|
June 22, 2022 CERTIFIED MAIL Ibrahim Munye, Authorized Agent East African Healing Services 8085 Wayzata Blvd, Suite 103 Golden Valley, MN 55426
License Number: 1102348
ORDER OF LICENSE REVOCATION Dear Ibrahim Munye, You are hereby notified that pursuant to Minnesota Statutes, section 245A.07, the Commissioner of the Department of Human Services (DHS) is revoking East African Healing Service’s license to provide substance use disorder treatment services under license number 1102348, located at 2021 East Hennepin Avenue, Suite 155, Minneapolis, MN 55413. The revocation goes into effect on July 7, 2022 at 5:00 p.m. to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. REASON FOR LICENSE REVOCATION Under Minnesota Statutes, section 245A.07, subdivisions 1 and 3, the Commissioner may revoke a license if a license holder fails to comply fully with applicable laws or rules. When applying a licensing sanction, the Commissioner shall consider the nature, chronicity, or severity of the violation of law or rule and the effect of the violation on the health, safety, or rights of persons served by the program. The Order of License Revocation is based on licensing violations determined during a modified licensing review conducted May 6, 9, and 12, 2022, governing the provision of substance use disorder treatment services under Minnesota Statutes, chapter 245G. During the licensing review, DHS licensors found 11 licensing violations. DHS has considered the nature and severity of these violations, as well as the health and safety of the clients served and included: Nature and Severity: Many of the violations determined during the licensing review and cited in this order are serious violations related to the health and safety of individuals receiving substance use disorder treatment services. East African Healing Services: • Failed to notify commissioner of change in program location, obtain approval from commissioner, and complete required inspections (citation numbered 1); PO Box 64242 * Saint Paul, Minnesota * 55164-0242 * An Equal Opportunity Employer http://www.dhs.state.mn.us/licensing
• Failed to notify clients of program closure within the required timeframe and inform clients how to access records (citation numbered 2); • Failed to keep protected health information safe (citation numbered 3); • Failed to meet background study requirements (citations numbered 4 through 6); • Failed to ensure that individual treatment plans were completed (citation numbered 7); • Failed to ensure comprehensive assessments and assessment summaries were completed (citation numbered 8); • Failed to ensure initial services plans were completed (citation numbered 9); • Failed to ensure documentation of treatment services and treatment plan reviews (citation numbered 10); and • Failed to ensure discharge summaries were completed (citation numbered 11). East African Healing Services begin providing substance abuse treatment services since July 20, 2020 to adults. In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. DHS licensor determined egregious non-compliance in providing oversight of treatment services by a qualified professional. The Commissioner has considered the license holder’s failure to comply with 245A, 245C, and 245G requirements and the nature and severity of the licensing violations and has determined that license revocation is warranted. LICENSING VIOLATIONS DETERMINED ON MAY 6, MAY 9, and MAY 12, 2022 DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies/Procedures/Practices 1. Citation: Minnesota Statutes, sections 245A.04, subdivisions 2 and 4, and 245G.03, subdivision 3.
Violation: The license holder failed to notify the commissioner before a change in location. On May 3, 2022, the license holder informed the commissioner that the program had moved to a new location and suspended services. The license holder failed to complete required inspections for the new program location, and obtain the commissioner's approval prior to moving to a new location.
2. Citation: Minnesota Statutes, section 245A.04, subdivision 15a.
Violation: The license holder failed to notify affected clients of the temporary program closure at least 25 days prior to suspending services, in addition to informing the clients how to access records.
3. Citation: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a).
Violation: The license holder failed to protect client records against loss, tampering or unauthorized disclosure according to section 254A.09, chapter 13, and Code of Federal Regulations, title 32, chapter 1, part 2, subpart B, sections 2.1 to 2.67, and title 45, parts 160 to 164. The license holder allowed full access of electronic medical records of all past and present clients associated with East African Healing Services 245G license number 1102348 to allow access by others within their Adult Rehabilitation Mental Health Services Program that were not associated with the 245G license number 1102648. Personnel 4. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g). Violation: The license holder failed to initiate a background study on two staff persons (SP1 and SP3) before they began in a position allowing direct contact with persons served by the program. a. SP1 was hired and began working in a position allowing direct contact with persons served by the program on 12/7/2020. A background study was not submitted until 12/11/2020. b. SP3 was hired and began working in a position allowing direct contact with persons served by the program on 12/20/21. A background study was not submitted until 12/28/2020.
5. Citation: Minnesota Statutes, section 245C.07, paragraph (f). Violation: A DHS licensor determined, during the licensing review that the license holder did not maintain an accurate active roster under NETStudy 2.0 to document background study subject affiliation. The DHS licensor determined that 15 background study subjects noted on the back ground study roster were not staff of license number 1102348. The license holder confirmed the staff were not in one of the categories of individuals to be studied identified in Minnesota Statutes, section 245C.03, subdivision 1. 6. Citation: Minnesota Statutes, section 245A.02, subdivision 5a, paragraph (a), clause (3).
Violation: Prior to the licensing inspection, the license holder failed to inform DHS Licensing of the controlling individual identified as the compliance officer under section 256B.04, subdivision 21, paragraph (g). Although, the license holder identified SP1 as the compliance officer during a phone call on May 9, 2022, SP1 indicated they were unaware that was a position they held or were responsible to fulfill. SP5 could not provide documentation that SP1 signed a position description or received training for this role. As per the violations noted within the revocation order, the license holder failed to ensure the duties of the compliance officer under section 256B.04, subdivision 21, paragraph (g) were conducted.
Client Files
7. Citation: Minnesota Statutes, sections 245G.06, subdivision 1, and 245G.09, subdivision 3, clause (6).
Violation: Sixteen of twenty one client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways:
a. The client file did not contain an individual treatment plan (client files numbered 3); b. The client files did not contain an individual treatment plan that was completed by qualified staff (client files numbered 1, 2, 5, and 7 through 13); c. The client files did not contain an individual treatment plan that was developed within five calendar days; 1) 5 days late (client file numbered 19); 2) 6 days late (client file numbered 14); 3) 7 days late (client file numbered 20); 4) 24 days late (client file numbered 16); and d. The client files did not contain an individual treatment plan that was signed by the client (client files numbered 1, 3, 5, 7 through 11, 13, and 15).
8. Citation: Minnesota Statutes, sections 245G.05, subdivisions 1 and 2, paragraphs (a) and (b), and 245G.09, subdivision 3, clause (3).
Violation: Seventeen of twenty one client files reviewed for requirements governing comprehensive assessments and assessment summaries did not meet requirements in the following ways:
a. The client files did not contain a completed comprehensive assessment and assessment summary (client files numbered 4 and 5); b. The client files did not contain a comprehensive assessment and assessment summary that were completed by a qualified staff member (client files numbered 1, 2, 7, 8, 10 through 13, 15, and 17 through 19); and c. The client files did not contain a comprehensive assessment and assessment summary completed within three calendar days of service initiation; 1) 8 days late (client file numbered 14) 2) 9 days late (client file numbered 20); and 3) 26 days late (client file numbered 16).
9. Citation: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3, clause (2).
Violation: Fourteen of twenty one client files reviewed for requirements governing initial services plans did not meet requirements in the following ways:
a. The client files did not contain an initial services plan (client files numbered 7, 9, 10, 12 through 16, 20, and 21); and b. The client files did not contain an initial services plan completed within 24 hours of the day of service initiation; 1) 4 days late (client file numbered 5) 2) 8 days late (client file numbered 11) 3) 67 days late (client file numbered 19); and 4) 82 days late (client file numbered 1).
10. Citation: Minnesota Statutes, section 245G.06, subdivision 3, paragraph (c).
Violation: Three of four client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements. The treatment plan reviews were not entered in the client files weekly, for the weeks ending:
a. May 6, June 13, June 27, July 11, July 18, July 25, August 1, August 8, August 15, August 22, September 12, 2021 (client file numbered 1); b. February 20, 2022 (client files numbered 1 through 3); c. February 27, 2022 (client file numbered 1); d. March 13, 2022 (client files numbered 1 and 3); e. March 20, 2022 (client file numbered 2); and f. April 17, 2022 (client files numbered 1 through 3).
11. Citation: Minnesota Statutes, sections 245G.06, subdivision 4, paragraph (a), and 245G.09, subdivision 3, clause (8).
Violation: Fifteen of sixteen client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways:
a. The service discharge summary was not completed (client files numbered 6 and 7); b. The service discharge summary was not completed by qualified staff (client files numbered 9 through 15); and c. The service discharge summary was not completed within five days of the client’s service termination; 1) 7 days late (client file numbered 3); 2) 8 days late (client file numbered 5); 3) 9 days late (client file numbered 16); 4) 19 days late (client file numbered 21); 5) 22 days late (client file numbered 19); and 6) 30 days late (client file numbered 20). License holders determined to have a background study violation are required to pay a $200 fine for each violation. Because license revocation is a more severe sanction against your license, DHS is not imposing this fine. YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If an appeal is filed within the timeframes described above, programs generally are allowed to continue to operate pending the outcome of an appeal. As your license is currently pending reopening due to your change of location, you may only operate once the required inspections have been conducted and DHS determines the new location meets licensing standards. If approved to operate, you must do so in full compliance with all licensing laws and rules. If additional violations are determined while you operate under appeal, the Department may take additional licensing actions, including immediate suspension of your substance use disorder treatment services license if the violations may adversely affect the health or safety of persons served. Legal authority for this licensing action • This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. • The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). • “Controlling individual” is defined under Minnesota Statutes, section 245A.02, subdivision 5a. • License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. • If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). • Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. Questions If you have any further questions regarding this matter, you may contact me, at 651-431- 6611. Sincerely,
Kristi Strang, Substance Use Disorder Unit Supervisor Licensing Division Office of Inspector General
|
