|
May 15, 2026 Melissa Winkler, Authorized Agent Northwood Children’s Home Society 714 W. College Street Duluth, MN 55811
License Number: 801777 (PRTF) Dear Melissa Winkler: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration regarding citation 3, paragraph b, and citation 8 in the Correction Order issued to you on February 4, 2026. After an independent review of the record, the Commissioner has determined it is appropriate to rescind paragraph b of citation 3. Citation 8 is affirmed. Also, the violations for which you did not request reconsideration are final and not within the scope of this review. Reconsideration Determination Violation 3: The license holder did not ensure the residents’ rights were protected in the following ways: a. The license holder did not comply with rights under Minnesota Statutes, section 144.651, subdivision 23, services for the facility. Residents were responsible for performing labor for the facility by having residents clean on the units without the labor being therapeutic or appropriately goal related; and b. Residents were not allowed to participate in the development of their treatment plan. Applicable Law Under Minnesota Variance, section R2960V.04, subpart 1, a resident has basic rights including, but not limited to, the rights in this subpart. The license holder must ensure that resident rights are protected. Resident rights include the right to participate in development of the resident’s treatment and case plan. Your Response You submitted a letter in which you indicated the citation was incorrect, and you submitted supporting documentation. You challenged only paragraph b of the violation. Reconsideration Determination After further review of the information contained in the file and the information you submitted, the Commissioner has determined it is appropriate to rescind paragraph b of the violation. Violation 8: The license holder did not meet requirements governing healthcare services. Schedule II drugs were not stored in a separately locked compartment from other medications.
Applicable Law Under Minnesota Variance, section R2960V.08, subpart 5, item 1, a license holder must have in place and implement written policies and procedures developed by a registered nurse that contains the following provisions: 1) A requirement that all drugs must be stored in a locked compartment. Schedule II drugs, as defined by Minnesota Statutes, section 152.02, must be stored in a separately locked compartment, permanently affixed to the physical plant or medication cart; 2) A system which accounts for all scheduled drugs each shift; 3) A procedure for recording the client’s use of medication, including the signature of the administrator of the medication with the time and date; 4) A procedure for destruction of discontinued, outdated, or deteriorated medications; 5) A statement that only authorized personnel are permitted to have access to the keys to the locked drug compartments; and 6) A statement that no legend drug supply for one client will be given to another client. Your Response You submitted a letter in which you indicated the violation was incorrect because Schedule II medications were behind two locks and in a separate compartment in both the nurses’ office and staff offices. You also indicated the medications were always kept separated and were in the nursing office from approximately 7:00 p.m. until 7:00 a.m. You submitted photographs showing where medications were stored. Reconsideration Determination During the licensing visit, the program indicated that Schedule II drugs were stored overnight in a locked cabinet in a central nursing office and that during the daytime, a nurse would bring all Schedule II drugs to each unit to be stored in the unit’s staff office with the rest of the medications. Licensors observed during the visit that when the Schedule II medications were on each unit in the staff office, the medications were kept in a separate cubby of the locked medication cabinet labeled “narcotics.” However, the cubby does not have an additional separate lock. The variance requires Schedule II drugs to be stored in a separately locked compartment, permanently affixed to the physical plant or medication cart. There is sufficient information to support the violation, and it is therefore affirmed. Disposition The Commissioner has reviewed the relevant laws and all the information you submitted in response to the Correction Order. Paragraph b of violation 3 is rescinded. The remaining violation for which you requested reconsideration is affirmed, and the violations for which you did not request reconsideration are affirmed. DHS will issue an Amended Correction Order. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
|
