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February 24, 2023 Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud 236 Clifton Avenue Minneapolis, MN 55403-3466 License Number: 1106751 (CRF) ORDER OF CONDITIONAL LICENSE Dear Daniel Pfarr:  The Department of Humans Services (DHS) is placing your license to provide children’s residential facilities group residential services (CRF) at , on conditional status for two years, beginning March 7, 2023. This order is based on your noncompliance with Children’s Residential Facility (CRF) licensing requirements. Details of our findings are provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On December 12 through 16 and 19, 2022, DHS licensors conducted a licensing review at your facility located at  . As a result of this licensing review, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF), citing 21 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of children served by the program. Nature and Severity: · The license holder failed to provide oversight by a medically licensed person (citation numbered 1); · The license holder failed to meet requirements governing health care services (citation numbered 2); · The license holder failed to comply with background study requirements (citation numbered 3 through 5); · The license holder failed to provide a physical environment that provided for the comfort, privacy and dignity of residents (citation numbered 6); · The license holder failed to submit critical incident reports to DHS licensing within ten days (citation numbered 7) · The license holder failed to meet requirements governing the limitations of length of stay in programs providing shelter care services (citation numbered 8); · The license holder failed to monitor implementation of their grievance policy (citation numbered 9);
· The license holder failed to provide complete orientation training to staff (citation numbered 10); · The license holder failed to provide ongoing staff training (citation numbered 11); Due to the nature and severity of these violations that impact the health and safety of children served in your care, your license to provide Children’s Residential Facility services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder failed to provide a medically licensed person to provide consultation and review of the license holder’s administration of medication on a monthly basis. At the time of the licensing review, the license holder had not maintained a medically licensed person on their staff since November 15, 2021. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A. 2. Violation: Four of four resident files reviewed for requirements governing health care services did not meet requirements in the following ways: a. The license holder failed to maintain a record of the resident’s medical, psychological, or dental care (resident files numbered 1 through 4); b. The license holder failed to contact a newly admitted resident's prescribing medically licensed person to verify the following information regarding prescribed medication (resident files numbered 1, 2, and 4): i. Instructions about how the medication must be administered; ii. The symptoms that the medication will alleviate; iii. The symptoms that would warrant consultation with the physician; c. Documentation did not identify the prescribing physician’s directions for monitoring medications used by the resident (resident files numbered 1 through 4); and d. The resident file did not include the following required medication documentation (resident file numbered 4): i. The quantity of medication initially received from the pharmacy; and ii. The amount of medication given, the dosage, and the time when the medication was taken. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items B, D and E 3. Violation: The license holder failed to meet background study (BGS) requirements for four staff. (personnel numbered 5 through 8). The license holder failed to initiate a BGS before an adult, regardless of whether or not the individual will have direct contact with persons served by the facility, begins working in the facility or setting. In addition, the license holder did not prohibit activities of working in the facility prior to receipt of notice of the BGS results. a. Staff person (personnel file numbered 5) began working in the facility August 20, 2022; however, the license holder did not have a BGS notice result until December 8, 2022; b. Staff person (personnel file numbered 6), was hired on July 1, 2021. License holder did not document the date of working in the facility as required; however, the license holder did not have a BGS notice result until December 8, 2022; c. Staff person (personnel file numbered 7) began working in the facility May 20, 2022; however, the license holder did not have a BGS notice result until December 8, 2022; and d. Staff person (personnel file numbered 8) began working in the facility August 19, 2021; however, the license holder did not have a BGS notice result until December 8, 2022. Statute Violated: Minnesota Statutes, section 245A.041, subdivision 5, 245C.04, subdivision 11, clause (5) and 245C.13, subdivision 2, paragraph (c). 4. Violation: The license holder failed to transfer a BGS from a closed license to an active license. On December 12, 2022, a DHS Licensor determined that the license holder did not notify the Commissioner to transfer background studies to an active license when license number 1062155 closed. Staff person (personnel file numbered 2) had BGS completed under Department of Corrections, license number 1062155. When the licensed closed on June 1, 2021, the license holder did not notify the Commissioner to transfer the BGS to an active licensed under 245C. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (b). 5. Violation: The license holder has multiple programs but failed to affiliate a staff person (personnel file numbered 4) on all active rosters. A BGS was submitted under license number 1074484; however, staff person was also working under license number 1106751 as of July 11, 2022. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f). 6. Violation: The license holder failed to ensure the physical environment provided for the comfort, privacy and dignity of residents. During the on-site licensing review, a DHS Licensor observed bedroom walls with vulgar graffiti, torn carpet, and evidence of water damage. Staff on site indicated that the programs usual practice of adequately maintaining the environment was not being followed due to the ongoing remodeling project. Rule Violated: Minnesota Rules, part 2960.0110, subparts 2 and 3, item A. 7. Violation: The license holder failed to submit critical incident reports to DHS Licensing within ten days. Five of ten incident reports reviewed from October 2022, through December 2022, met the definition of a critical incident but were not reported (November 4, 11, 15, 16 and 25, 2022). Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A. 8. Violation: The license holder failed to meet requirements governing the limitations of length of stay in programs providing shelter care services in the follow ways: a. The license holder retained residents for longer than 90 days without requesting a variance as directed by Minnesota Rules, part 2960.0530, subpart 1. During the review period of July 1, 2021, through December 15, 2022, nine residents remained in shelter beyond the 90 day limit; and b. Two of two resident files reviewed for requirements governing 30-day reviews did not meet requirement. There was no documentation to demonstrate the license holder reviewed the need for the resident to remain in shelter and consider alternative placement plans when the resident was in shelter for more than 30 days (resident files numbered 2 and 4). Rule Violated: Minnesota Rules, part 2960.0530, subparts 1 and 2. 9. Violation: Eleven of twelve grievances reviewed did not meet requirements in the following ways: a. There was no documentation to demonstrate that the person who submitted the grievance received a response (grievances dated December 25, 2021, February 26, 2022, March 13, 16, 26, and 29 (2) 2022, August 17, 2022, September 10, 2022, and two undated grievances); and b. The person that submitted the grievance did not receive a response within five days. Grievances dated July 30, 2022, and August 17, 2022, were responded to late. Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, items A and B. 10. Violation: Two of two personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. There was no documentation to demonstrate the staff person was trained on the following topics prior to having unsupervised contact with residents (personnel files numbered 1 and 3): i. Emergency procedures; ii. Maltreatment of minors reporting requirements; iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents; iv. General and special needs, including disability needs, of residents and families served; v. Operational policies and procedures of the license holder, including the program’s drug and alcohol policy; and vi. Data practices regulations and issues. b. There was no documentation to demonstrate the staff person was trained on the following topics within 72 hours of first providing direct contact services to vulnerable adults (personnel files numbered 1 and 3): i. Vulnerable adults maltreatment reporting requirements and definitions; ii. The license holder’s program abuse prevention plan (PAPP); and iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and c. Documentation of orientation did not include the date, number of hours, or the name of the entity that provided the training (personnel file numbered 1). Rule and Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, part C, 245A.65 subdivision 3, and Minnesota Rules, part 2960.0100, subpart 3, item A. 11. Violation: One personnel file reviewed for requirements governing ongoing training did not meet requirements in the following ways (personnel file numbered 2): a. The staff person did not receive annual training in 2021 to the following required topics: i. Vulnerable adult maltreatment and reporting requirements and definitions; ii. The license holders PAPP; iii. The license holders emergency plan; and b. Documentation of in-service training did not include the date and number of hours of training completed by each staff person in each topic area and the name of the entity that provided the training. Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subparts 3, item B, and 5. 12. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements in the following ways: a. The resident file did not contain the placing agency’s case plan, and there was no documentation of the license holder’s efforts to obtain the case plan (resident files numbered 1 through 3); b. There was no documentation of the inventory and handling of resident property (resident file numbered 1); c. Documentation indicated the license holder did not communicate the facility rules and due process system to the resident (resident files numbered 1 through 3); and d. Documentation indicated the license holder did not provide a copy of the resident rights to the resident (resident files numbered 1 through 3). Rule Violated: Minnesota Rules, parts 2960.0050, subpart 3, items A and B, and 2960.0070, subparts 3, item B, and 4, and 2960.0080, subpart 4. 13. Violation: One resident file reviewed for requirements governing the provision of services to vulnerable adults did not meet requirements in the follow ways (resident file numbered 4): a. An individual abuse prevention plan was not developed; b. The resident was not oriented to internal and external reporting policies; and c. The resident was not oriented to the program abuse prevention plan. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (c). 14. Violation: Four of four resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways: a. There was no documentation to demonstrate that a health screening was arranged within 24 hours of being admitted to the program (resident files numbered 1 through 4); b. The license holder failed to assess the residents vulnerability to maltreatment and to develop a plan to reduce the residents risk of maltreatment while in the shelter (resident files numbered 1 through 4); c. The license holder failed to specify short-term objectives and methods for meeting the immediate needs identified (resident files numbered 1 through 4); d. Documentation did not indicate the license holder’s responsibility for meeting the residents needs as identified by the placing agency (resident files numbered 1 and 3); and e. The license holder failed to document, within six working days of admission, the degree to which the family desires to be involved during the residents stay at the facility (resident files numbered 2 and 3). Rule Violated: Minnesota Rules, parts 2960.0070, subpart 5, item D; and 2960.0080, subpart 19; 2960.0520, subparts 2, items A and B, and 3, items B and C. 15. Violation: Three of three resident files reviewed for requirements governing program services did not meet requirements in the following ways: a. There was no documentation provided that demonstrated that the license holder worked with the resident, parent, or legal representative, and the resident's case manager and treatment team to implement the resident's case plan during the resident's stay in the facility (resident files numbered 1 and 2); and b. The license holder failed to identify and share information about the resident’s treatment and major treatment outcomes (resident files numbered 1 and 3). Rule Violated: Minnesota Rules, part 2960.0080, subpart 3, items A and B. 16. Violation: Three of three resident files reviewed for requirements governing discharge documentation did not meet requirements in the following ways: a. The license holder failed to document the extent to which the residents stay in the facility met the goals and objectives of the residents treatment plan (resident files numbered 1 and 4); b. The resident file did not contain a transition services plan, when the resident remained in shelter for more than 10 days (resident files numbered 1, 3 and 4); and c. Documentation did not identify the name and address of the party the resident was released to following discharge (resident file numbered 4). Rule Violated: Minnesota Rules, parts 2960.0190, subparts 1 and 2; and 2960.0520, subpart 2, item C. 17. Violation: The license holder’s plan for the transfer of client records upon closure did not meet requirements. There was no documentation to demonstrate the plan was reviewed by a controlling individual annually, for 2021 and 2022. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). 18. Violation: The license holder’s operational policies and procedures did not meet requirements in the following ways: a. The license holder failed to maintain a written schedule of daily activities that generally describes the residents activities for each day of the week; and b. The license holder failed to develop and implement a plan that offers appropriate recreation for residents Rule Violated: Minnesota Rules, part 2960.0080, subparts 6 and 10. 19. Violation: The license holder’s postings did not meet requirements. The rights posted in an area readily seen by residents and staff were incorrect and not applicable, and the resident’s rights were not posted in the staff workstation. During the on-site licensing review, the license holder posted the correct rights in all required areas. Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, items C and D. 20. Violation: The license holder’s review of the program abuse prevention plan (PAPP) did not meet requirements. There was no documentation to demonstrate that the license holder’s governing body reviewed the PAPP annually, for 2021 and 2022. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph item (a). 21. Violation: The license holder’s program evaluation did not meet requirements. The license holder failed to evaluate strengths and weaknesses of the program on an annual basis and use the results of the evaluation to make improvements in its program for 2021 and 2022. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A. Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected the violations. 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Madelyn Gilbertson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 If you fail to demonstrate substantial compliance with licensed children’s group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this order, you must notify current residents and all parties who refer residents to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new residents and referral sources the license is on conditional status before they begin receiving treatment services. The notification to new residents must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file. Within 30 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice. 2. Within 30 days of receipt of this order, you must develop a self-monitoring tool and plan that ensures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following: a. Names and titles of those responsible to carry out duties within the plan; and b. Procedure that includes a sample review of resident records, personnel files, treatment plans and reviews, transition and discharge plans, medication administration records and medication verifications, incident reports, grievances, and monitoring of the implementation of policies and procedures on a monthly basis. c. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on April 15, 2023, July 15, 2023, October 15, 2023, and January 15, 2024, April 15, 2024, July 15, 2024, October, 15, 2024, January 15, 2025 or until otherwise determined by DHS Licensing. 3. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on statute requirements for Background Studies under Minnesota Statute, chapter 245C. Individuals required to attend is your designated N2study sensitive information person and authorized agent. Training must be completed within 30 days of receipt of this order. 4. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on rule requirements for children's residential facilities Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. Individuals required to attend are the Program Manager, Registered Nurse, Compliance Officer, Director and Partner Experience must attend the training offered by DHS Licensing. Training must be completed within 60 days of receipt of this order. 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below 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. 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 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Children’s residential facilities are required to follow Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. 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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