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July 7, 2025 Stephen Williams, Authorized Agent Kadiri House 2131 N 6th St., STE 2 Minneapolis, MN 55411 License Number: 1095378 (CRF) Report Number: 202503071, 202503256, 202503334, 202503418, 202503461 CORRECTION ORDER Dear Stephen: On 5/13/2025 to 5/15/2025 a Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Kadiri House located at 2131 N 6th St., STE 2, Minneapolis, MN 55411. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, and children’s group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220. 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. Personnel 1. Violation: One of two personnel files reviewed for requirements governing orientation training (personnel file numbered 4) did not meet requirements. Documentation did not show that orientation to data practices regulations and issues was provided. Rule Violated: Minnesota Rules, part 2960.0100, subpart 3, Item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation for requirements governing orientation training. 2. Violation: Four of four personnel files reviewed for requirements governing documentation of training (personnel file numbered 1, 2, 3, and 4) did not meet requirements. Documentation of training did not include the entity that provided the training. Rule Violated: Minnesota Rules, part 2960.0100, subpart 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of orientation and ongoing training meets requirements. Within 30 days receipt of this correction order, submit training documentation that demonstrates compliance. Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same Rule. 3. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet requirements in the following way: I. Training on the program abuse prevention plan was completed late for the calendar year of 2024 (personnel file numbered 1) and was not completed for the calendar year of 2024 (personnel file numbered 2) and; II. The emergency plan was not reviewed at least once every six months for the calendar year 2024 (personnel file numbered 1) and was not completed for the calendar year 2024 and 2025 up to the time of the review (personnel file numbered 2). Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, part 2960.0080, subpart 14. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation for requirements governing ongoing training. Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same statute and rule. Residents 4. Violation: One of three resident files reviewed for requirements governing admission screenings did not meet requirements. The screening determined the resident was likely to have sexually abusive behaviors and there was no documentation to demonstrate a risk management plan was developed (resident file numbered 5). 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 the provision and documentation for requirements governing admission screenings. Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same rule. 5. Violation: Two of two resident files reviewed for requirements governing no-eject discharges did not meet requirements in the following ways: There was no documentation for a resident who did not reach their case plan goals to show that requirements were met, in the following way: I. There was no documentation to demonstrate the license holder conferred with other interested persons to review the issues involved in the decision (resident file numbered 4) and; II. There was no documentation to demonstrate the license holder determined whether the treatment team and the resident could develop additional strategies to resolve the issues leading discharge (resident files numbered 3 and 4); III. Documentation did not identify the reasons for the discharge and alternatives considered or attempted (resident file numbered 3 and 4). Rule Violated: Minnesota Rules, part 2960.0090, subpart 2. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the provision and documentation for requirements governing discharge and aftercare. Within 30 days receipt of this correction order, submit documentation of a no-eject discharge that demonstrates compliance. 6. Violation: Two of two resident files reviewed for requirements governing transition services plans did not meet requirements. Documentation did not indicate that a copy of the plan was given to the resident, or any subsequent treatment providers (resident file numbered 1 and 2). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, Item A. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the provision and documentation for requirements governing transition services plan. Within 30 days receipt of this correction order, submit a transition services plan that demonstrates compliance. Repeat Violation: In a Correction Order that DHS issued on June 16, 2023, you were previously found in violation of this same rule. 7. Violation: Two of two resident files reviewed for requirements governing discharge documentation did not meet requirements in the following ways: I. Documentation did not show how the facility met the goals and objectives identified in the treatment plan (resident file numbered 1) and; II. Discharge documentation was not completed (resident file numbered 2). Rule Violated: Minnesota Rules, part 2960.0140, subpart 2. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the documentation for requirements governing discharge. Within 30 days receipt of this correction order, submit discharge documentation for one resident that demonstrates compliance. 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. Submissions required as part of the corrective action ordered must be sent to your licensor by email at elissa.olson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: LICENSOR 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: 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 651-431-6276 or at elissa.olson@state.mn.us. Sincerely, Elissa Olson, Senior Licensor MH/SUC/CRF Licensing Division Office of Inspector General
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