|
June 1, 2026 Heather Gallivan, Authorized Agent Park Nicollet Melrose Center 3525 Monterey Dr. St. Louis Park, MN 55416-5275 License Numbers: 1053706 Park Nicollet Melrose Center (Rule 36) 1053704 Park Nicollet Melrose Center (CEDV) CORRECTION ORDER Dear Heather Gallivan: On March 16 through 18, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Park Nicollet Melrose Center, located at 3525 Monterey Dr., St. Louis Park, MN 55416. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Rule 36 under Minnesota Rules, parts 9520.0500 through 9520.0690, and the variance governing Children’s Eating Disorder Structured Living Programs (CEDV) under Minnesota Rules, part 2960.0100 to 2960.0710. 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. Throughout this Correction Order, the licensed programs will be referenced as follows: · Park Nicollet Melrose Center 1053706 (Rule 36); · Park Nicollet Melrose Center 1053704 (CEDV); and · When citations are specific to both licensed programs (ALL). LICENSING VIOLATIONS DHS determined that your program did not follow licensing rules and statutes, as described below. PERSONNEL All personnel files were reviewed for Rule 36 and CEDV requirements. 1. Violation: Seventeen of ninety personnel files reviewed for requirements of background studies did not meet requirements in the following ways: a. A staff person had a legal name change; however, the license holder did not initiate a new background study or notify the commissioner of the name change (personnel file numbered 18); and b. The license holder did not affiliate staff to the Rule 36 roster. The studies were submitted under the CEDV license number 1053704 (personnel files numbered 5, 19 through 33). Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 7, and 245C.07, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the background study meets all applicable requirements. This was corrected on site. 2. Violation: One of eighteen personnel files reviewed for Rule 36 requirements governing staff files (personnel file numbered 11) did not meet requirements. The file did not contain documentation of the staff person’s annual performance evaluation for the year 2025. Rule Violated: Minnesota Rules, section 9520.0600, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the staff files meet all applicable requirements. 3. Violation: One of eighteen personnel files reviewed for Rule 36 requirements governing staff files (personnel file numbered 11) did not meet requirements The personnel file did not contain documentation of an annual growth and development plan for the staff person for the year 2025. Rule Violated: Minnesota Rules, section 9520.0600, subdivision 2, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the staff files meet all applicable requirements. CLIENTS Client files reviewed are identified in the following manner: · Rule 36: Client files numbered (1,2 and 3) · CEDV: Client files numbered ( 4,5,6,7 and 8) 4. Violation: Two of three client files reviewed for requirements governing the individual program plan development did not meet the following requirements: a. The license holder did not complete a new individual program plan for a client who was re-admitted to the program (client file numbered 1); and b. The license holder did not complete an individual program plan within 30 days of a client being admitted to the program (client file numbered 2). Rule Violated: Minnesota Rules, section 9520.0640, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual program plans meet all applicable requirements. 5. Violation: Two of three client files reviewed did not meet discharge requirements in the following ways: a. The discharge summary did not include the following: i. A brief review of the client’s strengths (client files numbered 1 and 2); ii. The response of the client to his or her individual treatment plan and to the facility’s overall program (client file numbered 1); iii. The aftercare plan did not state who participated in the development of the aftercare plan (client file numbered 1); iv. The aftercare plan did not state the goals and objectives for the first three months after discharge or transfer (client file numbered 1); and v. The aftercare plan did not state the individual or agencies who will be working with the client after discharge and transfer (client file numbered 1). Rule Violated: Minnesota Rules, section 9520.0640, subdivision 4, paragraphs (a), (b) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Within 30 days receipt of this order, submit two client discharge summaries (Rule 36) that meet requirements in paragraph (a), (b) and (c) above. 6. Violation: One of three client files reviewed for admission documentation did not meet requirements. The license holder did not have documentation of legal authority for the client’s placement (client file numbered 5). Rule Violated: Minnesota Variances, section CEDV.0090, subpart 3, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission documentation meets all applicable requirements. 7. Violation: One of three client files reviewed for a diagnostic assessment (DA) did not meet requirements. A DA or DA update was not completed within five working days of admission (client file numbered 6). Rule Violated: Minnesota Variances, section CEDV.0100, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that DAs meet all applicable requirements. 8. Violation: Two of three client files reviewed for treatment plans did not meet requirements. The client’s treatment plan was not developed within 10 days of admission (client files numbered 4 and 6). Rule Violated: Minnesota Variances, section CEDV.0100, subpart 3. Repeat Violation: In a Correction Order that DHS issued on January 12, 2022, 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 treatment plans meet all applicable requirements. 9. Violation: Three of three client files reviewed for psychotropic medications did not meet requirements in the following ways: a. The client’s treatment plan did not include observable and measurable descriptions of the symptoms and behaviors that the psychotropic medication is to alleviate (client files numbered 4, 5, and 6); and b. The informed consents for the psychotropic medications did not include the level to which the medication is to change the symptoms and behaviors (client files numbered 4 and 5). Rule Violated: Minnesota Variances, section CEDV.0130, subparts 1, item B, and subpart 5, item A. Repeat Violation: In a Correction Order that DHS issued on January 12, 2022, 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 psychotropic medications meet all applicable requirements. Within 30 days receipt of order, submit documentation of one client’s treatment plan and informed consents that demonstrates compliance with all 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 Hannah.Horsch@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Hannah Horsch 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 651-431-6270 or at Hannah.Horsch@state.mn.us. Sincerely, Hannah Horsch, Licensor Licensing Division Office of Inspector General
|
