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October 24, 2023 Rachael Swanson, Authorized Agent Hazelden Plymouth 15251 Pleasant Valley RD PO Box 11 F0-1 Center City, MN 55012
License Number: 1038741 (CRF)
CORRECTION ORDER Dear Rachael Swanson, On August 21 through 24, 2023 a licensing review of Hazelden Plymouth located at 11505 36th Ave N, Plymouth, Minnesota 55441 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 services under Minnesota Rules, 2960.0130 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490 (Rule CRF). 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 violation(s) 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, Procedures, and Practices 1. Citation: Minnesota Statutes 245A.04, subdivision 14, paragraph (a) and Minnesota Rules, part 2960.0150, subpart 3, item G. Violation: The license holder’s Staffing Plan does not identify how the direct care staff to resident supervision ratios required for CRF residents will be met. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the Staffing Plan meets all applicable requirements. Within 30 days receipt of this order, submit a revised Staffing Plan that meets all applicable requirements to demonstrate compliance.
2. Citation: Minnesota Rules 2960.0450, subpart 2, item D and subpart 4. Violation: The license holder’s implementation of Therapeutic Recreation treatment services did not meet requirements. Services were not led by, directed by, or provided according to a plan developed by a qualified alcohol and drug counselor. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the treatment services provided meet all applicable requirements. Within 30 days receipt of this order, submit a Therapeutic Recreation plan that meets all applicable requirements to demonstrate compliance. 3. Citation: Minnesota Rules, part 2960.0060, subparts 3, item A. Violation: The license holder’s program evaluation did not meet requirements. An annual evaluation of the strengths and weaknesses of the program was not completed for calendar years 2021 and 2022. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that outcome measures and evaluations meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 4. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A. Violation: The license holder’s reporting of critical incidents did not meet requirements. Twelve of fifty-six incidents reviewed met the definition of a critical incident and were not reported to DHS: a. Eight incidents involved an ambulance transport to the hospital; and b. Four incidents involved a police response to the program due to elopement. The license holder also provides substance use disorder treatment services to youth under Minnesota Statutes, chapter 245G, in addition to Minnesota Rules, chapter 2960. Internal incident reports did not clearly identify which standards were applicable to each youth. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the reporting of Critical Incidents to DHS meets all applicable requirements. Within 30 days receipt of this order, submit an incident reporting policy outlining the program’s procedure to ensure the reporting of critical incidents for CRF residents to demonstrate compliance. 5. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D. Violation: The license holder’s use of time-out did not meet requirements. Incident report documentation reviewed indicated the use of time-out was implemented on January 2, February 6, and February 26, 2023, and April 20 and August 29, 2022, and August 11, 2021. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the use of time-out meets all applicable requirements. Within 30 days receipt of this order, submit a policy outlining how time-out will be used to demonstrate compliance. 6. Citation: Minnesota Rules, part 2960.0140, subpart 1, item A. Violation: The license holder’s satisfaction survey did not meet requirements in the following ways: a. The license holder did not attempt to survey the resident’s parents/guardians or referring agency regarding their satisfaction with services; and b. The survey did not include the following required components: 1. Sleeping accommodations; 2. The accuracy, usefulness, and appropriateness of the screening and assessment of the resident’s physical and emotional well-being and functioning; 3. Support of the resident’s regular and special education, related services, and support for implementing the resident’s individual education plan; 4. Support of obtaining needed dental services identified in the resident’s screening and assessments or otherwise observed or reported by staff or other persons involved with the resident’s care; and 5. Support of family reintegration, if appropriate. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that satisfaction surveys meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. Personnel Files 7. Citation: Minnesota Statutes, section 245A.041, subdivision 5. Violation: Five of five personnel files reviewed for requirements governing documentation did not meet requirements. The first date the staff person began working in the facility or setting was not documented (personnel files numbered 1 through 5). 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. 8. Citation: Minnesota Statutes, section 245C.04, subdivision 7. Violation: Four of nine personnel files reviewed for requirements governing background studies (personnel files numbered 6 through 9) did not meet requirements. A legal name change occurred during the staff person’s employment; however, the license holder had not yet initiated a new background study or notified the commissioner at the time of the licensing review. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure background studies meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.
9. Citation: Minnesota Rules, parts 2960.0100, subpart 3, item A, and subpart 5. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways: a. Orientation to the following was not completed before having unsupervised contact with residents (personnel file numbered 4): 1. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment; 2. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues; 3. General and special needs, including disability needs of residents and families served; 4. Operational policies and procedures of the license holder including the programs drug and alcohol policy; and 5. Data Practices, regulations, and issues; and b. Orientation training was not documented with the date, number of hours, and the name of the entity who provided the training in each topic area (personnel files numbered 1, 3, and 4). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days receipt of this order, submit a revised orientation training checklist template that meets all applicable requirements to demonstrate compliance. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 10. Citation: Minnesota Rules, part 2960.0080, subpart 14. Violation: Four of five personnel files reviewed for requirements governing the emergency plan (personnel files numbered 1, 2, 4, and 5) did not meet requirements. The emergency plan was not reviewed with the staff person at least once every six months. Corrective Action Ordered: Effective immediately and on an ongoing basis, the license holder must ensure the review of the emergency plan meets all applicable requirements. 11. Citation: Minnesota Rules, parts 2960.0100, subpart 5 and 2960.0150, subpart 4, item B. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: a. Ongoing training was not documented with the date, number of hours, and the name of the entity who provided the training in each topic area (personnel files numbered 2 and 5); and b. The license holder did not demonstrate the staff person completed at least 24 hours of in-service training for calendar year 2022 (personnel file numbered 2). Corrective Action Ordered: Effective immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. Resident Files 12. Citation: Minnesota Rules, part 2960.0160, subpart 2, item A. Violation: Three of three resident files reviewed for requirements governing admission criteria (resident files numbered 1 through 3) did not contain documentation of the license holder’s determination of whether the resident is a danger to themselves or others. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of admission criteria meets all applicable requirements. 13. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A, B and C. Violation: Two of three resident files reviewed for requirements governing admission screenings did not meet requirements. The following screens were not completed: a. Education (resident file numbered 3); and b. Cultural needs (resident file numbered 2).
Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission screenings are completed and meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 14. Citation: Minnesota Rules, part 2960.0490, subparts 2 and 3, items B, C, and E. Violation: Three of three resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The participation of others was not noted within each plan (resident files numbered 1 through 3); b. A treatment goal was not developed for dimension three, in which a problem had been identified, for plans dated August 3, 2023 (resident file numbered 1) and March 23, 2023 (resident file numbered 2); and c. Minimum outcomes to be met before the resident discharged were not included in the plan dated August 3, 2023 (resident file numbered 1). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 15. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D. Violation: Two of three resident files reviewed for requirements governing the safe delivery of medicine (resident files numbered 1 and 3) did not meet requirements. The resident was administered over the counter medications before they were prescribed by a licensed prescriber. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the safe delivery of medicine meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 16. Citation: Minnesota Rules, parts 2960.0090, subpart 3 and 2960.0190, subpart 1, item C. Violation: Two of two resident files reviewed for requirements governing discharge procedures (resident files numbered 2 and 3) did not meet requirements. The license holder’s discharge documentation did not demonstrate: a. The discrepancies between the resident’s inventoried property turned over to the facility at admission and the property returned to the resident at discharge, along with the resolutions of the discrepancies; and b. A written notice of discharge was provided to the resident and the residents parents, or legal guardian. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure discharge procedures meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.
17. Citation: Minnesota Rules, part 2960.0190, subpart 1, items A and B. Violation: Two of two resident files reviewed for requirements governing the transition services plan did not meet requirements in the following ways: a. A transition services plan was not developed (resident file numbered 2); b. Resources available in the community to meet the resident’s continued needs were not included for all needs identified (resident file numbered 3); c. Recommendations for how the resident may deal with issues and potential challenges within the environment they were returning to were not included (resident file numbered 3); d. The plan was not developed with input from the appropriate school district and the continued service provider identified (resident file numbered 3); e. A copy of the plan was not provided to the continuing treatment service provider that the resident will attend (resident file numbered 3); and f. The following elements were not included (resident file numbered 3): 1. Recreation and leisure; 2. Appropriate educational, vocational rehabilitation, or training services; 3. Description of the resident’s financial and employment status; 4. Health Services; and 5. Personal Safety Needs. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the transition services plan meets all applicable requirements. Within 30 days receipt of this order, submit a transition service plan for one resident to demonstrate compliance. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 18. Citation: Minnesota Rules, part 2960.0190, subpart 2, items A and B. Violation: Two of two resident files reviewed for requirements governing discharge documentation did not meet requirements. The discharge summary did not include: a. The education services, including who provided them, that the resident received during their stay in the program (resident files numbered 2 and 3); and b. The services, including education that were recommended in the resident’s treatment plan, but were not provided to the resident (resident file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure discharge documentation meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021. 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 schedule a meeting with their Licensor to discuss variance requirements to address the following: i. Group size; and ii. Storage of prescription stock medication. 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 your Licensor 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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