person used; i. For progress notes dated February 22 – 24, and March 11, and 15 – 18, 2025 (client file numbered 3); 4. The client's response to the intervention; i. For all progress notes dated December 19 – 25, 2024, and January 16 – 22, 2025 (client file numbered 1); ii. For all progress notes dated February 13 – 19, and March 20 – 26, 2025 (client file numbered 2); iii. For all progress notes dated February 21 – 22, 24 – 25, 27, and March 3 – 6, and 10 – 22, 2025 (client file numbered 3) iv. For all progress notes dated December 4, 2024, through January 7, 2025 (client file numbered 4); 5. The staff person's plan to take future actions, including changes in treatment that the staff person will implement if the intervention was ineffective; i. For all progress notes dated February 13 – 19, and March 20 – 26, 2025 (client file numbered 2); ii. For all progress notes dated February 21, 22, 24, 25, 27, and March 3 – 6, and 10 – 22, 2025 (client file numbered 3); and iii. For all progress notes dated December 4, 2024, through January 7, 2025 (client file numbered 4).
Statute Violated: Minnesota Statutes, section 245I.08, subdivision 4 Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 13. Violation: For two of seven personnel files reviewed, the license holder failed to verify that the information collected about a person was correct before initiating a background study request to DHS (personnel files numbered 1 and 5). Statute Violated: Minnesota Statutes, section 245C.05, subdivision 1 14. Violation: Seven of seven personnel files reviewed for requirements governing provider qualifications and scope of practice did not meet requirements in the following ways: a. The license holder failed to ensure that staff persons providing services within a mental health practitioners scope of practice were qualified (personnel files numbered 2 through 6)). During the onsite licensing review, DHS Licensors received information that the identified staff persons provided rehabilitation group, IMR group, crisis prevention planning, and health service(s). b. Mental health practitioner requirements were not met in the following ways: 1. The personnel file included documentation demonstrating the staff person did not meet the qualifications of a mental health practitioner (personnel file numbered 2); 2. The personnel file did not include verification of the staff person’s qualifications for the position (personnel files numbered 3 and 6); 3. There was no documentation to demonstrate the staff person received the additional 30 hours of training described in section 245I.05, subdivision 3, which was required for the staff person to qualify as a mental health practitioner (personnel file numbered 4); 4. A personnel file was not maintained for the staff person, and the license holder was unable to demonstrate they qualified as a mental health practitioner during the onsite licensing review (personnel file numbered 5); c. The personnel file did not contain a description of the staff person’s job responsibilities (personnel files numbered 1 and 3 through 6); and d. The personnel file did not contain verification of the staff person’s license renewals completed during their employment (personnel file numbered 7). Statute Violated: Minnesota Statutes, sections 245I.04, subdivision 5, paragraph (b), and 245I.07, paragraph (a). 15. Violation: Five of five personnel files reviewed for requirements governing initial training did not meet requirements in the following ways: a. Documentation did not demonstrate the staff person was oriented to the following required topics, prior to providing direct contact services: 1. Client rights and protections under section 245I.12 (personnel files numbered 1 and 3 through 6); 2. The Minnesota Health Records Act, including client confidentiality, family engagement under section 144.294, and client privacy (personnel files numbered 1 and 3 through 6); 3. Emergency procedures, including fire and inclement weather, reporting missing persons, and behavioral and medical emergencies (personnel files numbered 1 and 3 through 6); 4. Specific activities and job functions for which the staff person is responsible (personnel files numbered 1 and 3 through 6); 5. The license holder's program policies and procedures applicable to the staff person's position (personnel files numbered 1 and 3 through 6); 6. Professional boundaries that the staff person must maintain (personnel files numbered 1 and 3 through 6); and 7. Specific needs of each client to whom the staff person will be providing direct contact services (personnel files numbered 1, 4 and 5); b. Documentation did not demonstrate the staff person received the following required orientation within 72 hours of providing direct contact services: 1. Vulnerable adult maltreatment reporting requirements (personnel file numbered 5); 2. The program abuse prevention plan (personnel files numbered 4 and 5); 3. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 5); and 4. Maltreatment of minor reporting requirements and definitions in chapter 260E (personnel file numbered 5); c. Documentation did not demonstrate the staff person was trained on administering emergency overdose treatment (personnel files numbered 4 through 6); and d. Documentation did not demonstrate the staff person received training to the following required topics within 90 days of first providing direct contact services to an adult client: 1. Trauma-informed care and secondary trauma (personnel files numbered 4 through 6); 2. Person-centered individual treatment plans, including seeking partnerships with family and other natural supports (personnel files numbered 3 through 6); 3. Co-occurring substance use disorders (personnel files numbered 4 through 6); and 4. Culturally responsive treatment practices (personnel files numbered 3 through 6). Statute Violated: Minnesota Statutes, section 245I.05, subdivision 3, paragraphs (a) and (c) 16. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements. Documentation did not demonstrate the staff person received annual training on the following required topics, for calendar year 2025: a. Vulnerable adult maltreatment reporting requirements (personnel files numbered 2 and 9); b. The license holder's program abuse prevention plan (personnel files numbered 2 and 9); c. The maltreatment of minor reporting requirements and definitions in chapter 260E (personnel files numbered 2 and 9); d. Client rights and protections under section 245I.12 (personnel files numbered 2, 7 and 9); e. Minnesota Health Records Act training (personnel files numbered 2, 7 and 9), including: 1. Client confidentiality; 2. Family engagement under section Minnesota Statutes, section 144.294; and 3. Client privacy; f. Emergency procedures (personnel files numbered 2, 7 and 9), including: 1. Fire and inclement weather; 2. Responding to a report of a missing person; 3. Behavioral emergencies; and 4. Medical emergencies. Statute Violated: Minnesota Statutes, section 245I.05, subdivision 4, paragraph (a) 17. Violation: Four of four client files reviewed did not meet requirements when the license holder assisted the client with the safekeeping of funds or other property: a. There was no documentation to demonstrate the client was given their medications upon discharge (client file numbered 2); and b. There was no documentation to demonstrate the receipt or disbursement of funds or other property (client files numbered 3, 4 and 8). Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c) 18. Violation: Two of three client files reviewed did not meet individual abuse prevention plan (IAPP) requirements: a. The client file of a vulnerable adult did not contain an IAPP (client file numbered 5); and b. The assessment of the client’s risk of self-abuse did not include their history of elopement. The client eloped during their first treatment episode at the program, and this was not identified in their IAPP for their second treatment episode (client file numbered 13). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2 19. Violation: Three of three client files reviewed for requirements governing the substance use assessment did not meet requirements in the following ways: a. The client file did not include a substance use assessment (client file numbered 4); b. The substance use assessment was not completed within 30 days of admission (client files numbered 1 and 3); and c. The substance use assessment did not include the following (client file numbered 1): 1. An evaluation of the client's non-compliance with taking prescribed medications and with psychosocial treatment; 2. An assessment of the effects of the client's substance use on the client's relationships including with family members and others; and 3. Identified financial problems. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (h) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 20. Violation: Four of five client files reviewed did not meet discharge requirements in the following ways: a. The discharge summary was not completed (client file numbered 6); b. The discharge summary was not completed prior to a successful discharge (client file numbered 1); c. There was no documentation to demonstrate the client was provided a copy of the discharge summary (client files numbered 1, 2 and 12); d. For a successful discharge, the summary did not contain: 1. The client's response to their treatment plan (client file numbered 1); 2. The goals and objectives that the license holder recommends that the client addresses during the first three months after discharge (client file numbered 1); and 3. The client's crisis plan (client files numbered 1 and 2). e. For a program-initiated discharge, the summary did not contain (client file numbered 12): 1. The names of the individuals involved in the decision to discharge the client; and 2. A description of each individual's involvement in the decision to discharge the client; 3. Documentation to demonstrate the license holder consulted with the client, the client's family and other natural supports, and the client's case manager, if applicable, to review the issues involved in the program's decision to discharge the client from the program; 4. Documentation of the client's discharge review; and 5. A documented determination of whether the license holder, treatment team, and any interested persons can develop additional strategies to resolve the issues leading to the client's discharge and to permit the client to have an opportunity to continue receiving services from the license holder. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 18, paragraphs (a), (c), (g) and (h) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 21. Violation: Six of six client files reviewed did not meet requirements for giving clients notice of their rights in the following ways: a. The copy of the client rights given to the client on the day of admission were incorrect; they were the rights from an expired IRTS variance (client files numbered 1 through 5, and 12); and b. Documentation did not demonstrate the license holder explained the grievance procedure to the client (client files numbered 1, 5 and 12). Statute Violated: Minnesota Statutes, section 245I.12, subdivisions 3 and 5, paragraph (b) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 22. Violation: Four of four client files reviewed did not meet functional assessment requirements in the following ways: a. The functional assessment was not completed within 30 days of admission (client file numbered 2); b. Documentation did not identify the reasons that the license holder did not contact the client's family or other natural supports when conducting the functional assessment (client files numbered 1, 3 and 4); and c. The functional assessment was not updated within 60 days of admission (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245I.23, subdivision 7, paragraph (g); and 245I.10, subdivision 9, paragraph (a) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 23. Violation: Six of six personnel files reviewed for training documentation did not meet requirements. Documentation of training did not include the following required components: a. The topics of the training (personnel file numbered 5); b. The name of the trainee (personnel files numbered 5 and 6); c. The name and credentials of the trainer (personnel files numbered 1 and 3 through 7); d. The license holder's method of evaluating the trainee's competency upon completion of training (personnel files numbered 1 and 3 through 7); e. The date of the training (personnel files numbered 1 and 3 through 7); and f. The length of training in hours and minutes (personnel files numbered 1 and 4 through 7). Statute Violated: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 24. Violation: Five of five personnel files reviewed for treatment supervision plans did not meet requirements in the following ways: a. A written treatment supervision plan was not developed (personnel file numbered 3); b. The treatment supervision plan was not developed within 30 days of the staff person's first day of employment (personnel files numbered 4 through 6); c. The treatment supervision plan was not updated at least annually, for calendar year 2025 (personnel file numbered 7); d. The staff person's treatment supervision plan did not include the following required components: 1. The qualifications of the staff person receiving treatment supervision (personnel files numbered 4 through 6); 2. How frequently the treatment supervisors must provide treatment supervision to the staff person (personnel files numbered 4 through 6); 3. The staff person's authorized scope of practice (personnel files numbered 4 and 5); 4. A description of the client population that the staff person serves (personnel files numbered 4, 5 and 7); and 5. A description of the treatment methods and modalities that the staff person may use to provide services to clients (personnel files numbered 4, 5 and 7). Statute Violated: Minnesota Statutes, section 245I.06, subdivision 2, paragraph (a) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 25. Violation: Three of five client files reviewed did not meet requirements for orienting clients to vulnerable adult maltreatment reporting policies and procedures in the following ways: a. The client was not oriented to the program abuse prevention plan (PAPP) (client file numbered 5); and b. The client's orientation to the internal and external maltreatment reporting procedures was not completed within the required time frame (client files numbered 1, 4 and 5). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3 Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 26. Violation: One of seven client files reviewed did not meet requirements for daily documentation (client file numbered 1). The client file did not include a daily summary for each day the client was present in the program, for 12/24/2024.
Statute Violated: Minnesota Statutes, section 245I.23, subdivision 12, paragraph (a) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 27. Violation: Two of five client files reviewed for the immediate needs assessment did not meet requirements in the following ways: a. The file did not contain an immediate needs assessment (client file numbered 5); and b. Documentation did not identify whether the assessment included an evaluation of the client's immediate needs related to their responsibilities for employers (client file numbered 1). Statute Violated: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (a) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 28. Violation: One of five client files reviewed did not meet requirements for assessing the client's ability to self-administer medication (client file numbered 4). The file did not contain an assessment of the client’s ability to self-administer medication. Statute Violated: Minnesota Statutes, section 245I.11, subdivision 5, clause (1) Repeat Violation: In a Correction Order that DHS issued on August 19, 2024, you were previously found in violation of this same statute. 29. Violation: The license holder did not establish policies and procedures allowing, but not mandating, the internal reporting of alleged or suspected maltreatment of a vulnerable adult. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a) 30. Violation: The license holder's procedure for storing and accounting for medication did not include the following requirements: a. A method that ensures only authorized staff persons have access to stored client medications; b. A method that allows a client who self-administers medications to keep a private medication supply; and c. Prescription medications stored by the client include a prescriptions label that includes the client's name. Statute Violated: Minnesota Statutes, section 245I.11, subdivision 3, paragraphs (a) and (b) 31. Violation: The license holder's medication administration procedures did not include the following required components: a. Assessing the client's ability to self-administer medication including an evaluation of the client's ability to: 1. Comply with prescribed medication regimens; and 2. Store medications safely and in a manner that protects other individuals in the facility. b. Assisting the client to develop the skills necessary to safely self-administer medication; c. Monitoring the effectiveness of medications; d. Monitoring side-effects of medication; e. Monitoring adverse reactions to medications; f. Ensuring that no staff person gives a legend drug supply for one client to another client; g. Maintaining a record of incidents of deferring a client's medication; h. Documenting any incident when a client's medication is omitted; and i. Documenting and tracking medication errors including: 1. Documenting whether the license holder must notify anyone about the medication error; 2. Determining if the license holder must take any follow-up actions; and 3. Identifying the staff persons responsible for taking follow-up actions. Statute Violated: Minnesota Statutes, section 245I.11, subdivision 5, clauses (1) through (5) 32. Violation: The license holder's procedure for medication orders did not include the following: a. All orders to accept, administer, or discontinue client medications are written by a licensed prescriber; and b. How the program will maintain the client's right to privacy and dignity. Statute Violated: Minnesota Statutes, section 245I.11, subdivision 4, paragraph (a) 33. Violation: The license holder did not maintain a policy or procedure for receiving referrals and making admissions determinations. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 22, paragraph (b) 34. Violation: The license holder did not maintain the following required policies or procedures: a. Policies and procedures for reporting suspected maltreatment, abuse, or neglect of a client according to section 626.557; b. Policies and procedures allowing, but not mandating, the internal reporting of alleged or suspected maltreatment of a vulnerable adult; c. Policies and procedures for reporting a staff person's suspected maltreatment, abuse, or neglect of a client according to chapter 260E. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (a), and 245I.03, subdivisions 6 and 8 35. Violation: The license holder's policies and procedures did not meet requirements. The policy manual did not identify the date(s) policies or procedures were initiated or revised. Statute Violated: Minnesota Statutes, section 245I.03, subdivision 1 36. Violation: The license holder's review of their quality assurance and improvement plan did not meet requirements. The license holder did not review, evaluate and update the quality assurance and improvement plan at least annually, for calendar year 2024. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 23, paragraph (b) 37. Violation: The license holder's plan for transfer of clients and records upon closure did not meet requirements in the following ways: a. The plans for the transfer of closed case records did not include a signed agreement or other documentation indicating that a county or similarly licensed provider has agreed to accept and maintain the program's closed case records and to provide follow up services as necessary to affected clients. b. There was no documentation to identify a controlling individual reviewed and signed the plan for transfer of clients and records upon closure annually; the plan was signed late. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraphs (a) and (c) 38. Violation: The license holder’s provision of treatment supervision did not meet requirements. Information received during the onsite licensing review indicated that treatment supervision did not address the following topics related to the staff person's current caseload: a. A review and evaluation of each client's assessments for accuracy and appropriateness; b. A review and evaluation of each client's treatment plan for accuracy and appropriateness; and c. A review and evaluation of each client's progress notes for accuracy and appropriateness. Statute Violated: Minnesota Statutes, section 245I.06, subdivision 1, paragraph (b) 39. Violation: The license holder's training plan did not include a description of how the license holder will determine when a staff person needs additional training, including when the license holder will provide additional training. Statute Violated: Minnesota Statutes, section 245I.05, subdivision 1, clause (4) 40. Violation: The license holder's personnel policies did not meet requirements. The position descriptions did not include the following required components: a. The staff person's responsibilities; b. The staff person's authority to execute the responsibilities; and c. Qualifications for the position. Statute Violated: Minnesota Statutes, section 245I.03, subdivision 8 41. Violation: The program abuse prevention plan did not meet requirements. The plan did not identify factors which may encourage or permit abuse. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) 42. Violation: The license holder's behavioral emergency procedures did not meet requirements in the following ways: a. The behavioral emergency procedure did not include the following required components: 1. Contact information for emergency resources that staff must consult when a client's behavior cannot be controlled by the behavioral emergency procedures; and 2. Staff members authorized to implement emergency procedures. b. The behavioral emergency procedure did not describe the following restrictions: 1. Behavioral emergency procedures must not include secluding or restraining a client; 2. Staff persons must not use behavioral emergency procedures to enforce program rules; 3. Behavioral emergency procedures must not be used for the convenience of staff persons; and 4. Behavioral emergency procedures must not be part of any client's treatment plan. Statute Violated: Minnesota Statutes, section 245I.03, subdivision 4, paragraph (a) 43. Violation: The license holder's health services policies and procedures did not meet requirements. The license holder did not have procedures outlining circumstances in which staff must obtain medical care for a client. Statute Violated: Minnesota Statutes, section 245I.11, subdivision 2 44. Violation: The license holder's discharge policies and procedures did not meet requirements. The staff person(s) authorized to discharge clients from the program were not identified. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 18, paragraph (a) 45. Violation: The license holder's critical incident policy did not include that crucial incidents must be reported on a form approved by the commissioner. Statute Violated: Minnesota Statutes, section 245I.13 46. Violation: The license holder's quality assurance and improvement plan did not meet requirements. The plan did not include methods to obtain and evaluate feedback about services from referral sources. Statute Violated: Minnesota Statutes, section 245I.23, subdivision 23, paragraph (a) 47. Violation: The license holder's personnel policies did not include an organizational chart that indicates positions and lines of authority. Statute Violated: Minnesota Statutes, section 245I.03, subdivision 8, clause (1) YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: 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 10 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 Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must comply with the conditions described below. If you do not follow a law or rule that may impact the health or safety of individuals served by your program could result in the immediate suspension of your license. If you continue to operate pending the outcome of your appeal, you must comply with the following conditions: 1. While operating pending appeal, you cannot apply for or be issued an additional DHS License; 2. Within 14 days of filing an appeal, you must notify current clients and all parties who refer individuals to your program of the status of your license: revoked operating under appeal. While operating pending appeal, you must notify new clients and referral sources that the license is revoked and operating under appeal before they begin receiving services. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file.
3. Within 14 days of filing an appeal within the timeframes described above, you must submit a proposal to DHS for approval that describes how staff will be trained to provide enhanced Illness Management and Recovery (E-IMR). The plan must include the instructor, the instructor’s qualifications, the curriculum, the dates and time of training, and how staff persons competency to provide E-IMR will be assessed. Following DHS approval of your proposal, all staff persons providing E-IMR as well as the Authorized Agent, Compliance Officer, Treatment Director, Program Director and Registered Nurse must complete E-IMR training. Documentation must be submitted to your DHS Licensor to demonstrate compliance with this term. During the time period between when you filed an appeal and when all staff persons completed E-IMR training, new clients cannot be admitted to your program. 4. Within 14 days of filing an appeal, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of owner, treatment director or authorized agent. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. Two years of professional experience in the following: 1) A regulatory or compliance position; 2) Involved in direct care as a providing mental health services, or 3) If applicable, the development and implementation of mental health or substance use disorder treatment planning in a DHS licensed mental health or substance use disorder licensed program. b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and MN Statutes, Chapter 2451, Uniform Service Standards; and c. A bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field. 5. Within 30 days of compliance officer approval, you must implement DHS Licensing’s self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapter 245A and 245I. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the appeal or otherwise determined by DHS licensing. 6. While operating pending appeal, or as otherwise determined by DHS licensing, you must submit the following documentation regarding admissions and level of care assessments on a monthly basis: a. Documentation demonstrating how any newly admitted clients meet all required admission criteria, including all corroborating documentation; b. Documentation of all level of care assessments completed. You must complete level of care assessments for each client every thirty days. 7. Within 14 days of filing an appeal within the timeframes described above, you must submit a revised treatment services description and schedule. Upon request, you must submit documentation demonstration the provision of treatment services to your DHS licensor. 8. Within 30 days of filing an appeal within the timeframes described above, you must submit documentation to demonstrate all violations identified above have been corrected. This includes verification of staff training, revising noncompliant policies and procedures, etc. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. · The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). · “Controlling individual” is defined under Minnesota Statutes, section 245A.02, subdivision 5a. · License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. · If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. · Under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (b), the commissioner may include terms the license holder must follow pending a final order on appeal. Questions If you have any further questions regarding this matter, you may contact Katie Leuer, Supervisor, at 651-431-6259. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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