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April 16, 2025 Beth Holger, Authorized Agent The Link 1210 Glenwood Ave. Minneapolis, MN 55405 License Number: 1074613 (CRF) CORRECTION ORDER Dear Beth Holger:  On February 24-26, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Passageways, located at . 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. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Practices 1. Violation: The license holder did not maintain compliance with applicable health rules. A certified food manager was not employed between 11/27/2024 and 2/26/2025. Rule Violated: Minnesota Rules, part 2960.0120, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure to meet all applicable health rules. 2. Violation: The plan for transfer of clients and records upon closure was not signed by a controlling individual for calendar years 2023 and 2024. Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the facility plans meet all applicable requirements. 3. Violation: The program abuse prevention plan was not reviewed annually by the license holder’s governing body for calendar years 2023 and 2024. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the facility plans meet all applicable requirements. 4. Violation: Four of fourteen incident reports reviewed for requirements governing critical incident reporting did not meet the requirements. The following incidents were not reported as critical incidents as required: a. One incident requiring response by law enforcement and transport via ambulance dated 6/17/24; and b. Three incidents requiring response by law enforcement dated 8/13/24, 9/7/24 and 9/7/24. Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 critical incidents meet all applicable requirements. Personnel 5. Violation: One of two personnel files reviewed for orientation did not meet requirements (personnel file numbered 1). Documentation of training did not include: a. Cultural diversity and gender sensitivity, culturally specific services and information about discrimination and racial bias; b. General and special needs, including disability needs, of residents and families served; c. Concepts of trauma-informed care and how to provide services to each youth according to those concepts; and d. Impact of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences. Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h), and Minnesota Rules, part 2960.0100, subpart 3, item A Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 staff orientation meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel file numbered 1 to demonstrate compliance. 6. Violation: Two of two personnel files did not meet the requirements for ongoing training. a. There was no documentation of ongoing annual training in the maltreatment of minors reporting requirements for calendar year 2024 (personnel file numbered 1); b. The emergency plan was not reviewed at least every six months for calendar years 2023 and 2024 (personnel files numbered 1 and 3); c. Annual training was missing for concepts of trauma informed care and how to provide services according to these concepts for calendar year 2023(personnel files 1 and 3); d. Annual training was missing for impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma for 2023 (personnel files 1 and 3). Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 3, paragraph (h), and 245A.66, subdivision 4; and Minnesota Rules, part 2960.0080, subpart 14. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing staff training meets requirements. Within 30 days of this order, provide training and submit documentation for personnel files numbered 1 and 3 to demonstrate compliance. Resident Files 7. Violation: Three of three resident files did not meet requirements governing resident information (resident files numbered 1, 2 and 3). Documentation did not include the resident’s time of admission. Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that resident information meets all applicable requirements. 8. Violation: Three of three resident files did not meet requirements governing shelter admissions (resident files numbered 1, 2 and 3). The resident file did not include the following: a. An assessment of the resident’s vulnerability to maltreatment; b. An assessment of the resident’s immediate needs. Rule Violated: Minnesota Rules, part 2960.0520, subparts 2, items A and B; and 3 Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 that requirements governing shelter admissions meets all applicable requirements. Within 30 days receipt of this order, submit the following for one resident to demonstrate compliance: · An assessment of a resident’s vulnerability to maltreatment; · A plan to reduce the risk of maltreatment; · An assessment of a resident’s immediate needs; and · A plan for meeting a resident’s immediate needs. 9. Violation: Three of three resident files did not meet requirements governing admission procedures. a. The inventory of the resident’s property was not signed by both the resident and staff (resident files numbered 1 and 2); and b. The license holder did not provide documentation of informing resident’s parent, guardian or custodian within a reasonable time that resident’s basic rights information is available (resident files numbered 1, 2 and 3). Rules Violated: Minnesota Rules, part 2960.0070, subpart 4; and 2960.0050, subpart 3, item B. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 that requirements governing admission procedures meets all applicable requirements. 10. Violation: Two of three resident files did not meet requirements governing health care in the following ways: a. The license holder did not provide documentation that a newly admitted resident’s licensed prescribing medical person had been contacted to obtain the following (resident file numbered 3): i. Instructions for administering prescribed medication; ii. Symptoms the medication will alleviate; and iii. Symptoms that would warrant consultation with the physician; b. The license holder did not provide documentation indicating parental or guardian consent to administer prescribed medications (resident file numbered 1); and c. The license holder did not provide documentation of the quantity of medication initially received from the pharmacy (resident files numbered 1 and 3). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D and E. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 that requirements governing health care meets all applicable requirements. 11. Violation: One of two resident files did not meet requirements governing discharge procedures. The license holder did not document the return of the resident’s property with a signed receipt upon discharge (resident file numbered 1). Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 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 that requirements governing discharge procedures meets all applicable requirements. 12. Violation: Two of two resident files did not meet requirements governing shelter discharge. The license holder did not document the name and address of the party to whom the resident was released following discharge when the resident had been in shelter for more than ten days (resident files numbered 1 and 2). Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item C. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of the same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements governing shelter discharge meets all applicable requirements. 13. Violation: Two of two resident files did not meet requirements governing transition services plan. The license holder did not document that a copy of the transitional services plan was given to the resident or to the facility where the resident was placed(resident files numbered 1 and 2). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A. Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of the same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements governing transition services plan meets all applicable requirements. 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 Laura.Huff1@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Laura Huff 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 651-431-4234 or at Laura.Huff1@state.mn.us. Sincerely, Laura Huff, Licensor Licensing Division Office of Inspector General
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