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July 29, 2022 Deborah Mathews, Authorized Agent Transformation House 1410 Ferry Road Anoka, MN 55303 License Numbers: 803826 (Transformation House) 804982 (Transformation House I) 807288 (Transformation House II)
AMENDED CORRECTION ORDER Dear Deborah Mathews: On November 29 through December 3, 2021, licensing reviews of the following programs were conducted to determine compliance with state and federal laws governing the provision of substance use disorder treatment under Minnesota Statutes, chapter 245G: · Transformation House, located at 1410 S Ferry Road, Anoka, MN 55303 , license number 803826 · Transformation House I, located at 2532 N Ferry Road, Anoka, MN 55303, license number 804982 · Transformation House II, located at 351 74th Avenue NE, Bldg. A, Fridley, MN 55432, license number 807288 As a result of this review, a Correction Order was issued on December 29, 2021. The Department of Human Services (“DHS”), Division of Licensing received your request for reconsideration for citations 5, 6, 7, 8, 11 and 13 of that Correction Order on December 29, 2021. On June 8, 2022, DHS issued a Reconsideration Response Correction Order. This Amended Correction Order reflects the final agency decision. Citations 5, 6, 7, and 11 as to violation (b) were rescinded from the Correction Order issued on December 29, 2021. This Amended Correction Order supersedes the Correction Order issued on December 29, 2021, which must be destroyed. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder. The following violation(s) of state or federal laws and rules were determined as a result of these licensing reviews. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Policies, Practices, and Procedures 1. Citation: Minnesota Statutes, sections 245A.04, subdivisions 1, paragraph (h), and 14, paragraph (b), 245A.191, paragraph (a), 245G.10, subdivision 4, and 245G.12, clause (10). Violation: The license holder submitted requests for payment of public funds for treatment services that did not meet requirements in the following ways: a. The license holder failed to provide all clinical service hours required for high intensity residential treatment (client file numbered 7). Of the 30 hours of treatment service required each week, the client received: 1. 27.00 hours of services for the week ending November 8, 2020; 2. 28.00 hours of services for the week ending November 15, 2020; and 3. 19.00 hours of services for the week ending November 29, 2020; a. The license holder failed to provide all clinical service hours required for medium intensity residential treatment (client file numbered 7). Of the 15 hours of treatment service required each week, the client received 8.00 hours of services for the week ending January 24, 2021; b. Individual counseling treatment services for a non-residential client were not documented in the client file; however, services were billed on the following dates: 1. The client received 30 minutes of individual counseling on August 10 and 18, 2021; however, the license holder billed for 1.00 hour of service (client file numbered 1); and 2. The client received 30 minutes of individual counseling on August 18, 2021; however, the license holder billed for 1.00 hour of service (client file numbered 3); and c. The license holder provided group counseling services that exceeded 16 clients on August 30 and September 10, 2021 (807288). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all applicable requirements for programs that request payment of public funds for services are met. Additionally, the noncompliance with the requirements identified under 245A.191, paragraph (a) may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. The BHF Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 2. Citation: Minnesota Statutes, sections 245A.04, subdivision 14, paragraphs (a) and (c), and 245G.12. Violation: The license holder’s program policies and procedures manual did not meet licensing requirements. The policies and procedures manual contained multiple references to Rule 31 (Minnesota Rules, parts 9530.6405 through 9530.6505) which was repealed January 1, 2018 (803526, 804982, and 807288). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure policies and procedures meet all applicable requirements. 3. Citation: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245G.08, subdivision 5, paragraph (c), clause (8). Violation: The license holder failed to monitor implementation of medication administration policies and procedures by program staff to ensure policies and procedures were followed (803526, 804982, and 807288): The license holder’s policy titled Administration of Medications and Controlled Substances included a procedure for informing a registered nurse of problems with self-administration, including failure to administer and refusal of a medication. The policy contained a statement that “If a client refuses or misses three consecutive doses, a Medication Deviation Report is to be completed and submitted to the client’s counselor and RN or nurse manager” which does not reflect the license holder’s current practices. The license holder failed to monitor implementation of this policy to ensure Medication Deviation Reports were being conducted in a timely manner. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all medications are administered to clients as ordered and all staff follow the programs medication administration policies and procedures for administration of medications, assistance with self-administration of medication that meet all applicable requirements. Within 30 days of receipt of this order, submit a detailed plan that identifies how these requirements will be met and monitored on an ongoing basis. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 4. Citation: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (a), 245A.19, paragraphs (b) and (d), 245G.09, subdivision 3, clause (1), and 245G.12, clause (2). Violation: The license holder did not orient all clients to the commissioner approved HIV minimum standards within 72 hours of admission to the program (803526, 804982, and 807288). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure HIV policies and procedures meet all applicable requirements. Client Files Client files reviewed are identified in the following manner: · (803526) Client files numbered 1 and 2 · (804982) Client files numbered 3 through 5 · (807288) Client files numbered 6 and 7 5. Citation: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a). Violation: One of six client files reviewed for requirements governing vulnerable adult (VA) determinations and VA assessments did not meet requirements (client file numbered 1). The client file did not contain a VA determination and VA assessment completed within 24 hours of service initiation when the client transferred from residential to outpatient services. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all VA determinations and assessments are completed within the required timeframe and meet all applicable requirements.
6. Citation: Minnesota Statutes, sections 245G.05, subdivision 1, and 245G.09, subdivision 3, clause (3). Violation: Six of seven client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessment did not include information about the client’s needs that relate to substance use and personal strengths that support recovery, including: 1. A list of previous attempts for substance misuse or substance use disorder (client file numbered 3); 2. Substance use histories, for each substance used, including: i. An amount (client files numbered 1 and 3); ii. A duration (client files numbered 1 through 4); iii. Period of abstinence (client files numbered 1 and 7); and iv. Circumstances of relapse (client file numbered 3); 3. Specific problem behaviors exhibited by the client when under the influence of substances (client files numbered 3 and 4); 4. History of physical or sexual abuse (client file numbered 2); 5. Whether or not medical concerns need to be referred to an appropriate to an appropriate health care professional (client file numbered 1); 6. Ability to function appropriately in a work and educational setting (client files numbered 1, 2, 3, and 6); and 7. Leisure time activities that have been associated with substance use (client file numbered 1). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all comprehensive assessments are completed within the required timeframe and meet all applicable requirements. Within 30 days of receipt of this order, submit comprehensive assessments for two clients that demonstrate compliance. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 7. Citation: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2, clause (1), and 245G.09, subdivision 3, clause (6). Violation: Five of six client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. When the client chose to have family or others involved, the individual treatment plan did not include how the client’s family or others will be involved in the client’s treatment (client file numbered 1); b. The individual treatment plan’s specific methods used to address identified problems did not include an amount, frequency, or anticipated duration of a treatment service (client files numbered 2 through 4); c. The individual treatment plan was not updated when the client transferred from residential to outpatient services on July 23, 2021 (client file numbered 3); and d. The individual treatment plan was updated based on new information gathered about the client’s condition and on whether methods identified have the intended effect; however, changes to the plan were not signed by the client or the alcohol and drug counselor (client file numbered 6). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit individual treatment plans for two clients that demonstrate compliance. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 8. Citation: Minnesota Statutes, sections 245G.06, subdivision 3, paragraphs (a), clause (4), and (c), clause (1), and 245G.09, subdivision 3, clause (7). Violation: 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 weeks 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); and b. 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). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of treatment services are completed within the required timeframe and meet all applicable requirements. Within 30 days of receipt of this order, submit two treatment plan reviews that demonstrate compliance. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 9. Citation: Minnesota Statutes, sections 245G.06, subdivision 4, paragraphs (a) and (b), clauses (4) through (6), and 245G.09, subdivision 3, clause (8). Violation: Five of seven client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The client file did not contain documentation that a discharge summary was completed within five days of the client’s service termination. The discharge summary was completed six days late (client file numbered 3); b. The service discharge summary did not contain the following information: 1. The reasons for and circumstances of service termination for a client terminated at staff request (client files numbered 2 and 5); 2. The client’s living arrangements at service termination (client files numbered 2 and 4); and 3. Continuing care recommendations, including referrals made with specific attention to continuity of care for mental health (client file numbered 7). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all service discharge summaries are completed within the required timeframe and meet all applicable requirements. Within 30 days of receipt of this order, submit two service discharge summaries that demonstrate compliance. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. 10. Citation: Minnesota Statutes, section 245G.04, subdivision 13, paragraph (c), clause (1). Violation: One of five client files 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 (client file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all records related to client property management meet applicable requirements. Repeat Violation: This is a repeat violation. The license holder was previously cited for a similar violation in a Correction Order dated July 22, 2020. Personnel Files Personnel files reviewed are identified in the following manner: · (803526) Personnel files numbered 1 through 3 · (804982) Personnel files numbered 4 and 5 · (807288) Personnel file numbered 6 11. Citation: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivisions 1, clause (7), and 2, paragraphs (b), clause (3), (c), and (d), and chapter 260E. Violation: One of six personnel files reviewed for requirements governing staff training did not meet requirements in the following ways: a. The personnel file contained documentation of training; however, it did not occur annually on the following topics in 2021 (personnel file numbered 3): 1. Mandatory reporting as specified under Minnesota Statutes, sections 245A.65 (Maltreatment of Vulnerable Adults), 626.557 (Reporting of Maltreatment of Vulnerable Adults), and 626.5572 (Definitions for the Purpose of Reporting of Maltreatment of Vulnerable Adults), including specific training covering the facility’s policies for obtaining client releases of information; 2. Maltreatment of Minors; 3. Reporting of prenatal exposure to controlled substances; and 4. Human immunodeficiency virus (HIV) minimum standards; and a. The personnel file did not contain documentation that the staff member received training every two years on client rights as specified in Minnesota Statutes, sections 148F.165 and 253B.03 (personnel file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all staff persons receive all trainings as required and the personnel files contain documentation of the completed trainings. If you fail to correct the violations 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 a corrective action ordered must be sent to your Licensor at: Commissioner, Department of Human Services ATTN: Alyssa Arabadji Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. 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 December 29, 2021. As such, the decision is not subject to appeal. If you have any questions regarding this Correction Order, please contact Leah Wachter, Human Services Licensor at 651-431-6614. Paula Halverson, Unit Manager Licensing Division Office of Inspector General 651-431-6611
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