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June 8, 2022 Deborah Matthews, Authorized Agent Transformation House 1410 Ferry Road Anoka, MN 55303 License Numbers: 803826 (Transformation House) 804982 (Transformation House I) 807288 (Transformation House II) Dear Deborah Matthews: On January 31, 2022, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on December 29, 2021. You requested reconsideration of citations 5, 6, 7, 8, 11 and 13. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 5: The correction order stated the license holder’s personnel policies and procedures did not meet licensing requirements. Specifically, the personnel policies did not contain the following information: a. How the program will identify whether the behaviors of incidents are problematic substance use, including a description of how the program must address: 1. Receiving treatment for substance use within the period specified for the position in the staff qualification requirements, including medication-assisted treatment; and 2. The circumstances under which an individual who participates in the monitoring by the health professional services program for substance use or mental health disorder is able to provide services to the program’s clients; and b. The license holder’s policies and procedures for new staff member orientation did not include the following topics to be covered within 24 working hours: 1. Policies and procedures; 2. Client confidentiality; 3. HIV minimum standards; and 4. Client needs. Request for Reconsideration. Your submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.13, subdivision 1, clauses (5) and (7), a license holder must have written personnel policies that are available to each staff member. The personnel policies must identify how the program with identify whether behaviors or incidents are problematic substance use, including a description of how the facility must address specified criteria. The personnel policies must also include an orientation within 24 hours of starting for each new staff member based on a written plan that, at a minimum, must provide training related to the staff member’s specific job responsibilities, policies and procedures, client confidentiality, HIV minimum standards, and client needs. Information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation. Citation 6: The correction order stated that one of six client files (client file numbered 6) reviewed for requirements governing client orientation did not contain documentation that the client received orientation on the day of service initiation on the following topics: a. Internal and external reporting policies related to the prevention and reporting of maltreatment of individuals receiving services, including the telephone number for the Minnesota Abuse Reporting Center; and b. The license holder’s program abuse prevention plan. Request for Reconsideration. Your submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, sections 245A.04, subdivision 14, paragraphs (a) and (b), the license holder shall develop program policies and procedures necessary to maintain compliance with licensing requirements under Minnesota Statutes and Minnesota Rules. The license holder shall provide training, document the training and monitor implementation of policies and procedures by program staff. Under Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c), license holders serving vulnerable adults shall establish and enforce written policies and procedures related to suspected or alleged maltreatment and shall orient and mandated reporters as specified, including providing an orientation to the internal and external reporting procedures of all persons receiving services. Under subdivision, 2, paragraph (a), all license holders shall establish and enforce ongoing written program abuse prevention plans and individual abuse prevention plans as specified. Under Minnesota Statutes, section 245G.09, subdivision 3, clause (1), client records must contain documentation as specified. Information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation.
Citation 7: The correction order stated that one of six client files (client file numbered 6) reviewed for consent to seek disclosure of suspected maltreatment did not meet requirements. The license holder failed to seek consent for the disclosure of suspected maltreatment from the client, a guardian, or legal representative at the time of intake. Request for Reconsideration. Your request for reconsideration includes a document attesting that the client gave the program consent to release information on April 21, 2021, the same day of service initiation. You indicate the program was therefore in compliance with the requirement.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 626.557, subdivision 3a, clause (1), a maltreatment report is not required when federal law specifically prohibits a person from disclosing patient identifying information in connect with a report of suspected maltreatment, unless the vulnerable adult, or the vulnerable adult’s guardian, conservator, or legal representative, has consented to disclosure in a manner which conforms to federal requirements. Facilities whose patients or residents are covered by such a federal law shall seek consent to the disclosure of suspected maltreatment from each patient or resident, or a guardian, conservator, or legal representative, upon the patient’s or resident’s admission to the facility. Information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation. Citation 8: The correction order stated that one of six files (client file numbered 1) reviewed for requirements governing vulnerable adult (VA) determinations and VA assessments did not meet requirements. The client file did not contain a VA determination and VA assessment completed within 24 hours of service initiation when the client was transferred from residential to outpatient services. Request for Reconsideration. You indicate that within 24 hours of outpatient service initiation, the client completed a VA determination assessment, and you provided supporting documentation.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a), within 24 hours of the day of service initiation, a nonresidential program must determine whether a client is a vulnerable adult as defined in defined in statute. An adult client of a residential program is a vulnerable adult. The client file in the violation was mistakenly identified as client file numbered 1 and should have been identified as client file numbered 3. Client file numbered 3 did not have a VA Assessment and Determination completed when the client transferred to the outpatient program on July 23, 2021. There is therefore sufficient evidence to support the violation, and it is affirmed with the revision that the client file subject to the violation is client file numbered 3.
Citation 11: The correction order stated that five of six client files reviewed for requirements governing the documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. The client file did not include a review of treatment services entered into the client’s file weekly for the week’s ending: 1. May 30, 2021 (client file numbered 1); 2. February 7, 2021 (client file numbered 2); 3. May 2 and 30, 2021 (client file numbered 3); 4. November 21, 2020 (client file numbered 4); and 5. August 1, 2021 (client file numbered 6); b. The documentation of treatment services did not include a review of issues related to attendance for treatment services, including a reason for any client absence from a treatment service (client files numbered 1, 3, and 6); and c. The treatment plan review did not indicate the following: 1. The date of each service provided (client files numbered 1, 3 and 4); 2. The type and amount of each service provided (client files numbered 1, 3, and 4); and 3. The client’s response to each treatment service provided (client files numbered 1 through 4). Request for Reconsideration. You provided supporting documentation to indicate the program was in compliance with requirements. With regard to violations (a) and (c), you provided Services Summary Reports attached to related Weekly Treatment Services and Treatment Plan Review that you indicate show compliance. Reconsideration Determination. Pursuant to Minnesota Statutes, sections 245G.06, subdivision 3, paragraph (a), clause (4), a review of all treatment services must be documented weekly and include a review of: (issues related to attendance for treatment services, including the reason for any client absence from a treatment services. Under paragraph (c), clause (1), a treatment plan must be entered in a client’s file weekly or after each treatment service, whichever is less frequent, by the staff member providing the service. The review must indicate the span of time covered by the review and each of the listed six dimensions. The review must indicate the date, type and amount of each treatment service provided and the client’s response to each service. Under Minnesota Statutes, section 245G.09, subdivision 3, clause (7), client records must contain documentation of treatment services and treatment plan review according to section 245G.06, subdivision 3. Although the documents submitted by the program with the reconsideration request identify the week reviewed, the completion date is the date when the document is signed by the LADC. The violation was issued because the treatment plan reviews were not signed within the required time period as shown in the documentation submitted. With regard to violation (c), although the documents submitted with the request for reconsideration identify required elements for other clients, documentation was not submitted for clients 1 through 4. There is therefore sufficient evidence to support violations 11 (a) and (c), and they are affirmed. With regard to violation 11(b), Information submitted shows the license holder was in compliance with the requirement. As a result, it is appropriate to rescind the violation. Citation 13: The correction order stated that one of five client files (client file numbered 3) reviewed for requirements governing client property management did not document receipt and disbursement of client property at the time of receipt or disbursement, including client signatures or the signature of the conservator or payee. Request for Reconsideration. You indicate the client’s file did contain documentation of client property at the time of disbursement, and you submitted supporting documentation. Reconsideration Determination. The correction order incorrectly cited to Minnesota Statues, section 245G.04, subdivision 13, paragraph (c), clause (1), but the correct statutory authority is as follows. Pursuant to Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1), whenever the license holder assists a person served by the program with the safekeeping of funds or other property, the license holder must immediately document receipt and disbursement of the person’s funds or other property at the time of receipt or disbursement, including the person’s signature, or the signature of the conservator or payee. The client file did not contain documentation of a client signature indicating the receipt of client medications at the time of discharge. Documentation submitted with the reconsideration request shows a note in the client file documented by the RN stating medications were sent with the client at discharge. However, documentation of the client’s signature related only to the client’s cell phone and did not include medications. There is therefore sufficient evidence to support the violation, and it is affirmed with the revision to the correct statutory authority. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support citations 8, 13, and 11 as to violations (a) and (c), and they are affirmed. The Commissioner finds it is appropriate to rescind citations 5, 6, 7, and 11 as to violation (b). This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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