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July 25, 2024 Tony Sanders, Authorized Agent Grafton Integrated Health Network Minnesota 3150 Shawnee Dr. Winchester, VA 22601 License Number: 1109203 (PRTF) Report Number: 202402238 CORRECTION ORDER Dear Tony Sanders: On April 1 through 5, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Grafton Integrated Health Network Minnesota, located at 224 Kray Mill Rd., Cold Spring, MN 56320. This review was conducted to determine compliance with state and federal laws and rules governing the provision of psychiatric residential treatment facilities under the variance to Minnesota Rules, Chapter 2960; R2960V. 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. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Postings, Policies, and Practices 1. Violation: The license holder did not comply with posting requirements in the following ways: a. The program abuse prevention plan (PAPP) was not posted in a prominent location in the program; and b. A copy of the resident’s rights was not posted where it could be readily accessed by staff and residents. Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and Minnesota Variance R2960V.04, subpart 2, item B. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute and rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure postings meet all applicable requirements. This was corrected onsite, no further action required. 2. Violation: The license holder did not meet requirements governing the program’s access to a licensed mental health professional. The license holder did not maintain a current schedule of the available licensed mental health professionals to ensure a treatment staff’s access, either in person or by telephone, to a licensed mental health professional within 30 minutes. Rule Violated: Minnesota Variance, section R2960V.14, subpart 4. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program’s access to a licensed mental health professional meet all applicable requirements. This was corrected onsite, no further action required. 3. Violation: The license holder did not meet requirements of Minnesota Rules, chapter 9544, the Positive Supports Rule (PSR), in the following ways: a. The license holder’s policy, Program Rules OPS 130, and the Resident Handbook allowed for the use of time-out, a prohibited procedure; and b. The license holder did not develop policies and procedures to maintain compliance with the PSR. The license holder’s policies and procedures did not address the requirements of the PSR in the following ways: i. The license holder did not have a procedure to screen for and determine who qualifies for the PSR; ii. The license holder did not have a policy on the emergency use of manual restraint, for notifying a resident and their legal representative of the policy and the resident’s rights; iii. The license holder did not have a policy or procedure requiring that a positive support transition plan will be developed for a resident who has had either three incidents of emergency use of manual restraint within 90 days or four incidents of emergency use of manual restraint within 180 days; and iv. The license holder’s policies did not include the following in accordance with the standards identified in Minnesota Rules, chapter 9544: 1. Procedures for conducting functional behavioral assessments; 2. The prohibited and permitted use of procedures and restrictions; 3. Procedures for implementing and documenting the required positive support strategies and person-centered planning; and 4. Procedures for reporting the use of restrictive interventions and incidents to the commissioner on the behavior intervention report form required by the commissioner. Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 14; Minnesota Rules, parts 9544.0010, subpart 2, 9544.0030 through 9544.0080, 9544.0100, and 9544.0110; and Minnesota Variance, sections R2960V.02, subpart 1, and R2960V.10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of Positive Support Rule (PSR) meets all applicable requirements. Within 30 days receipt of this order, submit policies and procedures for the PSR areas identified above to demonstrate compliance. 4. Violation: The license holder did not provide the commissioner with timely and complete access to resident files, personnel files, and other documentation required to demonstrate compliance with applicable statutes and rules. The commissioner must be given access without prior notice and as often as the commissioner considers necessary if the commissioner is conducting a licensing inspection. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the commissioner’s right of access meet all applicable requirements. 5. Violation: The license holder did not meet requirements governing staff ratios. Documentation did not demonstrate: a. If at least one staff person to every three residents present within the living unit was scheduled during awake hours; and b. If at least one staff person to every six residents present within the living unit was scheduled during sleeping hours and if there was access to other staff persons available within the facility. Rule Violated: Minnesota Variance, section R2960V.14, subparts 1 through 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff ratios meet all applicable requirements. Within 30 days receipt of this order, submit two consecutive weeks of unit staff schedules and the corresponding daily resident census per each living unit to demonstrate compliance. 6. Violation: The license holder did not meet requirements governing clinical supervision. For three of three weeks reviewed, the license holder did not ensure all treatment team members participated either in clinical supervision or an ancillary meeting for each calendar week they worked, for the weeks of: a. December 24, 2023 (11 of 44 staff persons); b. March 3, 2024 (7 of 38 staff persons); and c. March 10, 2024 (11 of 38 staff persons). Rule Violated: Minnesota Variance, section R2960V.13. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same requirement. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision for program staff meets all applicable requirements. 7. Violation: The license holder failed to ensure that all PRTF service staff in regular contact with residents were aware and understood each resident’s needs, goals, and services identified in the residents’ plan of care. During the licensing review, DHS licensors received information indicating that staff persons did not know how to implement interventions identified in resident plans of care. Rule Violated: Minnesota Variance, section R2960V.06, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the that all PRTF service staff in regular contact with residents are aware and understand each resident’s needs, goals, and services identified in the residents’ plan of care. 8. Violation: The license holder did not meet requirements governing quality assurance and improvement in the following ways: a. The license holder did not complete a review of the data or information related to the following required components every three months: i. Resident outcomes, including identifying ways to improve effectiveness of the services provided to residents and to improve resident outcomes; ii. Restraint data, according to part R2960V.11; iii. Serious occurrences and other significant incidents, including: 1. Determining whether policies and procedures were followed; 2. Evaluating the staff’s response to the serious occurrence and other significant incidents; 3. Assessing what could have prevented the serious occurrence and other significant incidents from occurring; and 4. Modifying policies, procedures, training plans, or resident’s ITPs in response to the findings of the review; and iv. Self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF Variance, R2960V, and demonstrating action to improve the program’s compliance with the requirements; and b. The license holder did not at least annually review, evaluate, and update the quality assurance and improvement plan required to include documentation of the actions the license holder would take as a result of the information obtained from the monitoring activities outlined in the plan and goals to improve service delivery for the next year. Rule Violated: Minnesota Variance, section R2960V.17, subparts 1 and 2. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quality assurance and improvement plan meets all applicable requirements. 9. Violation: The license holder did not complete a quarterly review of the patterns of the use of restraint procedures that considered the following: a. Any patterns or problems indicated by similarities in the time of day, day of the week, duration of the use of a procedure, individuals involved, or other factors associated with the use of restraint and seclusion procedures; b. Any injuries resulting from the use of restraint and seclusion procedures; c. Actions needed to correct deficiencies in the program's implementation of restraint and seclusion procedures; d. An assessment of opportunities missed to avoid the use of restraint and seclusion procedures; and e. Proposed actions to be taken to minimize the use of restraint and seclusion. Rule Violated: Minnesota Variance, section R2960V.11, subpart 5. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the review of the patterns of the use of restraint procedures meet all applicable requirements. 10. Violation: The license holder’s governing body did not annually review the Program Abuse Prevention Plan (PAPP) using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review for calendar years 2022 and 2023. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual review of the PAPP meet all applicable requirements. 11. Violation: A controlling individual of the program did not annually review and sign the plan for transfer of clients and records upon closure for calendar years 2022 and 2023. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual review of the plan for transfer of clients and records upon closure meet all applicable requirements. Personnel Files 12. Violation: Five of five personnel files reviewed for requirements governing training for staff providing services to individuals who qualify for the Positive Support Rule (PSR) did not meet requirements. Documentation did not demonstrate the following: a. Whether the following training was completed: i. At least eight hours of core training, for staff persons responsible for developing, implementing, monitoring, supervising, and/or evaluating positive support strategies, a positive support transition plan, and/or the emergency use of manual restraint, to the following required topics (SP1 through SP5): 1. Principles of person-centered service planning and delivery, and how they apply to direct support services provided by staff; 2. The safe and correct use of manual restraint on an emergency basis; 3. Staff responsibilities related to prohibited procedures; why the procedures are not effective for reducing or eliminating symptoms or interfering behavior; and why the procedures are not safe; 4. Staff responsibilities related to restricted and permitted actions and; 5. The procedures and forms staff must use to monitor and report use of restrictive interventions that are part of a positive support transition plan; 6. Understanding of the person as a unique individual and how to implement treatment plans and responsibilities assigned to the license holder; and 7. Personal staff accountability and staff self-care after emergencies; b. An additional four hours of function-specific training based upon the level of responsibility and qualifications, prior to assuming responsibilities, for staff persons who develop positive support strategies and program managers, to the following required topics (SP4 and SP5): i. Functional behavior assessments; ii. How to apply person-centered planning; iii. How to design and use data systems to measure effectiveness of care; and iv. Supervision, including how to train, coach, and evaluate staff and encourage effective communication with the resident and the resident’s support team; and c. A minimum of an additional two hours of function-specific training for staff persons in manager positions to the following required topics (SP4 and SP5): i. How to include staff in organizational decisions; ii. Management of the organization based upon person-centered thinking and practices and how to address person centered thinking and practices in the organization, and iii. Evaluation of organizational training as it applies to the measurement of behavior change and improved outcomes for persons receiving services. Rule Violated: Minnesota Rules, part 9544.0090, subparts 1 through 5; and Minnesota Variance, section R2960V.02, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff training for PSR meets all applicable requirements. 13. Violation: Five of five personnel files reviewed for requirements governing background study subjects and staff files did not meet requirements. The files did not include: a. Verification of the staff persons qualifications specific to the position including required credentials and/or professional licensure (SP5); b. The date of hire (SP2 through SP4); c. Job description (SP1 and SP3 through SP5); d. The date the background study subject/staff person had direct contact with persons served by the license holder’s program (SP2 and SP5); e. An annual job performance evaluation (SP5); and f. An annual development and training plan (SP5). Statute and Rule Violated: Minnesota Statutes, section 245A.041, subdivision 6 and Minnesota Variance, section R2960V.15, subpart 5. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated May 5, 2023 · Correction Order dated February 27, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the inclusion of background study requirements and staff files meet all applicable requirements. 14. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements. The staff person did not receive orientation to the following prior to direct contact (SP2 through SP4): a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, section 245A.65, subdivision 3, and 626.557 and 626.5572, and the license holder’s program abuse prevention plan (PAPP); and b. Training related to the specific activities and job functions that the staff person will be responsible to carry out. Rule Violated: Minnesota Variance, section R2960V.16, subpart 2, item A. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of orientation training meets all applicable requirements. 15. Violation: Two of two personnel files reviewed for requirements governing annual training did not meet requirements. The staff person did not receive annual training to the following: a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, section 245A.65, subdivision 3, and 626.557 and 626.5572, and the license holder’s program abuse prevention plan (PAPP) (SP1 and SP5); and b. Resident behavioral emergency procedures (SP1); and c. Treatment services for residents with co-occurring disorders (SP1 and SP5). Rule Violated: Minnesota Variance, section R2960V.16, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of annual training meets all applicable requirements. 16. Violation: Five of five personnel files reviewed for requirements governing documentation of orientation and training (SP1 through SP5) did not meet requirements. Documentation did not include names and credentials of the people who certified the completion of the training. Rule Violated: Minnesota Variance, section R2960V.16, subpart 6. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of orientation and training meet all applicable requirements. Resident Files 17. Violation: Two of two resident files reviewed for requirements governing the Positive Support Rule did not meet requirements in the following ways: a. The license holder utilized a prohibited action and/or procedure for a behavioral or therapeutic program to reduce or eliminate a behavior in the following ways: i. Use of a show of force on November 26, 2023 (R3); ii. Use of an intervention that constituted an aversive or deprivation procedure on March 2, 2024 (R1); and iii. Use of time-out on December 7, 25, and 26, 2023, and January 9, 10, and 12, 2024 (R3); b. The license holder did not use the behavior intervention report form (BIRF) required by the commissioner to report the following incidents to the commissioner: i. An emergency use of manual restraint on March 23 and 31, 2024 (R1) and on January 13, 2024 (R3); and ii. A behavioral incident that resulted in a call to 911 on February 25, 2024 (R1) and on November 26, 2023 (R3). Rule Violated: Minnesota Rules, parts 9544.0060, subpart 1 and 9544.0110; and Minnesota Variance, section R2960V.02, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of PSR meets all applicable requirements. 18. Violation: Three of three resident files reviewed for requirements governing resident rights (R1 through R3) did not meet requirements. Documentation of the resident’s receipt of basic rights information did not demonstrate that the license holder explained the rights to the resident in a language that the resident could understand and upon the time of admission. Rule Violated: Minnesota Variance, section R2960V.04, subpart 2, item A. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of resident rights meet all applicable requirements. 19. Violation: Three of three resident files reviewed for requirements governing program rules (R1 through R3) did not meet requirements. Documentation did not demonstrate that the license holder communicated the program rules and details for the due process system used in the facility, both verbally and in writing, to the resident. Rule Violated: Minnesota Variance, section R2960V.10. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of program rules meets all applicable requirements. 20. Violation: Three of three resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways: a. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize safety risks (R1 through R3); b. The plan of care was not reviewed at least once during the first 10 days following admission (R2 and R3); c. Treatment objectives were not measurable and did not include target dates for achievement (R1 through R3); d. Strategy interventions did not identify the staff who were responsible to deliver the interventions (R1 through R3); e. Strategy interventions did not identify the frequency they were to be implemented (R1 through R3) f. Medication management treatment goals were not reflected on the plan (R1 through R3); g. There was no documentation to demonstrate an individual support plan was developed for individuals that displayed behaviors that might require the use of restraint or seclusion (R1 through R3); and h. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (R1 and R3). Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, items A and B. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 30 days receipt of this order, submit an Individual Plan of Care and Individual Support Plan for one resident that meets all applicable requirements to demonstrate compliance. 21. Violation: Three of three resident files reviewed for requirements governing medication reconciliation and medication administration did not meet requirements in the following ways: a. Medication reconciliation was not completed upon admission (R1 through R3) and upon discharge (R3). Documentation did not demonstrate the following process was followed: i. A list of current medications was developed, including the dose and frequency along with other drug interactions and allergies from the residents last residence or hospitalization; ii. Prescriptions or admission orders were compared to the current medication list and any discrepancies were identified, and any differences were reconciled; iii. The prescriber was notified of any discrepancies so the prescriber could make clinical decisions based on the comparison; iv. If required, new orders were obtained; and b. The medication administration record included blank time entries and there was no notation to indicate if the medication was administered as prescribed (R1 through R3); and c. There was no documentation in the file to demonstrate the quantity of medications initially received from the pharmacy (R1 through R3). Rule Violated: Minnesota Variance, section R2960V.08, subparts 3, and 4, items A through C. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication reconciliation meets all applicable requirements. 22. Violation: Three of three resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways (R1 through R3): a. The prescribing practitioner did not document the following required information: i. A description in observable and measurable terms of the symptoms and behaviors the psychotropic medication is to alleviate; and ii. Data collection methods the license holder must use to monitor and measure changes in symptoms and behaviors that are to be alleviated by the psychotropic medication; and b. Resident file documentation did not demonstrate that the license holder considered the following for each psychotropic medication review conducted by the prescribing practitioner: i. Targeted symptoms and behaviors of concern; ii. Data collected since the last review; and iii. Side effects observed and actions taken. Rule Violated: Minnesota Variance, section R2960V.08, subpart 6, items B and C. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure psychotropic medication reviews meet all applicable requirements. 23. Violation: Two of three resident files reviewed for requirements governing informed consent did not meet requirements in the following ways: a. The license holder did not obtain informed consent, either orally or in writing, prior to the administration of a psychotropic medication (R1 and R3); b. The license holder did not obtain informed consent, in writing only, prior to the administration of an antipsychotic medication. Requirements were not met in the following ways: i. The informed consent was not signed by the legal representative (R2); ii. There was no informed consent form in the file for an antipsychotic medication that was administered to a resident (R3); and iii. A medication was administered on June 15, 2023, prior to informed consent provided by the legal representative for authorization on September 22, 2023 (R3); c. Documentation did not demonstrate if the resident was informed and involved, if possible, in the decision making for each medication prescribed and administered (R1 through R3); d. Informed consent was not obtained by the license holder within 30 days to continue the use of psychotropic medication for a resident admitted with prescribed psychotropic medication (R1 and R3); e. Informed consent documentation for prescribed psychotropic and antipsychotic medications did not contain the following required information: i. The diagnosis for which the medication was prescribed (R3); ii. The pharmacological and non-pharmacological treatment options available and the course of the condition with and without the treatment options (R3); iii. Specific information about the psychotropic medication to be used, including (R3): 1. The route of administration; 2. The estimated duration of therapy; and 3. The possible dosage range or maximum dose; iv. How the serious risks and possible side effects of the medication must be managed (R3); v. An explanation that consent may be refused or withdrawn at any time and that the consent is time-limited and automatically expires within 30 days for oral consent and yearly for written consent (R3); vi. The names, addresses, and telephone numbers of appropriate professionals to contact if questions or concerns arise (R3); and vii. The signature of the resident to acknowledge the prescribing practitioner or designee talked about the medication with the resident, answered questions, and that the resident agreed to the medication and dosage (R1 through R3). Rule Violated: Minnesota Variance, section R2960V.08, subpart 7, items A and E, and subpart 8. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure informed consents meet all applicable requirements. 24. Violation: Three of three resident files reviewed for requirements governing medication side effect monitoring did not meet requirements in the following ways (R1 through R3): a. The license holder did not document and monitor for side effects within 24 hours of admission; b. The license holder did not monitor for side effects weekly as determined by the prescribing psychiatric practitioner; and c. Standardized checklists, rating scales, or scales developed for a specific drug or drug class were not used as monitoring tools as determined by the prescribing psychiatric practitioner. Rule Violated: Minnesota Variance, section R2960V.08, subparts 2, item G, and 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of medication side effects meet all applicable requirements. 25. Violation: Two of two resident files reviewed for requirements governing debriefings for the use of restraint and seclusion did not meet requirements. The debriefing following the use of restraint did not meet requirements in the following ways: a. Staff debriefing sessions were not conducted after the use of restraints for the following occurrences: i. March 23 and 31, 2024 (R1); and ii. January 24, 2024 (R3); and b. Precipitating factors and alternative techniques that might have prevented the use of restraints were not incorporated into the resident’s individual support plan to prevent future use (R1 and R3). Rule Violated: Minnesota Variance, section R2960V.11, subpart 3, items A and C. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of debriefings meet all applicable requirements. 26. Violation: Two of two resident files reviewed for requirements governing administrative reviews of restrictive procedures did not meet requirements in the following ways: a. The administrative review was not completed within three working days for the following incident dates: i. March 23 and 31, 2024 (R1); and ii. January 13, 2024 (R3); b. The administrative review was not completed by someone other than the person who decided to impose the restraint, or that person’s immediate supervisor for the use of restrictive procedures on January 13, 2024 (R3); c. Documentation did not identify that the resident or the resident's representative had an opportunity to present evidence and argument to the reviewer about why the procedure was unwarranted, for the following incidents: i. March 23 and 31, 2024 (R1); and ii. January 13, 2024 (R3); and d. The record of the administrative review for incidents dated March 23 and 31, 2024 (R1) and January 13, 2024 (R3) did not include the following required components: i. If the required documentation was recorded; ii. If the restrictive procedure was used in accordance with the treatment plan; iii. An evaluation of whether the rule standards governing the use of restrictive procedures were met; and iv. Whether or not the staff who implemented the restrictive procedure were properly trained. Rule Violated: Minnesota Variance, section R2960V.11, subpart 4. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of administrative reviews of restrictive interventions meet all applicable requirements. 27. Violation: One resident file reviewed for requirements governing discharge and aftercare plans (R3) did not meet requirements in the following ways: a. Documentation did not demonstrate that the discharge plan was developed at least 10 days before discharge; b. The aftercare plan did not include the following: i. Medical needs; ii. Discharge diagnosis; iii. Appointments with after discharge service providers indicating date, time, and place; iv. Contact information for internal PRTF providers; v. Contact information for the PRTF educational provider; and c. There was no documentation to demonstrate the license holder shared documents related to the resident’s care in their facility to any mental health providers who will be providing aftercare services. Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, items B and C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge documentation and aftercare plans meet all applicable requirements. 28. Violation: Three of three resident files reviewed for requirements governing documentation standards did not meet requirements in the following ways: a. Documentation in the resident’s file did not include direct care and nursing staff person’s titles (R1 through R3); b. A mental health professional did not co-sign and date required treatment service notes for a clinical trainee who provided treatment services to a resident on February 8 and 21, 2024 and March 6, 7, and 8, 2024 (R2); c. A daily summary was not completed for each day sampled: i. February 22, 2024, and March 3, 4, 5, and 9, 2024 (R1); and ii. December 12, 2023, and January 4, 5, 14, 17, and 19, 2024 (R3); and d. Documentation did not demonstrate case coordination activities occurred with other professionals, including case managers and community-based mental health providers, or others (R1 & R2). Rule Violated: Minnesota Variance, section R2960V.06, subpart 1, item C, and R2960V.19, subparts 2 through 4. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident file documentation meet all applicable requirements. 29. Violation: One resident file reviewed for requirements governing the no eject policy (R3) did not meet requirements. Documentation did not demonstrate: a. Whether the license holder conferred with all interested persons to review the issues involved in the decision to discharge the resident; and b. Whether the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder; and c. Any alternatives considered or attempted. Rule Violated: Minnesota Variance, section R2960V.07, subpart 4. Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure no-eject documentation 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 at tina.christensen@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Tina Christensen 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 651-431-6610 or at tina.christensen@state.mn.us .  Sincerely, Tina Christensen, Senior Licensor Licensing Division Office of Inspector General
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