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June 10, 2026 Francene Lizette Young Rolstad, Authorized Agent Amherst H. Wilder Foundation 451 Lexington Parkway N. St. Paul, MN 55104-4636
License Numbers: 802690 (MHC) 1083231 (245G) Dear Francene Lizette Young Rolstad: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration regarding citations 11, 14, and 15 in the Correction Order issued to you on February 25, 2026. After an independent review of the record, the Commissioner has determined it is appropriate to rescind citations 11 and 14. Citation 15 is affirmed, and the violations for which you did not request reconsideration are final and not within the scope of this review. Reconsideration Determination Violation 11: The license holder’s policy on behavioral emergencies (emergency care) (ALL) did not meet requirements. The policy did not include the following: a. The types of emergency procedures staff may use, and b. That seclusions and restraints are not allowed. Applicable Law Under Minnesota Statutes, section 245G.16, a license holder or applicant must have written behavioral emergency procedures that staff must follow when responding to a client who exhibits behavior that is life threatening to the safety of the client or others. Programs must incorporate person-centered planning and trauma-informed care in the program’s behavioral emergency policies. The procedures must include: the types of procedures that may be used, circumstances under which behavioral emergency procedures may be used, and other items as specified in the statute. Under Minnesota Statutes, section 245I.03, subdivision 4, paragraph (b) and (c), a license holder’s behavioral emergency procedures must include: the types of behavioral emergency procedures that a staff may use, the specific circumstances under which the program may use behavioral emergency procedures and other items as specified in the statute. The license holder’s behavioral emergency procedures must not include secluding or restraining a client except as allowed under section 245.8261. Your Response You submitted a letter in which you indicated the citation was incorrect, and you included supporting documentation. Reconsideration Determination After further review of the information contained in the file and the information you submitted, the Commissioner has determined it is appropriate to rescind the violation. Violation 14: One of five personnel files reviewed for annual job performance evaluations did not meet requirements when there was no documentation of an annual job performance of a staff person for calendar year 2025 (personnel file numbered 4), and the job performance evaluation was completed late. Applicable Law Under Minnesota Statutes, section 245G.13, subdivision 1, a license holder must have written policies that are available to each staff member. The policies must provide for a job performance evaluation based on standards of job performance conducted on a regular and continuing basis, including a written annual review. Under Minnesota Statutes, section 245I.07, paragraph (a), for each staff person, a license holder must maintain a personnel file that includes annual job performance evaluations. Your Response You submitted a letter in which you indicated the citation was incorrect, and you submitted supporting documentation. Reconsideration Determination After further review of the information contained in the file and the information you submitted, the Commissioner has determined it is appropriate to rescind the violation. Violation 15: Three of three personnel files reviewed for first date of direct contact did not meet requirements. License holder had no documentation of the first date of contact for staff persons (personnel files numbered 1, 4, and 7). Applicable Law Under Minnesota Statutes, section 245A.041, subdivision 6, license holders must document the first date that a background study subject has direct contact with a person served by the license holder’s program. Under Minnesota Statutes, section 245I.07, paragraph (a), for each staff person, a license holder must maintain a personnel file that includes documentation related to the staff person’s background study. Under Minnesota Statutes, section 245C.02, subdivision 11, direct contact means providing face-to-face care, training, supervision, counseling, consultation, or medication assistance to persons served by the program. Your Response You submitted a letter in which you indicated the first day of client contact is recorded in the facility’s electronic health record, and staff training dates are recorded in the facility’s learning management system. You indicated both first date of contact and training date requirements were met for all three personnel files requested. You indicated client-related information is not stored in the learning management system to protect confidentiality, but the facility conducts regular quality and compliance monitoring in both the electronic health record and learning management system. You did not provide any supporting documentation. Reconsideration Determination The statute requires the license holder to document the first date that each background study subject began working in the license holder’s program. The program did not provide this documentation during the licensing visit or with the request for reconsideration, and the program’s training transcript did not indicate the date of first contact. There is sufficient information to support the violation, and it is therefore affirmed. Disposition The Commissioner has reviewed the relevant laws and all the information you submitted in response to the Correction Order. Violations 11 and 14 are rescinded. Violation 15 is affirmed, and the violations for which you did not request reconsideration are affirmed. DHS will issue an Amended Correction Order. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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