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June 18th, 2024 Wylie Boehmlehner, Authorized Agent 1326 East Ripley Street, Litchfield, MN 55355 License Number: 1047343 Report Numbers: 202306482 202309219
CORRECTION ORDER Dear Wylie Boehmlehner, On April 24th, 25th, and 26th, 2024 the Department of Human Services (DHS) conducted a licensing review and investigation at your facility, Wings, located at 1326 E. Ripley St, Litchfield, MN 55355. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, chemical dependency treatment program certification standards under Minnesota Rules, parts 2960.0430 through 2960.0500. As a result of this visit, 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. Policies and Practices 1. Violation: The license holder’s operational policies and procedures did not meet requirements in the following ways: a. The license holder’s policy for a resident’s communication and visitation with others inside and outside of the facility, Call & Visitation Rules, did not include that the license holder will allow for parental visits at times that accommodate the parent’s schedule; b. The license holder’s written staffing plan did not identify the staffing assignments of the program based on the needs of the residents and the features of the physical plant; and c. The license holder’s written maintenance plan did not include procedures for detecting, reporting, and correcting building and equipment deterioration, safety hazards, and unsanitary conditions Rule Violated: Minnesota Rules, parts 2960.0080, subpart 15, item B, 2960.0150, subpart 3, and 2960.0200, subpart C Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure operational policies and procedures meet all applicable requirements. Within 30 days receipt of this order, submit a revised maintenance plan and a revised staffing plan that meet all applicable requirements to demonstrate compliance. 2. Violation: The license holder’s plan for transfer of clients and records upon closure did not meet the requirements as they did not retain a signed copy of the plan for calendar year 2023. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a) Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the plan for the transfer of clients and records upon closure meets all applicable requirements. 3. Violation: The license holder’s satisfaction surveys did not meet requirements. The survey did not address satisfaction with the support of family and community reintegration. Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, Item A Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of satisfaction survey’s meets all applicable requirements. Within 30 days receipt of this order, submit a revised survey that demonstrates compliance. 4. Violation: The license holder did not meet requirements governing staff ratios. Documentation did not demonstrate that at least one direct care staff was present for every twelve residents during awake hours for the following dates and months of 2023: a. May 1, 8, 22, 23; and b. June 5, 7, 9, 14, 23, and 26. Rule Violated: Minnesota Rules, part 2960.0150, subpart 3, item G. Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the documentation of minimum staff to resident ratios meets all applicable requirements. Within 30 days receipt of this order, submit documentation of staff ratios for one week that demonstrates compliance. Personnel Files 5. Violation: One of two personnel files reviewed for requirements governing programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), did not meet requirements (personnel file numbered 5). There was no documentation to demonstrate the staff person received 8 hours of training in co-occurring disorders annually in 2022. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191 Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of co-occurring annual training meets all applicable requirements. 6. Violation: One personnel file reviewed for requirements governing staff qualification did not meet the requirements in the following ways (personnel file numbered 4): a. There was no documentation to demonstrate the staff person had an additional 30 hours of classroom instruction in adolescent development; and b. There was no documentation to demonstrate the staff person received the required weekly supervision by a licensed alcohol and drug counselor for February through April, 2024. Rule Violated: Minnesota Rules, part 2960.0460, subpart 5, item B and part 2960.0460, subpart 6a, item A Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of staff qualifications meets all applicable requirements. 7. Violation: Four of six personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. The specific medication assistance training provided by the registered nurse was not documented in the personnel record (personnel file numbered 2); b. The staff person was not oriented to cultural diversity and gender sensitivity prior to providing direct contact services (personnel file numbered 2); c. The staff person was not oriented to vulnerable adult maltreatment reporting and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services (personnel files numbered 1, 2, 3, and 6); and d. There was not documentation of the staff person’s competency in crisis intervention techniques consistent with the program’s protective procedures plan (personnel file numbered 3). Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, Minnesota Rules, part 2960.0080, subpart 11, item D, part 2960.0100, subpart 3, item A, and part 2960.0460, subpart 8, item C Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of orientation training meets all applicable requirements. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022. 8. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet the requirements in the following ways: a. The staff person’s training on vulnerable adult maltreatment reporting, the program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was completed late in 2023 (personnel file numbered 4); and b. The license holder did not document the name of the entity that provided the training as they documented the supervisor instead (personnel files numbered 4 and 5). Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, Minnesota Rules, part 2960.0100, subparts 3, item A, and 5 Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of ongoing training meets all applicable requirements. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022. Resident Files 9. Violation: One resident file reviewed for requirements governing the individual abuse prevention plan did not meet requirements (resident file numbered 4). The license holder did not identify referrals that were made when the vulnerable adult was susceptible to abuse outside the scope or control of the licensed service. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of the individual abuse prevention plan meets all applicable requirements. 10. Violation: Two of three resident files reviewed for requirements governing program services did not meet requirements in the following ways: a. The license holder did not obtain the placing agency’s case plan goals for the resident and did not document their efforts to do so (resident file numbered 3). b. Documentation did not demonstrate that the license holder identified and shared important information about the resident’s behaviors with persons who were directly involved in the resident’s treatment plan nor that they received and responded to a parent/guardian’s request for a resident’s records (resident file numbered 8). Rule Violated: Minnesota Rules, part 2960.0080, subpart 3, items A, B, D, and F Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the program services meets all applicable requirements. 11. Violation: One of three resident files reviewed for requirements governing required treatment services and documentation did not meet requirements (resident file numbered 3). Documentation did not demonstrate the resident received at least 15 hours of service per week for the week of May 29, 2023. Rule Violated: Minnesota Rule, part 2960.0450, subpart 2 Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment services meets all applicable requirements. 12. Violation: Two of three resident files reviewed for requirements governing health care did not meet requirements in the following ways: a. There was no documentation to demonstrate the license holder attempted to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident files numbered 3). b. The license holder failed to ensure that the prescribing physician’s directions for monitoring medications used by a resident were followed (resident file numbered 8). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. 13. Violation: Two of two resident files reviewed for requirements governing time out procedures did not meet requirements in the following ways (resident files numbered 5 and 7): a. Documentation did not identify to where the resident was escorted; and b. There was no documentation to demonstrate that time-out was used under the direction of a mental health professional, the facility director, or the program manager. Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of time out procedures meets all applicable requirements. Within 30 days receipt of this order, submit time-out documentation that demonstrates compliance. 14. Violation: One of three resident files reviewed for requirements governing no eject discharges did not meet requirements (resident file numbered 5) in the following ways: a. There was no documentation to demonstrate the license holder conferred with other interested persons to review the issues involved in the decision to discharge the resident prior to the discharge; b. There was no documentation to demonstrate if the license holder determined if they, the treatment team, or interested persons, could develop any additional strategies to resolve the issues leading to the discharge as they did not develop a plan; and c. The license holder did not document the reason for the discharge being warranted and the alternatives considered or attempted. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2 Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of no eject discharges meets all applicable requirements. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022. 15. Violation: One of three resident files reviewed for requirements governing programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), did not meet requirements (resident file numbered 2). The diagnostic assessment was not completed within 10 days of admission. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191 Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of co-occurring resident files meets all applicable 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 (michael.s.cihla@state.mn.us) or mail: Commissioner, Department of Human Services ATTN: Michael Cihla 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960. · 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 651-431-5909. Sincerely, Michael Cihla, Licensor Licensing Division Office of Inspector General
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