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August 25, 2025 Heidi Seaton, Authorized Agent North Homes, Inc 303 SE 1st St Grand rapids, MN, 55744 License Numbers: 1010657 (CRF – Itaskin Treatment Center) 1047010 (CRF – North Homes Cottage) CORRECTION ORDER Dear Heidi Seaton: On June 9 through 12, 2025, DHS licensors conducted a licensing review of Itaskin Treatment Center, located at 1880 River Rd, Grand Rapids, MN, 55744, and North Homes Cottage, located at 1920 SE River Rd, Grand Rapids, MN, 55744. This review was conducted to determine compliance with state and federal laws governing children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0220, shelter care services for children under Minnesota Rules, part 2960.0510 through 2960.0530, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, restrictive techniques standards under Minnesota Rules, part 2960.0710, and qualified residential treatment programs under Minnesota Statutes, section 245A.25. 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. Throughout this order, the licensed programs will be referenced as follows: · Itaskin Treatment Center (ITC); · North Homes Cottage (NHC); and · When citations are specific to both licensed programs (ALL). Procedures 1. Violation: The license holder’s grievance procedure did not meet requirements (ALL). The procedure did not require that a person filing a grievance would receive a response within five days. The procedure included multiple steps by which a grievance would be reviewed, and the first step did not include a timeframe. Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedure meets all applicable requirements. Within 30 days receipt of this order, submit a revised grievance procedure that demonstrates compliance. Practices 2. Violation: The license holder’s program evaluation for 2023 and 2024 did not meet requirements in the following ways (ALL): a. The evaluation of strengths and weaknesses did not include the following required performance indicators: i. Accidents; and ii. Information from Minnesota Rules, part 2960.0060, subparts 1 and 2, regarding the program’s outcome measures; and b. Documentation did not include an evaluation of the program’s strengths and weaknesses based on results of resident and family satisfaction surveys. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program evaluations include all required components. 3. Violation: Two of two weeks of documentation reviewed for requirements governing clinical supervision did not meet requirements. All staff providing program services did not receive weekly face-to-face clinical supervision: a. For the treatment week beginning June 1, 2025: Three staff persons (NHC); and One staff person (ITC); and b. For the treatment week beginning December 15, 2025: One staff person (ALL). [Rule/Statute] Violated: Minnesota Rules, part 2960.0630, subpart 2 Repeat Violation: In a Correction Order that DHS issued on December 3, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of clinical supervision meets all applicable requirements. Resident Files Resident files reviewed are identified in the following manner: o Resident files numbered 1 through 5, and 7 (NHC); o Resident files numbered 2 through 4, 6 and 7 (ITC). 4. Violation: One of six resident files reviewed for requirements governing the license holder’s ability to meet residents' needs did not meet requirements (resident file numbered 2). There was no documentation to demonstrate the license holder determined the program could meet the resident’s cultural, emotional, educational, mental health and physical needs. Rule Violated: Minnesota Rules, part 2960.0160, subpart 2, item C Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of admission criteria meets all applicable requirements. 5. Violation: Six of seven resident files reviewed for resident screenings did not meet requirements in the following ways: a. For a shelter admission, there was no documentation to demonstrate a health screening was arranged for within 24 hours of admission (resident file numbered 2); b. The health screening did not include all required components. Documentation did not identify the resident’s most recent clinic name, address, and telephone number (resident files numbered 1 through 5 and 7); and c. The cultural screening was not completed, it was blank (resident file numbered 7). Rule Violated: Minnesota Rules, parts 2960.0520, subpart 2, item B, and 2960.0070, subpart 5, items B and C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the completion of resident screenings meets all applicable requirements. 6. Violation: Three of seven resident files reviewed for requirements governing admission procedures did not meet requirements. There was no documentation to demonstrate the license holder provided the following required information: a. The facility’s rules and details of the due process system used in the facility, verbally and in writing to the resident (resident files numbered 2 and 5); b. A written copy of the resident’s basic rights information (resident files numbered 2 and 5); c. That information on the resident’s basic rights is available, to the resident’s parent, guardian or custodian (resident files numbered 2, 4, and 5); and d. How to contact the appropriate state-appointed ombudsman (resident files numbered 2 and 5); and e. A copy of facility rules (resident file numbered 2). Rule Violated: Minnesota Rules, parts 2960.0160, subpart 4; 2960.0080, subpart 4; and 2960.0050, subpart 3, items A, B, and E Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission procedures meet all applicable requirements. 7. Violation: Six of six resident files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed within 10 working days of admission, it was completed late (resident files numbered 1 and 4); b. The ITP did not include a schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 4, 6 and 7); c. The ITP did not include all goals and objectives of treatment (resident file numbered 7). Documentation in the resident file indicated the license holder provided family therapy, and there was no related goal or objective in the ITP; and d. The ITP did not include the use of all psychotropic medications (resident files numbered 2 and 4). Rule Violated: Minnesota Rules, part 2960.0600, item A and part 2960.0620, subpart 1, item A Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 30 days receipt of this order, submit an ITP that demonstrates compliance. 8. Violation: One resident file reviewed for requirements governing family involvement in a qualified residential treatment program (QRTP) did not meet requirements (resident file numbered 6). There was no documentation to demonstrate how the program maintains the youth’s connections to their siblings. Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (h) Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of family involvement meets all applicable requirements. 9. Violation: Four of four resident files reviewed for requirements governing the review of the resident’s case and treatment plans did not meet requirements (resident files numbered 2, 3, 6 and 7). There was no documentation to demonstrate the plan was reviewed on a monthly basis. Rule Violated: Minnesota Rules, part 2960.0180, subpart 2, item B Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of the treatment plan review meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating a monthly review took place. 10. Violation: Three of five resident files reviewed for requirements governing psychotropic medications did not meet requirements. There was no documentation to demonstrate the following was completed as required: a. Monitoring for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication (resident files numbered 3, 4 and 7); and b. Monitoring for tardive dyskinesia at least every three months if the resident is prescribed antipsychotic medication (resident files numbered 3 and 7). Rule Violated: Minnesota Rules, part 2960.0620, subparts 2 and 3 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of the use of psychotropic medication meets all applicable requirements. 11. Violation: One resident file reviewed for requirements governing time-out did not meet requirements (resident file numbered 7). Discharge documentation identified the use of time-out occurred on November 30, 2024, and there was no documentation of the time-out that included the factors or circumstances which caused the need for the use of time-out, the resident’s response, their ability to de-escalate during the time-out or their ability to maintain acceptable behavior after the time-out. Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of the use of time-out meets all applicable requirements. 12. Violation: One of three resident files reviewed for requirements governing restrictive procedures did not meet requirements (resident file numbered 7). The license holder documented the use of physical holds in a “Restrictive Procedure Report”. Documentation in the resident file referenced multiple instances of physical holds and physical escorts between June 24, 2024, and August 2, 2024, and there were no corresponding “Restrictive Procedure Reports” in the resident file. Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, item K. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure 13. Violation: Five of five resident files reviewed for requirements governing the administrative review of the use of restrictive procedures did not meet requirements in the following ways: a. The administrative review was not completed within three working days for the following instances of restrictive procedures: i. March 31 and April 6, 2025 (resident file numbered 5); and ii. August 29, October 28, November 26 and 27, 2024 (resident file numbered 7); and b. The administrative review did not include whether the rule standards governing the use of restrictive procedures were met (resident files numbered 1, 3 through 5, and 7). Rule Violated: Minnesota Rules, part 2960.0710, subpart 10, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the completion of administrative reviews meets all applicable requirements. 14. Violation: Six of six resident files reviewed for requirements governing transition services plans did not meet requirements (resident files numbered 1, 2, and 4 through 7). Documentation did not demonstrate a copy of the plan was given to the resident. 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 transition services plans meet all appliable requirements. 15. Violation: Two of three resident files reviewed for requirements governing the provision of aftercare in a qualified residential treatment program (QRTP) did not meet requirements (resident files numbered 2 and 7). There was no documentation to demonstrate the license holder provided discharge planning and family-based aftercare support to each youth for at least six months after discharge. Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (i). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of aftercare services meets all applicable requirements. Personnel Files Personnel files are identified as follows: o Personnel files numbered 1 through 15 (ALL) 16. Violation: Two of six personnel files reviewed for requirements governing documentation of staff qualifications did not meet requirements (personnel files numbered 3 and 4). The personnel file did not include records showing that the staff person’s professional licensure is current. Rule Violated: Minnesota Rules, part 2960.0150, subpart 2 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of staff qualifications meets all applicable requirements. 17. Violation: Nine of nine personnel files reviewed for requirements governing annual training did not meet requirements in the following ways: a. There was no documentation to demonstrate the staff person received annual training on the program abuse prevention plan (PAPP) in 2024 (personnel files numbered 1, 3, 4, 6, 7, and 9 through 11); and b. There was no documentation to demonstrate the license holder reviewed the emergency plan with the staff person at least once every six months (personnel file numbered 12). Rule and Statute 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 of annual training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating all staff have received training on the PAPP. 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 Alyssa.nelson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Alyssa Nelson 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 in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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 Legal authority for this licensing action 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 651-431-6259 or at katie.a.leuer@state.mn.us Sincerely, Katie Leuer, Unit Supervisor Licensing Division Office of Inspector General
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