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August 10, 2022 CERTIFIED MAIL Shanthala Marulasiddaiah, Authorized Agent A Way Out Recovery 1240 3rd Ave E, Suite 107 Shakopee, MN 55379-1749 License Number 1102173 (245G) AMENDED ORDER OF LICENSE REVOCATION NOTICE: This Amended Order of License Revocation supersedes the Order of License Revocation issued on August 3, 2022, which must be destroyed. The Amended Order of License Revocation clarifies the legal basis for the action and revises citation numbered 2, paragraph (b), to update the violation, which creates an additional basis for the revocation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (a), clause (2). Dear Shanthala Marulasiddaiah: The Department of Human Services (DHS) is revoking your license to provide substance use disorder treatment services at 1240 3rd Ave E, Suite 107, Shakopee, MN 55379-1749. This revocation is based on failing to provide supervision to a disqualified individual, providing false and misleading information to the commissioner, and failure to comply with licensing laws and rules. Details of our findings are provided below. Our next steps and your options are also detailed. The revocation goes into effect on August 24, 2022 at 5:00 pm 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. 1. Disqualification of a controlling individual On February 25, 2022, DHS notified you that a controlling individual (SP4) had a disqualification. On March 29, 2022, the Department of Human Services received SP4’s request for reconsideration. On August 4, 2022, DHS notified you and SP4 that the disqualification was not set aside and a variance was not granted. If you appeal this revocation order, the issue of whether SP4 poses a risk of harm to persons served by the program will be reviewed as a part of the contested case hearing. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(2). 2. Failure to comply with licensing laws and rules The Order of License Revocation is based on licensing violations determined during a modified licensing review conducted June 16, 21, 23, and 24 2022, governing the provision of substance use disorder treatment services under Minnesota Statutes, chapter 245G. During the licensing review, DHS licensors found 21 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. A Way Out Recovery: · Provided false and misleading information (citation numbered 1); · Failed to meet background study requirements (citation numbered 2); · Failed to ensure staff were qualified for the staff positions s/he held (citations numbered 3 through 8); · Failed to ensure staff received the required orientation and annual training (citations numbered 9 through 11); · Failed to ensure initial services plans and vulnerable adult determinations were completed as required (citations numbered 15 and 16); · Failed to ensure comprehensive assessment summaries were completed as required (citation numbered 17); · Failed to ensure treatment plans were completed as required (citation numbered 18); and · Failed to ensure documentation of treatment services and treatment plan reviews were completed as required (citation numbered 19). A Way Out Recovery was issued a substance abuse treatment service license under MN Statute, Chapter 245G effective January 8, 2021 to serve adults. In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. DHS licensors determined egregious non-compliance with background studies and controlling individual’s providing false and misleading information. The Commissioner has considered the license holder’s failure to comply with MN Statute, Chapters 245A, 245C, and 245G requirements and assessed the nature and severity of the licensing violations and has determined that license revocation is warranted. Legal Authority: Minnesota Statutes, sections 245A.04, subdivision 5; and 245A.07, subdivision 3, paragraph (a), clause (1) and (3). Due to the serious and chronic nature of these violations in the program, which impact the health and safety of persons served in your care, your license to provide substance use disorder treatment services is revoked. LICENSING VIOLATIONS DETERMINED ON June 16, 21, 23, and 24 2022 DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder provided false and misleading information and knowingly withheld relevant information in the following ways: a. DHS Licensing determined staff person (SP) 4, a controlling individual and an officer of the organization, was not identified by the authorized agent on the application or issuance of the license on January 8, 2021; b. On February 25, 2022, authorized agent received a background study notice informing the license holder that SP4 was disqualified and able to work in the program but was required to have continuous direct supervision. Authorized agent communicated to a DHS supervisor that the SP4 was not working within the program. However, the investigation identified that SP4 was indeed working at the facility, was there on a daily basis operating as a managerial official, and was the only one with full access to electronic health records and personnel files. c. The authorized agent stated that following the disqualification s/he eliminated SP4’s access to the electronic health record (EHR) system so SP4 could not access client information or clinical records. During the investigation, SP4 indicated s/he was a “superuser status”, that s/he had provided training to new staff on the EHR the week of June 6, 2022 to new staff persons, and was the only individual able to grant DHS licensing access to the electronic health records. In addition, clients (C4, C5, C6, C9, and C10) records had entries noted from SP4. Rule/Statute Violated: Minnesota Statutes, section 245A.07, subdivision 3, paragraph (a), clause (3). 2. Violation: The license holder failed to follow back ground study requirements in the following ways: a. The license holder failed to submit a background study for a controlling individual (SP4) upon application for licensure before individuals specified in 245C.03, subdivision 1, began a position allowing direct contact in any licensed program; b. The license holder failed to provide supervision to a disqualified individual (SP4) from direct contact or access during the appeal process. On May 2, 2022, DHS learned that the program was identifying SP4, an individual with a disqualification and not set aside as a controlling individual within the program. Further information obtained during a site visit on June 16, 2022, identified that SP4 was not only identified as a controlling individual, was also identified as the Operations Manager and provided peer recovery support services. Additionally, the authorized agent and SP4 were notified on August 4, 2022, that SP4’s disqualification had not been set aside and a variance had not been granted. c. The license holder initiated a background study before the individual began in a position of direct contact with persons served by the program on staff person (SP5). However, the license holder failed to provide supervision as required by law. The individual who was present at the program when SP5 was working, was SP4, a disqualified individual who also required supervision. SP5 began working in a position providing services on June 6, 2022, and was filling in for another staff person while s/he was on vacation. d. The license holder failed to provide documents of verification that the information collected about SP3 was correct before initiating a background study request to DHS. Rule/Statute Violated: Minnesota Statutes, sections 245A.07, subdivision 3, paragraph (a), clause (2), 245C.04, subdivision 1, paragraph (g), 245C.05, subdivision 2, and 245C.18, paragraph (a). 3. Violation: The license holder failed to identify a controlling individual as the compliance officer under Minnesota Statutes, section 256B.04, subdivision 21, paragraph (g). During the investigation, the authorized agent stated that s/he was the compliance officer. Through further requests related to his/her job duties as compliance officer, the authorized agent clarified that s/he was not the compliance officer, but it was actually SP3. Although the license holder identified SP3 as the compliance officer, SP3 indicated s/he never held that position, nor was SP3 hired to fulfill that 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. Rule/Statute Violated: Minnesota Statutes, section 245A.02, subdivision 5a, paragraph (a), clause (3). 4. Violation: A paraprofessional is not allowed to admit, transfer or discharge a client. During the investigation, it was determined that SP4 was making decisions to admit and discharge clients. Rule/Statute Violated: Minnesota Statutes, section 245G.11, subdivision 6. 5. Violation: Five of five personnel files reviewed for requirements governing staff qualifications did not contain a statement attesting to freedom from problematic substance use (SP1 through SP5). Rule/Statute Violated: Minnesota Statutes, section 245G.11, subdivision 1. 6. Violation: The license holder failed to document in the personnel record how the treatment director knows and understands the implications of MN Statutes, Chapters 245A, 245G, 260E, and sections 626.557 and 626.5572 (SP3). Rule/Statute Violated: Minnesota Statutes, section 245G.11, subdivisions 3 and 4, paragraph (a). 7. Violation: Two of four personnel files reviewed for requirements governing alcohol and drug counselor qualifications did not contain a copy of their professional licensure (SP3 and SP5). Rule/Statute Violated: Minnesota Statutes, section 245G.11, subdivision 5, paragraph (a). 8. Violation: Two of two personnel files reviewed for requirements governing qualifications for a peer recovery specialist hired by the license holder did not contain the following information (SP4 and SP6): a. Documentation of training on knowledge of client rights, according to section 148F.165, and staff member responsibilities; b. Documentation of a high school diploma or equivalent; c. Documentation of a current credential from the Minnesota Certification Board, the Upper Midwest Indian Council on Addictive Disorders, or the National Associate for Alcoholism and Drug Abuse Counselors; and d. Documentation of ongoing supervision in areas specific to the domains of the recovery peer’s role by an alcohol and drug counselor. Rule/Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 2 (8), and 245G.11, subdivisions 6 and 8. 9. Violation: Five of five personnel files reviewed for requirements governing staff orientation (SP1 through SP5) did not meet requirements. The personnel files did not contain any documentation of orientation received as required. SP4 indicated that s/he was unaware that s/he was required to maintain documentation of orientation. Rule/Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 1, clause (7). 10. Violation: Two of two personnel files reviewed for requirements governing annual staff training (SP1 and SP4) did not meet requirements. Personnel files did not contain any documentation that staff persons received the required annual training. Rule/Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (c) and (d), and 260E. 11. Violation: Two of two personnel files reviewed for requirements governing additional trainings did not contain documentation that the staff members received 12 hours of training in co-occurring mental health problems and substance use disorders (SP1 and SP2). Rule/Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (e). 12. Violation: Five of five personnel files reviewed for requirements governing personnel file contents did not meet requirements. The personnel files did not contain the following documentation: a. A completed application for employment signed by the staff member and containing the staff member’s qualifications for employment (SP4 and SP5); b. An inquiry required by sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (SP1 through SP3 and SP5); and c. A written annual review of the employee’s job performance (SP1 and SP4). Rule/Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. 13. Violation: Eight of eight client files reviewed for requirements governing client orientation did not contain documentation that the clients received orientation on the day of service initiation on the following topics (C1 through C8): a. Written statement of client rights and responsibilities identified in Minnesota Statutes, section 148F.165 and documentation that staff reviewed the statement with the client; b. The license holder’s grievance procedure; c. HIV minimum standards according to Minnesota Statutes, section 245A.19 (within 72 hours); d. Information on tuberculosis; e. The license holder’s personal electronic device policy; f. 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 (within 24 hours); g. The license holder’s program abuse prevention plan; and h. Consent to the disclosure of suspected maltreatment from the resident, or a guardian, conservator, or legal representative upon admission. Rule/Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (a), 245A.19, paragraph (b), 245A.65, subdivision 1, paragraph (c) and 2, paragraph (a), 245G.09, subdivision 3, clause (1), 245G.15, subdivisions 1, 2, and 3, and 626.557, subdivision 3a, clause (1). 14. Violation: Two of eight client files reviewed for requirements governing confidentiality of client records (C3 and C6) did not meet requirements. Documentation in the files indicated that clients gave verbal authorization for the release of their information to the entities but did not contain a signature of the client according to requirements in the Code of Federal Regulations, Title 42, Chapter 1, Part 2, Section 2.31. Rule/Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). 15. Violation: Five of eight client files reviewed for requirements governing initial services plans did not meet requirements in the following ways: a. The plans were not completed within 24 hours of the day of service initiation (C2, C5 through C8); and b. The plans were not person-centered and client specific (C7 and C8); c. The plans did not address immediate health and safety concerns (C7 and C8); and d. The plan did not identify the treatment needs to be addressed during the time between the day of service initiation and the development of the treatment plan (C8). Rule/Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3, clause (2). 16. Violation: Three of eight client files reviewed for requirements governing the determination of vulnerable adult status contained determinations that were not completed on the day of service initiation (C1 and C2) and not signed by the staff person (C8). Rule/Statute Violated: Minnesota Statute, section 245G.04, subdivision 2, paragraph (a). 17. Violation: Two of eight client files reviewed for requirements governing comprehensive assessment summaries did not meet requirements. Comprehensive assessment summaries were not signed within 3 calendar days from the day of service initiation (C1 and C3). Rule/Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 2, paragraph (a), and 245G.09, subdivision 3, clause (4). 18. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. The plan was not completed within 5 calendar days from the day of service initiation (C6); b. The plans were not signed by the client and did not document the client's involvement in the development of the plan (C3, C4, and C6); c. The plans did not include how the client’s family or others would be involved in their treatment (client files numbered C7 and C8); d. The plans did not address issues identified in the assessment summary (C4 through C6); e. The plans did not include specific goals and methods to address each identified need in the comprehensive assessment summary, including amount, frequency, and anticipated duration of treatment service (C1 through C8); f. The plans did not include resources to refer the client to when needs are to be addressed concurrently by another provider (C5 and C6); g. The plans did not include the goals the client must reach to complete treatment and terminate services (C4 through C8); h. The plans were not updated based on new information gathered about the client’s condition and on whether methods identified have the intended effect: 1) The client self-reported relapsing on 6/5/22 and the plan was not updated (C1); 2) Treatment plan reviews for the time period 4/15/22 to 6/20/22 stated the methods for the goal in dimension 6 were not effective, and the methods were not updated (C6); and 3) Treatment plan reviews completed 5/17/22, 5/23/22, 6/6/22, 6/15/22, and 6/20/22 identified that the client was struggling with attendance and the treatment plan was not updated (C6); and i. Changes to the plan were not signed by client (C6). All goals and methods were modified on 4/15/22 due to a change in counselor, and methods were added to address the goals in dimensions 3 and 5 on 5/6/22. Rule/Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2, and 245G.09, subdivision 3, clause (6). 19. Violation: Eight of eight client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. A review of all treatment services was not documented weekly for the weeks ending: i. 6/17/22 (C3); ii. 3/27/22, 4/17/22, 5/1/22, 5/15/22, 5/29/22, 6/5/22, and 6/12/22 (C5); and iii. 4/24/22, 5/15/22, and 6/5/22 (C6). b. A review of care coordination activities was not included (C2 through C5); c. Issues related to attendance for treatment services, including the reason for any client absence from a treatment service was not included in client’s file (C6); d. Reviews were not completed based on the treatment week identified in the program’s policies (C1 through C5, C7, and C8); e. Reviews did not include the dates of services (C1 through C8); f. Reviews did not include the type and amount of each treatment service provided (C3 through C8); g. Reviews did not address each goal in the treatment plan and whether the methods to address the goals are effective (C2 and C5 through C7); h. Reviews did not include monitoring of any physical and mental health problems (C5); i. Reviews indicated an Individual Abuse Prevention Plan (IAPP) was reviewed, however the clients did not have an IAPP in the file (C1 and C5); and j. Reviews did not include collaboration with continuing care mental health providers and their involvement in treatment planning meetings (C5 and C6). Rule/Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. 20. Violation: Eight of eight client files reviewed for requirements governing record keeping did not meet requirements. The content and format of client records were not uniform and entries in each record were not signed and dated by the staff member making the entry (C1 through C8). Rule/Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1. 21. Violation: One of two client files reviewed for requirements governing service discharge summaries did not meet requirements. The discharge summary was completed and states the client has been discharged from the program’s intensive outpatient services but will attend aftercare at the program, indicating the client has not been discharged from services (C5). Rule/Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. 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 651-222-4731; 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 you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license. 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. · When a revocation of a license is based on a disqualification for which reconsideration was timely requested and which was not set aside, the scope of the contested case hearing for the revocation shall also include the risk of harm review under Minnesota Statutes, section 245A.08, subdivision 2a, paragraph (g). The Commissioner’s decision not to grant a variance is final under Minnesota Statutes, section 245C.30, subdivision 5, and would not be included in the scope of the hearing. · Minnesota Statutes, section 245.095 defines which programs administered by DHS are included in the exclusion provision, and further defines “excluded,” “individual,” and “provider.” · 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 Kristi Strang, Supervisor, at 651-431-6611. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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