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April 4, 2023 Daniel Pfarr, Authorized Agent 180 Degrees Rochester 236 Clifton Avenue Minneapolis, MN 55403-3466 License Number: 1106748 (CRF) CORRECTION ORDER Dear Daniel Pfarr:  On December 6 and 7, 2022, a modified licensing review of 180 Degrees Rochester, located at  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, group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and residential shelter services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). As a result of this modified licensing review and licensing investigation a Correction Order is being issued. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. PHYSICAL PLANT 1. Citation: Minnesota Rules, part 2960.0200, item A. Violation: The license holder failed to keep the carpet, walls and ceiling in good repair. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the physical environment remains in good repair. Within 30 days receipt of this order, submit documentation to demonstrate repairs have been made to the areas identified above. PRACTICES 2. Citation: Minnesota Statutes, section 245A.04, subdivision 15, item (a). Violation: The license holder failed to maintain a signed plan for transfer of clients and records upon closure for the year 2022. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the plan is reviewed and signed on an annual basis. PERSONNEL FILES 3. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g). Violation: The license holder failed to initiate a background study on an individual (personnel file numbered 3) required to have a background study under Minn. Stat. § 245C.03 subdivision. 1 before the individual began in a position of direct contact with or, access to persons served by the program. Corrective Action Ordered: You must comply with background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance will be maintained in the future. 4. Citation: Minnesota Rules, parts 2960.0100, subparts 3, item A, and 5, and 2960.0150, subpart 3 and 4, item C. 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 that the staff person was oriented to the following: i. Physical, mental, sensory and health related disabilities (personnel file numbered 4); ii. 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 (personnel file numbered 3); iii. General and special needs, including disability needs, of residents and families served (personnel file numbered 3); iv. Operational policies and procedures of the license holder, including the programs drug and alcohol policy (personnel numbered 3); b. Documentation of orientation did not include the number of hours, and the name of the entity who provided the training (personnel file numbered 3); and c. The personnel file did not include documentation that a volunteer agreed to abide by facility policies (personnel file numbered 4). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of orientation training meets all requirements. Within 30 days receipt of this order, submit documentation that staff identified have received training in the areas above. 5. Citation: Minnesota statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0080, subpart 14, 2960.0100, subparts 3, item B and subparts 5 and 14, and 2960.0150, subpart 4, item B. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: a. There was no documentation to demonstrate that the staff person received training on the following: i. Annual training in vulnerable adult maltreatment reporting requirements and definitions (personnel files numbered 1 and 2); ii. The license holders program abuse prevention plan (personnel file numbered 2); iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 and 2); iv. Review of the emergency plan at least once every six months for the year 2021 and 2022 (personnel files numbered 1 and 2); b. There was no documentation that the staff person received any ongoing training in 2022 (personnel file numbered 5); and c. Documentation of ongoing training did not include the date, number of hours of in-service training completed by each staff person in each topic area and the name of the entity that provided the training (personnel file numbered 2). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of ongoing training meets all requirements. Within 30 days receipt of this order, submit documentation that staff identified have received all required training in the areas above. RESIDENT FILES 6. Citation: Minnesota Rules, parts 2960.0050, subpart 3, item A, 2960.0070, subpart 3, item B and 2960.0160, subparts 2, item C, and 4, item B. 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 include a description of assets and strengths (resident files numbered 1 and 3); and b. There was no documentation to indicate the program determined they were able to meet the residents cultural, emotional, educational, mental health and physical needs (resident files numbered 1 and 3); and c. The resident file did not include documentation demonstrating the resident received information about their basic rights within 24 hours (resident files numbered 2 and 3) or that the information was available for the resident’s parent, guardian or custodian (resident file numbered 3); d. The resident file did not include documentation demonstrating the resident received a copy of a description of the applicable programs and activities within 24 hours (resident files numbered 2 and 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of admission standards meets all requirements. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 2, item (b). Violation: One resident file reviewed for requirements governing the provision of services to vulnerable adults did not meet requirements in the following ways (resident file numbered 3): a. The resident was not oriented to vulnerable adult maltreatment reporting policies and procedures or the program abuse prevention plan; b. An individual abuse prevention plan was not developed Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of services to vulnerable adults meets all applicable requirements. 8. Citation: Minnesota Rules, part 2960.0520, subpart 2, items A and B, and subpart 3, items A through C. Violation: Three of three resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways: a. There was no documentation to demonstrate that the health screening was arranged for within 24 hours of admission (resident file numbered 1); and b. A plan to reduce the resident’s risk of maltreatment was not developed (resident file numbered 2); and c. There was no documentation to demonstrate an assessment of the resident’s situation, condition, and immediate needs was completed (resident file numbered 1); and d. An immediate needs plan was not developed (resident file numbered 1); and e. The immediate needs plan did not include short term objectives (resident file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of shelter admissions meets all applicable requirements. 9. Citation: Minnesota Rules, part 2960.0070, subpart 5, item C. Violation: Three of three resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. Documentation did not demonstrate the resident’s health screening was completed within 24 hours (resident file numbered 1); b. The health screening did not include the most recent physicians name, clinic name or the address and telephone number of the physician (resident file numbered 3); and c. There was no documentation to demonstrate that the mental health and substance use disorder screenings were completed within six working days of admission (resident files numbered 1 and 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of admission screenings meets all applicable requirements. 10. Citation: Minnesota Rules, part 2960.0080, subpart 14. Violation: One of two files reviewed for requirements governing program services did not meet requirements (resident file numbered 3). The emergency plan was not reviewed with the resident at least once every six months. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of program services meets all applicable requirements. 11. Citation: Minnesota Rules, part 2960.0180, subpart 2, item B. Violation: Two of two resident files reviewed for requirements governing treatment plans did not meet requirements (resident file numbered 1 and 3). Documentation did not identify when the resident transitioned from receiving shelter care to group residential services. As a result, documentation did not demonstrate if the treatment plan was developed within 10 days. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of treatment plans meets all applicable requirements. 12. Citation: Minnesota Rules, part 2960.0080, subpart 11, item E. Violation: One resident file reviewed for requirements governing health care did not meet requirements (resident file numbered 2). The resident was administered over-the-counter medications and the file did not include resident specific orders by the prescribing medically licensed person. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of health care meets all applicable requirements. 13. Citation: Minnesota Rules, part 2960.0530, subpart 2. Violation: Two of two resident files reviewed for requirements governing length of stays in a shelter did not meet requirements. The 30-day review of a resident receiving shelter services was completed late (resident file numbered 1) and there was no documentation that a copy of the summary of the 30 day review was sent to the placing agency (resident files numbered 1 and 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of length of stays in a shelter meets all applicable requirements. 14. Citation: Minnesota Rules, part 2960.0190, subpart 1, item C. Violation: One file reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 3). There was no documentation that the license holder gave written notice of the residents projected discharge date to the resident, the resident’s case manager and parents, the providing school district, or the school district the resident will go to, if known. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of discharge procedures meets all applicable requirements. 15. Citation: Minnesota Rules, part 2960.0190, subpart 2, items A and B. Violation: One of two files reviewed for requirements governing discharge documentation did not meet requirements (resident file numbered 2). Documentation did not include the extent to which the resident’s stay in the facility met the goals and objectives of the treatment plan. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of discharge documentation meets all applicable requirements. 16. Citation: Minnesota Rules, parts 2960.0190, subpart 1, item A and 2960.0520, subpart 2, item C. Violation: One file reviewed for requirements governing shelter discharge documentation did not meet requirements (resident file numbered 3). A transition services plan was not completed. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of shelter discharge documentation meets all applicable requirements. If you fail to correct the violations 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 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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