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November 25, 2024 Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud 236 Clifton Avenue Minneapolis, MN 55403-3466 License Number: 1106751 (CRF) CORRECTION ORDER Dear Daniel Pfarr:  On September 5, 2024, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at . As a result of this visit, DHS determined that you are in violation of 6 of the shelter care services requirements under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). 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 personnel file reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 2). The following trainings were not completed annually for 2024: a. Vulnerable adults maltreatment reporting requirements; b. The license holders program abuse prevention plan c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; d. Maltreatment of minors reporting requirements; e. Concepts of trauma informed care and how to provide services according to these concepts; f. Impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma; and g. Human trafficking training. Statute/Rule Violated: Minnesota Statues, section 245A.25, subdivision 3, paragraph (h) and subdivision 5, paragraph (f) and 245A.65, subdivision 3 and 245A.66, subdivision 4 and Minnesota Rules part 2960.0100, subpart 3, items A and B and subpart 5 and 2960.0150, subpart 4, items B and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation for personnel file numbered 2 that demonstrates compliance. 2. Violation: One personnel file reviewed for requirements governing training did not meet requirements (personnel file numbered 2). There was no documentation that the emergency plan was reviewed with staff at least every six months for the calendar year 2024. Rule Violated: Minnesota Rules, part 2960.0080, subpart 14. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance. RESIDENT FILES 3. Violation: Two of two resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1 and 2). The inventory and handling of resident property upon admission did not include a date the form was completed. DHS licensing was unable to determine if it was completed upon admission. Rule Violated: Minnesota Rules, part 2960.0070, subpart 4. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating compliance. 4. Violation: One resident file reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements (resident file numbered 3). There was no documentation to demonstrate that the resident was involved in the creation of the IAPP. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. 5. Violation: One resident file reviewed for requirements governing health care services did not meet requirements (resident file numberd 1). There was no documentation to demonstrate that the license holder contacted the residents prescriber to verify the following information regarding prescribed medication: a. Instructions about how the medication must be administered; b. The symptoms the medication will alleviate; and c. The symptoms that would warrant consultation with the physician. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care services meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating compliance. 6. Violation: One resident file reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 2). The license holder did not provide the resident with a signed receipt of their personal property inventory upon discharge. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meets all applicable requirements. If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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 a corrective action ordered must be sent to DHS Licensing at: 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Gilbertson 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: 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 Questions If you have any further questions regarding this matter, you may contact Maddy Gilbertson, Senior Licensor, at 651-431-4585. Sincerely,  Maddy Gilbertson, Senior Licensor Licensing Division Office of Inspector General
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