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June 29, 2023 Jack Benson, Authorized Agent On-Belay of Minnesota Inc 115 Forestview Ln. N Plymouth, MN 55441 License Number: 1038850 (CRF) Investigation Report Numbers: 202209067 202300231
CORRECTION ORDER Dear Jack Benson: On March 28 through 30, 2023, a licensing review of Anthony Louis Center North located at 1000 Paul Parkway, Blaine, MN 55434, 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 chemical dependency services under Minnesota Rules, parts 2960.0430 through 2960.0490. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder. The following violations of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Policies and Practices 1. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, parts 2960.0050, subpart 1, item J; 2960.0080, subpart 4, item B and subpart 15, items A and B; and 2960.0160, subpart 4, item A. Violation: The license holder failed to meet requirements pertaining to facility rules in the following ways: a. The license holder’s policies and procedures did not describe their practices related to visitation and correspondence. During the licensing review a DHS licensor determined, through resident interviews and interactions with administrative staff persons, that the license holder had been utilizing a visitation and correspondence practice, referred to as Black-Out Week, which was described as restricting visitation and correspondence, including with parents/guardians, the first week following admission; b. The practice of Black-Out Week was not included in the copy of facility rules that were provided and explained to the residents upon admission; c. The license holder’s use of Black-Out Week did not ensure the residents’ rights to reasonable communication and visitation with family and unrestricted visitation with parents were protected; and d. The license holder failed to indicate the consequences that will be applied to modify unacceptable behavior. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the facility rules meet requirements. Within 30 days receipt of this order, submit a revised discipline policy and a copy of facility rules provided to residents that demonstrates compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated June 16, 2020. 2. Citation: Minnesota Statutes, section 245A.66, subdivision 1. Violation: The license holder’s internal reviews of alleged or suspected maltreatment of minors, did not meet requirements. For incidents dated November 1, 2022, and January 9, 2023, the documentation did not include an evaluation of whether the reported events were similar to past events with the children or the services involved. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of internal reviews meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 3. Citation: Minnesota Rules, parts 2960.0450, subpart 2, items B through D and subpart 4. Violation: The license holder failed to provide required treatment services in the following ways: a. Therapeutic recreation treatment services that were led by, directed by, or provided according to a plan developed by a qualified alcohol and drug counselor; and b. Group counseling and/or information on chemical awareness treatment services were not provided by a qualified alcohol and drug counselor. Resident documentation and staff interviews determined that there were multiple instances in which substance use disorder treatment services were not led and provided by a qualified alcohol and drug counselor. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the treatment services provided meets all applicable requirements. Within 30 days receipt of this order, submit a therapeutic recreation plan that meets all applicable requirements to demonstrate compliance. 4. Citation: Minnesota Rules, part 2960.0050, subpart 1, item O. Violation: The license holder failed to ensure a resident right was protected. Minnesota Statute section 144.651, subdivision 23 prohibits residents from performing labor or services for the facility unless those activities are included for therapeutic purposes and consistent with the residents’ treatment plan. Through review of resident and facility documentation and staff and resident interviews, DHS Licensors determined that residents were being assigned to “super clean” multiple areas of the building that were not for therapeutic purposes and consistent with the resident’s treatment plan. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the rights of residents are protected. Within 30 days receipt of this order, submit a copy of the description of applicable programs and activities, including living skills for residents that meets applicable requirements to demonstrate compliance. 5. Minnesota Rules, part 2960.0060, subparts 3, item A and 4. Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not meet requirements in the following ways: a. The following required performance indicators were not included: 1. Grievances; and 2. Information from the programs identified outcomes and outcome measures; and b. The program evaluation reports and findings for the identified performance indicators were not used to make improvements in the program. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated June 16, 2020. 6. Citation: Minnesota Rules parts 2960.0100, subparts 3 and 4; 2960.0050, subpart 1, item D; and 2960.0150, subpart 4, item A. Violation: The license holder did not meet requirements of personnel training in the following ways: a. The annual training plan to demonstrate in-service training offered by the program was not developed; and b. The training provided was not sufficient for employees to accomplish their job duties and to ensure the residents’ right to positive and proactive adult guidance was protected. A critical incident occurred leading to a licensing investigation. Through staff interviews it was indicated that staff did not feel competent in their job duties and roles based upon the training they were provided. Additionally, through review of training materials and reported training procedures, DHS licensors determined that the training did not meet the needs of individual staff persons and that specialized training was not sufficient for staff to develop adequate skills to care for residents. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of training meets all applicable requirements. 7. Citation: Minnesota Rules, section 2960.0080, subpart 17, item A. Violation: Three incident reports reviewed for requirements governing critical incident reports did not meet requirements. Critical incident reports were not submitted to DHS for incidents involving emergency responders (January 5, February, 1, and March 3, 2023). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the reporting of critical incidents meets all applicable requirements. 8. Citation: Minnesota Rules, part 2960.0080, subpart 18, item B. Violation: Nine of ten grievances reviewed for requirements governing grievances did not meet requirements. The license holder’s response did not include the findings and action taken for grievances dated a. November 30, 2022; b. January 10, 2023 (x3); c. January 15, 2023 (x3); and d. January 17, 2023 (x2). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of grievances meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident grievance that demonstrates compliance. 9. Citation: Minnesota Rules, part 2960.0140, subpart 1, item A. Violation: The license holder’s satisfaction survey did not contain an assessment of the following components: a. The accuracy, usefulness, and appropriateness of the screening and assessment of the resident's physical and emotional well-being and functioning; b. Provisions for the resident’s safety; and c. The positive and negative effects on the resident’s family of the treatment offered to the resident. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of satisfaction surveys meets all applicable requirements. Personnel Files 10. Citation: Minnesota Statutes, section 245A.041, subdivision 5. Violation: Six of six personnel files reviewed for requirements governing documentation requirements (personnel files numbered 1, 2, and 5) did not meet requirements. Documentation did not include the first date the staff person began working in a facility or setting. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements. 11. Citation: Minnesota Rules, parts 2960.0150, subpart 2 and 2960.0460, subpart 5, items A through C. Violation: Three of three files reviewed for alcohol and drug counselor qualifications did not meet requirements. The file for a staff person providing treatment services did not contain documentation to demonstrate they were qualified in the following ways: a. The staff person had an additional 30 hours of classroom instruction in adolescent development or a variance approval prior to providing treatment services (personnel file numbered 8); b. The staff person had 150 hours of supervised experience as an adolescent alcohol and drug counselor or a variance approval prior to providing treatment services (personnel files numbered 4 and 8); c. The staff person was either licensed or exempt from licensure (personnel files numbered 4, 5, and 8); and d. A copy of the professional license for a staff person licensed (personnel files numbered 4, 5, and 8). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of an alcohol and drug counselor’s qualifications meets all applicable requirements. This violation was corrected during the licensing review for items c and d above. Within 30 days receipt of this order provide personnel file documentation to demonstrate that all current ADC staff persons are qualified to demonstrate compliance. 12. Citation: Minnesota Rules 2960.0460, subpart 8, item b. Violation: One personnel file reviewed for requirements governing qualifications of an overnight staff person and personnel file documentation (personnel files numbered 2) did not meet requirements. The file did not contain documentation of their knowledge of and ability to perform basic first aid procedures, including cardiopulmonary resuscitation and first aid for seizures, trauma, and fainting. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of an overnight staff person’s qualifications meets all applicable requirements. Within 30 days receipt of this order provide personnel file documentation for one overnight staff person to demonstrate they are qualified to demonstrate compliance. 13. Citation: Minnesota Rules, part 2960.0460, subpart 6a, item A. Violation: Two of two personnel files reviewed for requirements governing supervision of an individual with a temporary permit (personnel files numbered 4 and 8) did not meet requirements. The file did not contain documentation that the staff person received supervision by an LADC for the weeks of August 26, 2022 and September 2, 2022. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of supervision for individuals with a temporary permit meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated June 16, 2020. 14. Citation: Minnesota Statutes, section 245A.19, paragraph (a), and Minnesota Rules, parts 2960.0100, subparts 3, item A and 5; and 2960.0150, subpart 4, item C. Violation: Four of six personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways: a. The staff person was not oriented to the following required topics before having unsupervised contact (personnel files numbered 1 and 3): 1. Emergency procedures; 2. Maltreatment of Minors reporting requirements under Minnesota Statutes, section 260E; 3. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues; and 4. General and special needs, including disability needs of residents and families served; 5. Operational policies and procedures of the license holder; and 6. Data practices regulations and issues; b. The staff person was not oriented to HIV Minimum Standards within 72 hours of first providing direct contact services (personnel files numbered 1 and 3); and c. Documentation did not include the date, number of hours, and the name of the entity/person(s) providing the training for each topic area (personnel files numbered 1 through 4). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit a template for documenting orientation training to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated June 16, 2020. Resident Files 15. Citation: Minnesota Rules, part 2960.0490, subparts 2, 3, items C and F, and 5.
Violation: Three of three resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The treatment plan dated January 3, 2023 (resident file numbered 1) and March 27, 2023 (resident file numbered 4) did not include a resident signature); b. The participation of others was not noted in the plans dated November 25, 2022 (resident file numbered 2), February 24, 2023, and March 27, 2023 (resident file numbered 4); c. The frequency of the intervention was not identified for each objective and the objectives were not time limited and measurable for the plan dated February 24, 2023 (resident file numbered 4); d. The minimum outcomes that were to be met before the resident discharged were not included in the plan dated February 24, 2023 (resident file numbered 4); and e. The treatment plan was not reviewed at least every two weeks for the treatment weeks ending: 1. January 7 and 28, 2023 and February 23, 2023 (resident file numbered 1); and 2. March 2, 2023 (resident file numbered 4). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plans and service plan reviews meet all applicable requirements. Within 30 days receipt of this order, submit one Treatment Plan and one Treatment Plan Review for one resident to demonstrate compliance. 16. Citation: Minnesota Rules, part 2960.0090, subpart 2.
Violation: Two of two resident files reviewed for requirements governing no-eject (resident files numbered 3 and 4) did not meet requirements. The file did not contain documentation to demonstrate the following: a. A description of how the license holder conferred with other interested persons to review the issues involved in the decision to discharge a resident prior to reaching their case plan goals; b. If any additional strategies to resolve the issues leading to discharge could have been developed to allow the resident opportunity to continue receiving services; and c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of no-eject meets all applicable requirements. Within 30 days receipt of this order, submit a template/form to document no-eject requirements to demonstrate compliance. B. Recommendations The following recommendations are not requirements of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas. 1. It is recommended that the license holder create a formalized hiring and training system that includes the following: i. A written guide that includes all licensing requirements involved around the hiring of staff persons in relation to background studies, qualifications for specific positions, documentation required in a personnel file, and vetting new employees; ii. Training curriculums; iii. Protocols for specific practices and job duties; iv. Training competencies for trainings provided; v. Training/competency checklist specific to each position; and vi. In-person trainings that allows for an interactive experience. 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: tina.christensen@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Tina Christensen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 C. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Tina Christensen, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6610
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