|
August 9, 2022 Su-Fei Wong, Authorized Agent Volunteers of America Minnesota and Wisconsin 7625 Metro Blvd Minneapolis, MN 55439-3053 License Number: 1036848
CORRECTION ORDER Dear Su-Fei Wong: On July 28, 29 and August 1, 2022, a modified licensing review of Volunteers of America, Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN 55303, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0220, chemical dependency certification under Minnesota Rules, parts 2960.0430 through 2960.0490, shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530, mental health certification under Minnesota Rules, parts 2960.0580 through 2960.0690 and restrictive procedures certification under Minnesota Rules, part 2960.0710 As a result of this modified licensing review a Correction Order is being issued. 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 violations of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Practices 1. Citation: Minnesota Rules, part 2960.0710, subpart 11, item A. a. Duration and day of the week (Omegon unit); and b. Time of day, day of the week and individuals involved (Bar None Shelter Plus East). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the restrictive procedure quarterly review meets all applicable requirements. 2. Citation: Minnesota Rules, parts 2960.0450, subpart 2, item B and 2960.0460, subpart 5, item C. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all chemical dependency treatment services are provided by a qualified alcohol and drug counselor and meet all applicable requirements. 3. Citation: Minnesota Statutes, section 245A.081, paragraph (a), clause 2. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must monitor the implementation of the Hazardous Materials, Chemicals, and Sharps Safety Plan and meet all applicable requirements. Within 30 days of receipt of this order, submit a plan that includes how compliance with this term will be monitored and the bi-weekly safety check documentation completed from August 1-August 31, 2022.
Personnel Files 4. Citation: Minnesota Rules, part 2960.0100, subpart 5. Violation: Two of five personnel files reviewed for requirements governing the documentation of training (personnel files numbered 4 and 5) did not meet requirements. The annual training plan did not include the name of the entity that provided the training. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of training meets all applicable requirements Resident Files Resident files reviewed are identified in the following manner: · Omegon mental health and chemical dependency treatment unit: Resident files numbered 1, 2, 4, 5 and 7 · Bar None Shelter Plus unit: Resident files numbered 3 and 6 5. Citation: Minnesota Rules, part 2960.0520, subpart 3, item B. Violation: One of two resident files reviewed for requirements governing the immediate needs plan (resident file numbered 3) did not meet requirements. The plan did not specify short-term objectives and methods for meeting each need identified in Minnesota Rules, part 2960.0520, subpart 3, item A. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the immediate needs plan meets all applicable requirements. Within 30 days of receipt of this order, submit an immediate needs plan for one resident to demonstrate compliance. 6. Citation: Minnesota Rules, part 2960.0070, subpart 4. Violation: One of three resident files reviewed for requirements governing the inventory and handling of resident property (resident file numbered 2) did not meet requirements. The file did not contain documentation to demonstrate that the resident’s belongings were inventoried upon admission. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the inventory and handling of resident property meets all applicable requirements. 7. Citation: Minnesota Rules, part 2960.0485. Violation: One of two resident files reviewed for requirements governing the initial services plan (resident file numbered 4) did not meet requirements. The initial services plan was not completed during or immediately following the intake interview. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the initial services plan meets all applicable requirements. 8. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D. Violation: One resident file was reviewed for requirements governing educational services (resident file numbered 3) and did not meet requirements. The file did not contain documentation to demonstrate the license holder provided education about chemical health to a resident who has had a problem with inappropriate chemical use, but does not have sufficient history to refer to treatment. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure educational services are provided and meet all applicable requirements. 9. Citation: Minnesota Rules, parts 2960.0490, subparts 2, 3, items C, D and E and 2960.0600, item A, 2960.0620, subpart 1, item B. Violation: Four of four resident files reviewed for requirements governing the individual treatment plan did not meet requirements in the following ways: a. The treatment plan did not include the following: 1. Specific objectives to be used to address the treatment goals in which a problem has been identified (resident file numbered 5); 2. The frequency for each intervention listed (resident files numbered 2 and 5); 3. Specific interval at which resident progress should be reviewed (resident file numbered 2); 4. Minimum outcomes that are to be met before the resident is discharged (resident files numbered 2, 4 and 5); 5. Individuals responsible for providing treatment (resident files numbered 1,2, 4 and 5); 6. The symptoms and behaviors that the psychotropic medication is to alleviate (resident files numbered 1, 2 and 5). b. The treatment plan was not signed by the resident and the licensed alcohol and drug counselor (resident files numbered 2 and 4); and c. The treatment plan was not signed by the resident for plans completed after December 30, 2021 (resident file numbered 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements. Within 30 days of receipt of this order, submit individual treatment plans for two residents to demonstrate compliance has been achieved. 10. Citation: Minnesota Rules, part 2960.0490, subpart 5. Violation: Three of three resident files reviewed for requirements governing the treatment plan review did not meet requirements in the following ways: a. The individual treatment plan was not reviewed no less frequently than every two weeks for the following: 1. July 1, 2022 through July 23, 2022 (resident file numbered 2); 2. July 8, 2022 through July 29, 2022 (resident file numbered 4); and 3. July 7, 2022 through July 27, 2022 (resident file numbered 5). b. Services did not change when expected outcomes were not being achieved by the resident as demonstrated by the resident’s increase in chemical use (resident file numbered 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the treatment plan is reviewed by an alcohol and drug counselor and meets all applicable requirements. 11. Citation: Minnesota Rules, part 2960.0450, subpart 2, item C. Violation: Two of three resident files reviewed for requirements governing required chemical dependency treatment services (resident files numbered 2 and 5) did not meet requirements. The file did not contain documentation to demonstrate that the license holder provided education concerning tobacco addiction and cessation resources. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that chemical dependency treatment services are provided and meet all requirements. 12. Citation: Minnesota Rules, part 2960.0490, subpart 4. Violation: Three of three resident files reviewed for requirements governing progress notes (resident files numbered 2, 4 and 5) did not meet requirements. Progress notes did not include whether the services have had the desired impact. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit two weekly progress reviews and two group notes for two residents to demonstrate compliance has been achieved. 13. Citation: Minnesota Rules, part 2960.0620, subparts 5, item A, 7, items A and C. Violation: Two of two resident files reviewed for requirements governing the psychotropic medication review and the informed consent (resident files numbered 1 and 2) did not meet requirements in the following ways: a. The psychotropic medication reviews completed after admission did not include the data collected since the last review; and b. Admission informed consent information did not include: 1. Diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed; and 2. The course of the condition with and without the pharmacological and nonpharmacological treatment options. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the psychotropic medication review and the informed consent meets all requirements. Within 30 days of receipt of this order, submit informed consents for two residents to demonstrate compliance has been achieved. 14. Citation: Minnesota Rules, part 2960.0710, subparts 6, item K, 10. Violation: One resident file was reviewed for requirements governing restrictive procedures and the administrative review (resident file numbered 1) and did not meet requirements in the following ways: a. Restrictive procedure documentation did not include why less restrictive measures failed or were found to be inappropriate for procedures on January 19 and March 20, 2022; and b. The administrative review was not conducted by someone other than the person who decided to impose the restrictive procedure or that person’s immediate supervisor for a procedure on March 20, 2022. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures and the administrative review meets all applicable requirements. 15. Citation: Minnesota Rules, part 2960.0190, subparts 1, item A and 2. Violation: Three of three resident files reviewed for requirements governing discharge documentation did not meet requirements. The plan did not include: a. How the resident may deal with issues and potential challenges within the environment they will return to (resident files numbered 3 and 6); b. Which services included education, were provided directly or indirectly to the resident and who provided the services (resident files numbered 3, 6 and 7); and c. Which services, including education, that were recommended in the resident’s case plan or treatment plan but were not provided to the resident (resident files numbered 3, 6 and 7). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that discharge documentation meets all applicable requirements. Within 30 days of receipt of this order, submit a transition services plan from each unit to demonstrate compliance. 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 DHS Licensing at: 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Madelyn Gilbertson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Recommendation The following recommendation is not a requirement of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas. · DHS recommends the license holder develops a process to eliminate the use of multiple treatment plans and have one unified treatment plan for chemical dependency and mental health treatment services. Failure to follow this recommendation will not result in a fine or action against your license at this time. However, should failure to follow this recommendation result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license. C. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact Madelyn Gilbertson as soon as possible at 651-448-3583. Heather Prior, MH/SUD/CRF Licensor Licensing Division Office of Inspector General 651-431-2694
|
