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February 21, 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 December 11, 2023, a Department of Human Services (DHS) licensor conducted a modified licensing review at your facility located at . As a result of this visit, DHS determined that you are in violation of 10 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. PRACTICES 1. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A. 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 September 4, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must document their attempts to hire a medically licensed person. In the future, the license holder will be responsible for notifying the DHS licensor if they fail to employ a medically licensed person. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 2. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A. Violation: The license holder failed to submit critical incident reports to DHS Licensing within ten days. Two of nine incident reports reviewed from June 2023, through September 2023, met the definition of a critical incident but were not reported (August 5 and 9, 2023). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that critical incident reporting meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. PERSONNEL FILES 3. Citation: Minnesota Rules, part 2960.0080, subpart 14. Violation: One personnel file reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 1). The staff person did not receive ongoing training, every six months, on the license holder’s emergency plan. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. RESIDENT FILES 4. Citation: Minnesota Rules, part 2960.0070. subpart 3, item B. Violation: One of two resident files reviewed for requirements governing resident information did not meet requirements (resident file numbered 1). The license holder failed to document the placing agency’s case plan goals for the resident. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client information meets all application requirements. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 5. Citation: Minnesota Rules, part 2960.0070, subpart 4. Violation: Two of two resident files reviewed for requirements governing admission procedures did not meet requirements. The license holder failed to document the inventory and handing of resident property upon admission in the following ways: a. Documentation of inventory and handling of resident property was completed late and was not signed by the resident. The document was signed by one staff person and is required to be signed by two, if the resident refuses to sign (resident file numbered 1); and b. The inventory and handling of resident property form was started, but never completed, including signatures from staff and the resident (resident file numbered 2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding the inventory and handling of resident property meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 6. Citation: Minnesota Rules, part 2960.0520, subpart 2, items A and B. Violation: Two of two resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways (resident files numbered 1 and 2): a. The license holder failed to document whether a health screening was arranged for within 24 hours of admittance to the program (resident file numbered 2); and b. The license holder failed to assess the resident’s vulnerability to maltreatment and develop a plan to reduce the resident’s risk of maltreatment while in shelter (resident files numbered 1 and 2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding shelter admissions meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 7. Citation: Minnesota Rules, part 2960.0080, subpart 11, item E. Violation: One resident file reviewed for requirements governing health care services did not meet requirements (resident file numbered 2). The license holder failed to record the quantity of medication received from the pharmacy for a resident who receives prescription drugs at the facility. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding health care services meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. 8. Citation: Minnesota Rules, part 2960.0530, subparts 1 and 2. Violation: Four of four resident files reviewed for requirements governing limitations on length of stay in a shelter did not meet requirements in the following ways: a. The license holder failed to apply for a variance to retain a resident in shelter beyond 90 days (resident files numbered 1, 3, and 4); and b. The license holder did not complete a 30-day review after a resident remained in the shelter for more than 30 days. The review was completed late, after the resident had surpassed 30 days. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding limitations on length of stay in a shelter meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 9. Citation: Minnesota Rules, part 2960.0090, subpart 3. Violation: One resident file reviewed for requirements governing the handling of resident’s personal property upon discharge did not meet requirements (resident file numbered 2). The license holder failed to obtain a date or signature on the document that logged the inventory of the resident’s personal property upon discharge. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding the handling of resident’s personal property upon discharge meets all applicable requirements. 10. Citation: Minnesota Rules, part 2960.0190, Subpart 1, items A and B and 2960.0520, subpart 2, item C. Violation: Two of two resident files reviewed for requirements governing transition services plans did not meet requirements in the following ways: a. The plan did not consider the environment that the resident would return to and recommend how the resident may deal with issues and potential challenges within that environment (resident files numbered 1 and 2); and b. The plan did not demonstrate that it was developed with input from the resident’s family members, the providing school district, and the persons who will provide support services to the resident upon release (resident files numbered 1 and 2); and c. Documentation did not demonstrate that a copy of the plan was given to the resident and to the school, or to the residential treatment facility that the resident will attend or is placed in after release (resident file numbered 2); and d. The transition services plan did not include the following required components: i. Housing, recreation, and leisure arrangements (resident file numbered 2); and ii. Appropriate educational, vocational, rehabilitation or training services (resident files numbered 1 and 2); and iii. A budget plan and description of the resident’s financial and employment status (resident files numbered 1 and 2); and iv. Transportation (resident files numbered 1 and 2); and v. Health services (resident files numbered 1 and 2); and vi. Personal safety needs (resident files numbered 1 and 2). e. The name and address of the party the resident was released to following discharge (resident file numbered 2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding transition services plans meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023. 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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