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May 27, 2026
Melissa Winkler, Authorized Agent Northwood Children’s Home Society 714 W College Street Duluth, MN 55811 License Number: 801777 (PRTF) AMENDED CORRECTION ORDER NOTICE: This Amended Correction Order supersedes a Correction Order issued February 4, 2026, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on March 10, 2026. This Amended Order reflects the final decision on the request for reconsideration issued on May 15, 2026. Dear Melissa: On December 8 through 11, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Northwood Children's Services - West Campus, located at 4000 West 9th Street, Duluth, MN 55807. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Psychiatric Residential Treatment Facilities (PRTF) under Minnesota Rules, part 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 did not follow licensing rules and statutes, as described below. Physical Plant 1. Violation: The license holder did not meet requirements of facility postings. A copy of the resident’s rights was not posted in the Wolverines or Huskies units. Rule Violated: Minnesota Variance, section R2960V.04, subpart 2, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure postings in the physical plant meet all requirements. 2. Violation: The license holder’s physical environment did not provide for the comfort, privacy, and dignity of residents. The Scouts unit did not have window coverings on windows in the residents’ rooms. Rule Violated: Minnesota Variance, section R2960V.20, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the physical environment meets all requirements. Practices 3. Violation: The license holder did not ensure the residents’ rights were protected in the following way: a. The license holder did not comply with rights under Minnesota Statutes, sections 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. Rule Violated: Minnesota Variance, section R2960V.04, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of resident’s rights. 4. Violation: The license holder’s resident handbooks describe a program that is not individualized, trauma informed, or person centered, as evidenced by the following: a. “High expectations for self-care and personal hygiene,” including daily showers and rules around facial hair and hair length and tidiness; b. Expectations around how rooms are kept such as “top of dresser clean of dust, decorations neatly organized on top,” “stuffed animals arranged neatly on top of comforter,” and “bulletin board decorated nicely;” c. Language around treatment including “at the end of every shift, the staff working with you with decide if you pass or fail your shift based on your objective;” and d. A proscriptive dress code that does not allow for individualization. Rule Violated: Minnesota Variance, sections R2960V.06, subpart 2. Corrective Action Required: Immediately an on an ongoing basis, the license holder must comply with all requirements of program rules. Within 30 days receipt of order, seek guidance from the Behavioral Health Administration and submit resident handbooks for all units that demonstrate compliance with person centered and trauma informed treatment. 5. Violation: The license holder did not meet requirements of clinical supervision. For the treatment weeks of September 2 through 8, 2024, and November 24 through 30, 2025, the license holder did not have documentation of the following: a. That all treatment team members participated either in clinical supervision or an ancillary meeting; b. An accurate account of the names of staff who attended the supervision; and c. That the ancillary meeting was conducted by the clinical supervisor or a mental health practitioner who participated in the weekly meeting. Rule Violated: Minnesota Variance, section R2960V.13. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Within 30 days receipt of order, submit a plan that outlines how the program will maintain compliance with requirements of clinical supervision, as well as a week of clinical supervision documentation that demonstrates compliance. 6. Violation: The license holder did not meet requirements of staff ratios in one of two weeks reviewed. The license holder did not have documentation to demonstrate that they had a ratio of at least one staff person to three residents within the living unit on the following dates: a. September 2, 3, 5, and 6 , 2024, on the Huskies unit; b. September 2 and 4, 2024, on the Wolverines unit; and c. September 2, 2024, on the Scouts unit. Rule Violated: Minnesota Variance, section R2960V.14, subpart 2. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of staff ratios. Within 30 days receipt of order, submit a plan that outlines how they program will maintain and document compliance with requirements of staff ratios. 7. Violation: The license holder did not meet requirements governing quality assurance and improvement. The license holder did not complete a quarterly review for calendar year 2024 and 2025 quarter 1 through 3, that considered the following components: a. Evaluating feedback from residents, family members, staff, and referring agencies concerning the services provided; b. Reviewing significant incidents to all requirements; and c. Reviewing self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF variance and demonstrating action to improve the program’s compliance with the requirements. Rule Violated: Minnesota Variance, section R2960V.17, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of quality assurance and improvement measures. Within 30 days receipt of order, submit an outline of the quarterly review that demonstrates compliance with all requirements. 8. Violation: The license holder did not meet requirements governing healthcare services. Schedule II drugs were not stored in a separately locked compartment from other medications. Rule Violated: Minnesota Variance, section R2960V.08, subpart 5, item 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of healthcare services. Within 30 days receipt of order, submit pictures that demonstrate that all schedule II drugs are stored in a way that meets requirements. 9. Violation: The license holder did not meet requirements governing the quarterly review of patterns of the use of restraint. DHS licensors reviewed a sample size of restraints for calendar years 2024, quarters 1 through 4, and 2025, quarters 1 through 3. The review did not consider 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; b. Any injuries resulting from the use of restraint; c. Actions needed to correct deficiencies in the program’s implementation of restraint; d. An assessment of opportunities missed to avoid the use of restraint; and e. Proposed actions to be taken to minimize the use of restraint. Rule Violated: Minnesota Variances, section R2960V.11, subpart 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the review of patterns of the use of restraint. Within 30 days receipt of order, submit an outline of a quarterly review process that demonstrates compliance with all requirements. 10. Violation: The license holder did not meet requirements governing staff training and management. The license holder did not provide documentation of a schedule of training opportunities that was updated at least annually for the calendar years 2024 and 2025. Rule Violated: Minnesota Variance, section R2960V.16, subpart 1, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of staff training and management. Personnel 11. Violation: Eleven of twenty-two personnel files reviewed for requirements of background studies did not meet requirements in the following ways: a. A staff person began a position allowing direct contact with persons served by the program on January 26, 2024. The staff person has since had a legal name change; however, the license holder did not initiate a new background study or notify the commissioner of the name change (personnel file numbered 21); b. A staff person began a position allowing direct contact with persons served by the program on June 9, 2025. A background study was submitted under license number 801755; however, the staff person was also working under license number 801777. The license holder did not affiliate the staff person to all required rosters (personnel file numbered 8); c. A staff person began a position allowing direct contact with persons served by the program on June 6, 2011. A background study was submitted under license number 801755; however, the staff person was also working under license number 801777. The license holder did not affiliate the staff person to all required rosters (personnel file numbered 22); and d. The license holder did not document the first date that the staff person had direct contact with persons served by the program (personnel files numbered 2, 4, 5, 8, 9, 13, 18, 19, and 20). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6, 245C.04, subdivision 7, and 245C.07, paragraph (f). Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. 12. Violation: Four of twenty files reviewed for information in staff files did not meet requirements. The staff files did not contain: a. Verification of the staff’s qualifications (personnel file numbered 10); b. A job description that identifies the date that specific job responsibilities are effective (personnel files numbered 4, 9, and 13); and c. Documentation of orientation (personnel files numbered 4, 9, and 13). Rule Violated: Minnesota Variance, section R2960V.15, subpart 5. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of information in staff files. 13. Violation: Ten of ten personnel files reviewed for requirements governing orientation training did not meet requirements in these ways: a. There was not documentation to demonstrate that staff received orientation on the following topics prior to providing direct contact services: i. Emergency procedures (personnel file numbered 8); and ii. The specific activities and job functions that the staff person will be responsible to carry out (personnel files numbered 4, 8, 9, and 13). b. There was not documentation to demonstrate that staff received training on the following topics within 30 days of providing direct contact services (personnel files numbered 2, 4, 5, 8, 9, 12, 13, 18, 19, and 20): i. Facility policies and procedures; and ii. Best practices service delivery including the characteristics and treatment of residents with special needs such as substance abuse, obsessive compulsive disorder, and eating disorders and co-occurring disorders as defined by the population being served. Rule Violated: Minnesota Variance, section R2960V.16, subpart 2, items A and B. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of orientation training. Within 30 days receipt of order, submit a staff orientation plan that demonstrates compliance. 14. Violation: Ten of ten personnel files reviewed for requirements governing annual training did not meet requirements. There was not documentation to demonstrate that staff received annual training on the following topics: a. Treatment services for residents with co-occurring disorders for calendar years 2024 and 2025 (personnel files numbered 1, 3, 6, 7, 10, 11, 14, 15, 16, and 17); and b. Staff not licensed as mental health practitioners did not receive the required additional annual training for the calendar years 2024 and 2025. Their additional annual training did not include a minimum of four subjects from Minnesota Variance, section R2960V.16, subpart 3, item 5 (personnel files numbered 1, 6, 10 (2024 only), 11, 14, 15, and 17) and did not total at least 24 hours for the calendar years 2024 and 2025 (personnel file numbered 11). Rule Violated: Minnesota Variance, section R2960V.16, subparts 3 and 4. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of annual training. 15. Violation: Thirteen of twenty personnel files reviewed for requirements governing the documentation of orientation and training did not meet requirements in these ways: a. Documentation of the staff member’s training did not include the following: i. The subjects covered and the names and credentials of the people who certified the completion of the training (personnel files numbered 2, 4, 5, 8, 9, 12, 13, 14, 18, 19, and 20); and ii. The competency evaluation for training on the use of restraint (personnel files numbered 2, 5, 9, 12, 13, 18, 19, and 20). b. Documentation did not demonstrate that the staff person’s training needs were evaluated at least annually (personnel files numbered 11) (calendar year 2025). Rule Violated: Minnesota Variance, sections R2960V.15, subpart 2 and R2960V.16, subpart 6. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the documentation of orientation and training. Within 30 days receipt of order, submit documentation of a staff person’s training record that demonstrates compliance with all requirements. Residents 16. Violation: Four of five resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways: a. The immediate needs assessment did not include an assessment of needs related to the resident’s health (resident files numbered 1, 2, 3, and 5); b. The plan of care did not reflect the resident’s changing condition and was not updated following instances of physical holding, suicidal ideation or self-injurious behavior (resident file numbered 5); c. The plan of care was not reviewed every 30 days (resident files numbered 3 and 5) and the review didn’t consider all applicable and appropriate treatment modalities (resident files numbered 1, 3, and 5); d. The plan of care did not include the following (resident files numbered 1 through 4): i. Target dates for the treatment objectives; ii. The frequency of the interventions and the staff responsible for delivering them; and iii. Medication management goals. Rule Violated: Minnesota Variance, sections R2060V.07, subpart 1, items A and B, and R2960V.08, subpart 2, item J. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the individual plan of care. Within 30 days receipt of order, submit an immediate needs assessment and individual plan of care for two resident that meets all requirements. 17. Violation: One of four resident files reviewed for therapeutic leave days did not meet requirements. A psychotropic medication review from November 5, 2025, noted that the resident had been out on leave; however, the objectives for the leave days were not included in the resident’s individual plan of care (resident file numbered 5). Statute and Rule Violated: Minnesota Variance, section R2960V.07, subpart 2. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license hold must comply with all requirements of therapeutic leave days. 18. Violation: Two of four resident files reviewed for requirement treatment services did not meet requirements. Documentation in the resident’s file did not demonstrate that they received the following: a. Active treatment seven days a week for the weeks of October 5 through 11, 2025 and November 23 through 29, 2025 (resident file numbered 5); b. Individual therapy, provided a minimum of twice per week for the weeks of June 3, 10, 17, 2024, and July 1 and 8, 2024 (resident file numbered 1); c. Family engagement activities, provided a minimum of once per week for the weeks of April 15, 2024, May 13, 2024, June 3, 10, and 24, 2024, July 18 and 29, 2024, and August 19, 2024 (resident file numbered 1) and February 24, 2025, March 3, 2025, April 7, 2025, May 12, 2025, June 2, 2025, June 16, 2025, August 18, 2025, and September 29, 2025 (resident file numbered 3); and d. Education about chemical health for a resident who displayed issues related to inappropriate chemical use (resident file numbered 5). Rule Violated: Minnesota Variance, sections R2960V.06, subpart 1, item C, and R2960V.07, subpart 1, item B. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately an on an ongoing basis, the license holder must comply with all requirements of treatment services. Within 30 days receipt of order, seek support from the Behavioral Health Administration regarding providing treatment services to residents. 19. Violation: Four of four resident files reviewed for requirements of medication reconciliation did not meet requirements. The license holder did not have documentation to demonstrate that they performed medication reconciliation for the resident (resident files numbered 1, 2, 3, and 5). Rule Violated: Minnesota Variance, section R2960V.08, subpart 3. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of medication reconciliation. Within 30 days receipt of order, submit an intake medication reconciliation for one resident that demonstrates compliance with all requirements. 20. Violation: Two of four resident files reviewed for requirements of medication administration did not meet requirements in the following ways: a. The license holder did not have documentation of why a medication wasn’t administered and subsequent reporting for medications not administered on May 14 and June 27, 2024 (resident file numbered 1); b. There was not documentation of the date that medications were started (resident file numbered 5); c. Not all staff who administered a medication had their initials on the signature form (resident file numbered 5); and d. The disposition of the resident’s medication following discharge was not documented in the resident’s file (resident file numbered 1). Rule Violated: Minnesota Variance, section R2960V.08, subpart 4, items B and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of medication administration. 21. Violation: Four of four resident files reviewed for requirements of psychotropic medication reviews did not meet requirements in the following ways: a. There was not documentation from the prescribing practitioner of a description of the symptoms and behaviors that the psychotropic medication is to alleviate along with data collection methods the license holder must use to monitor and measure changes in these (resident files numbered 1, 2, 3, and 5); and b. Documentation did not demonstrate that the prescribing practitioner conducted a psychotropic medication review at least weekly for the first month (resident file numbered 5) or that this review included targeted symptoms and behaviors, data collected, and side effects observed and actions taken (resident files numbered 1, 2, 3, and 5). Rule Violated: Minnesota Variance, section R2960V.08, subpart 6, items B and C. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of psychotropic medication reviews. Within 30 days receipt of order, submit a review that demonstrates compliance with all requirements. 22. Violation: Four of four resident files reviewed for requirements of information included in medication informed consents did not meet requirements. Documentation in the informed consents did not include: a. The diagnosis and behaviors for which each psychotropic medication was prescribed (resident files numbered 1, 2, 3, and 5); b. The expected benefits for each medication (resident files numbered 1, 2, 3, and 5); c. The other pharmacological and nonpharmacological treatment options available for each medication (resident files numbered 1, 2, 3, and 5); d. The estimated duration of therapy for each medication (resident files numbered 1, 2, 3, and 5); e. The more frequent and rarer, but serious side risks and side effects of each medication and how these must be managed (resident files numbered 1, 3, and 5); f. The names and telephone numbers of appropriate professionals to contact for questions or concerns (resident files numbered 1, 2, 3, and 5); and g. A signature of the resident and the resident’s legal guardian acknowledging that the prescribing practitioner or designee has talked with them about the medication and answered any questions (resident filed numbered 1, 2, 3, and 5). Rule Violated: Minnesota Variance, section R2960V.08, subpart 8. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of information included in informed consents. Within 30 days receipt of order, submit documentation of one resident’s informed consents that demonstrates compliance with requirements. 23. Violation: Four of four resident files reviewed for requirements governing the monitoring of medication side effects did not meet requirements. There was no documentation that the nurse determined and documented the frequency of side effects monitoring within the resident file (resident files numbered 1, 2, 3, and 5). Rule Violated: Minnesota Variance, section R2960V.08, subpart 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the monitoring of side effects. Within 30 days receipt of order, submit documentation for two residents that demonstrates compliance with this requirement. 24. Violation: Five of five resident files reviewed for requirements of the use of restraint did not meet requirements in the following ways: a. Documentation of the restrictive procedure did not include a description of prior events that may have been a contributing factor to the incident and why less restrictive interventions failed or were found to be inappropriate for restrictive procedures that occurred on September 19 and 21, 2025, and November 13 and 23, 2025 (resident file numbered 5); b. Documentation of the debriefing did not include additional staff training that resulted from the debriefings for restrictive procedures that occurred on the following dates: i. August 2, 6, 15, 16, 25, 29, 30, September 5, and 7, 2024 (resident file numbered 1); ii. October 24, November 19, and December 4, 2025 (resident file numbered 2); iii. February 23, April 21, June 30, August 7, 24, October 14, and November 4, 2025 (resident file numbered 3); and iv. September 19 and 21, 2025, and November 13 and 23, 2025 (resident file numbered 5). c. The license holder did not incorporate precipitating factors and alternative techniques that might have prevented the use of restraint into the resident’s individual support plan to prevent future use of restraint (resident files numbered 1 through 5); and d. There was not documentation that staff involved in a restrictive procedure that resulted in an injury to the resident or the staff member met with supervisors staff for an evaluation of the circumstances that caused the injury and to develop a plan to prevent future injuries for restrictive procedures that occurred on September 5, 2024 (resident file numbered 1), November 19, 2025 (resident file numbered 2), and November 13 and 23, 2025 (resident file numbered 5). Rule Violated: Minnesota Variance, section R2960V.11, subparts 2 and 3, items A, C, and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of restraint and seclusion. Within 30 days receipt of order, submit documentation of a restrictive procedure and debriefing that demonstrates compliance with all requirements. 25. Violation: Four of four personnel files reviewed for the administrative review of the use of restraint did not meet requirements in the following ways: a. An administrative review for a restraint that took place on September 19, 2025, was conducted by the Mental Health Professional who approved the hold (resident file numbered 5); and b. Documentation did not state whether the required documentation was recorded or if the standards governing the use of restrictive procedures were met for holds that occurred on the following dates: i. August 2, 6, 15, 16, 25, 29, and 30, 2024, and September 5 and 7, 2024 (resident file numbered 1); ii. October 24, 2025, November 19, 2025, and December 4, 2025 (resident file numbered 2; iii. February 23, 2025, April 21, 2025, June 30, 2025, August 7 and 24, 2025, October 14, 2025, and November 4, 2025 (resident file numbered 3); and iv. September 19 and 21, 2025, and October 13 and 23, 2025 (resident file numbered 5). Rule Violated: Minnesota Variance, section R2960V.11, subpart 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of administrative reviews of the use of restrictive procedures. Within 30 days receipt of order, submit documentation of two administrative reviews that demonstrates compliance with all requirements. 26. Violation: One of two files reviewed for requirements of discharge planning did not meet requirements. The aftercare plan did not include the contact number for the program’s education provider (resident file numbered 1). Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, item B. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of discharge planning. 27. Violation: One of four resident files reviewed for requirements governing documentation standards did not meet requirements. Documentation in a resident’s record on August 13, 2025, inaccurately used the name of a different resident (resident file numbered 5). Rule Violated: Minnesota Variance, section R2960V.19, subpart 2. Repeat Violation: In a Correction Order that DHS issued on December 10, 2021, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of documentation standards. 28. Violation: Three of four resident files reviewed for requirements governing daily documentation did not meet requirements. The summaries for each day that a resident was present in the program did not include observations about the resident’s symptoms for the following dates: a. June 10, 11, 12, 13, and 16 and August 20, 22, 23, 24, and 25, 2024 (resident file numbered 1); b. November 18, 20, 21, 22, 24, 25, 26, and 30, 2025 (resident file numbered 2); and c. October 7 through 11 and November 24 through 29, 2025 (resident file numbered 5). Rule Violated: Minnesota Variance, section R2960V.19, subpart 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of daily documentation. Written Response Required If you do not 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 Hannah.Horsch@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Hannah Horsch Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Final Agency Decision As stated above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated August 8, 2024. As such, the decision is not subject to appeal. 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 651-431-6270 or at Hannah.Horsch@state.mn.us. Sincerely, Hannah Horsch, Licensor Licensing Division Office of Inspector General
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