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September 27, 2022 Brian Zirbes, Authorized Agent Northstar Behavioral Health LLC 1350 Arcade St St. Paul, MN 55106 License Number 1101848: Northstar Behavioral Health (Fergus Falls) (245G) License Number 1096260: Northstar Behavioral Health Geneva (Geneva) (245G) License Number 1083755: Northstar Behavioral Health Cranberry Acres LLC (Cranberry) (245G) CORRECTION ORDER Dear Brian Zirbes, On July 25 through 29, 2022, a licensing review of the following programs were conducted to determine compliance with state and federal laws and rules governing the provision of substance abuse treatment under Minnesota Statutes, chapter 245G: · Northstar Behavioral Health, located at 1174 Western Ave, Fergus Falls 1101848 · Northstar Behavioral Health Geneva, located at 5713 Geneva Ave, Oakdale 1096260 · Northstar Behavioral Health Cranberry Acres LLC, 5810 Cranberry Acres, Linwood 1083755 As a result of the licensing reviews 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 violation(s) of state or federal laws and rules were determined as a result of the licensing re-inspection. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Policy, Procedures, and Practices 1. Citation: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (b) and 626.557, subdivision 4a, paragraph (b). Violation: The license holder did not meet requirements for maltreatment reporting, both external and internal reporting practices for maltreatment of vulnerable adults, for an incident dated July 19, 2021, in the following ways (1101848): a. The license holder failed to report maltreatment within 24 hours of awareness of the suspected maltreatment; b. The license holder failed to provide a written notice to a mandated reporter stating whether the facility reported the incident to the common entry point, in writing, within two working days; and c. An internal review was not completed, including an evaluation of whether: 1. Related policies and procedures were followed; 2. Policies were adequate; 3. There was a need for additional staff training; 4. The reported event was similar to past events with the vulnerable adults or other services involved; and 5. There is a need for any corrective action to be taken by the license holder to protect the health and safety of the vulnerable adult. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure maltreatment reporting meets all applicable requirements. Within 30 days of receipt of this order, provide documentation demonstrating that all staff were re-trained on maltreatment reporting requirements to demonstrate compliance. Client Client files reviewed are identified in the following manner: · Fergus Falls: Client files numbered 1 and 2 · Geneva: Client files numbered 3 and 4 · Cranberry Acres: Client files numbered 5 and 6 2. Citation: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), 245A.191. Violation: The license holder failed to provide all clinical services hours required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b), clause (8) to clients receiving public funding reimbursement for high intensity residential treatment. Of the 30 hours of treatment services required, the client received 27.5 hours for the treatment week ending June 5, 2022 (client file numbered 3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that services are provided in the amount for which they are billed. The noncompliance identified above 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 CCDTF Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG 3. Citation: Minnesota Statutes, sections 245G.09, subdivision 3, clause (1) and 245G.15, subdivision 1. Violation: One of four client files reviewed for client orientation (client file numbered 3) did not meet requirements. For a client on commitment, the file did not contain documentation of orientation to client rights under 253B.03. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 4. Citation: Minnesota Statutes, 245G.04, subdivision 1 and 245G.09, subdivision 3, clause (2). Violation: One of six client files reviewed for requirements governing initial services plans (client file numbered 1) did not meet requirements. The initial services plan was not completed within 24 hours of the day of service initiation. Corrective Action Required: Immediately and on an ongoing basis the, the license holder must ensure that the initial service plans meet all applicable requirements. 5. Citation: Minnesota Statutes, 245G.04, subdivision 2, paragraph (a). Violation: One of two client files reviewed for requirements governing vulnerable adult assessment and determination (client file numbered 1) did not meet requirements. The vulnerable adult determination was not completed within 24 hours of service initiation. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure vulnerable adult assessment and determination meets all applicable requirements. 6. Citation: Minnesota Statutes, 245G.05, subdivisions 1, paragraph (a) and 2, paragraph (a) and 245G.09, subdivision 3. Violation: Five of six files reviewed for requirements governing comprehensive assessment and comprehensive assessment summary did not meet requirements in the following ways: a. The comprehensive assessment and comprehensive assessment summary were not completed within 3 calendar days from the day of service initiation and a person-centered delay was not documented (client files numbered 4 and 5); b. The comprehensive assessment and comprehensive assessment summary were not completed within 3 calendar days on which a treatment session has been provided from the day of service initiation and a person-centered delay was not documented (client files numbered 2); and c. The comprehensive assessment did not include information about the client’s needs that relate to substance use and personal strengths that support recovery, including: 1. Previous attempts at treatment for mental illness (client file numbered 1); 2. Presence of physical or sexual abuse (client file numbered 1); 3. Mental health history, including symptoms, and the effect on the client’s ability to function (client files numbered 1 and 3); 4. Current mental health treatment (client file numbered 1); and 5. Psychotropic medications needed to maintain stability (client file numbered 1). Corrective Action Required: Immediately and on an ongoing basis the, the license holder must ensure that the comprehensive assessment and comprehensive assessment summary meets all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment for two clients (Fergus Falls) that demonstrates compliance.
6. Citation: Minnesota Statute 245G.06, subdivision 1 and 245G.09, subdivision 3. Violation: Five of six client files reviewed for requirements governing individual treatment plan (ITP) did not meet requirements in the following ways: a. The ITP as not completed within ten calendar days from the day of service initiation for residential programs (client files numbered 4 and 5); b. The plan did not include how the family would be involved in treatment services for clients who chose to have family involved (client files numbered 5 and 6); c. The plan did not include specific goals and methods to address each identified need, including the amount, frequency and anticipated duration of the treatment service (client files numbered 1, 2 and 5); and d. The plan did not include resources to refer the client when needs are to be addressed concurrently by another provider (client file numbered 5). Corrective Action Required: Immediately and on an ongoing basis the, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit individual treatment plans for two clients (ALL) that demonstrates compliance. 7. Citation: Minnesota Statute 245G.06, subdivision 3, paragraph (c). Violation: Six of six client files reviewed for requirements governing combined documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. Reviews were not entered for the treatment week ending February 20, 2022 (client file numbered 6); b. Reviews contained conflicting time spans (client files numbered 1 through 4); c. The review did not address each goal in the treatment plan and whether the methods to address the goals are effective (client file numbered 1); and d. The review did not include: 1. The reasons for the clients’ absences from group (client files numbered 3, 4, 5 and 6); 2. The client’s response to each service (client file numbered 3); and 3. Monitoring of the client’s mental health problems (client file numbered 5). Corrective Action Required: Immediately and on an ongoing basis the, the license holder must ensure treatment plan reviews meet all applicable requirements. 8. Citation: Minnesota Statute 245G.06, subdivision 4, paragraph (a). Violation: Two of three client files reviewed for requirements governing discharge summaries (client files numbered 4 and 6) did not meet requirements. Discharge summaries were not completed within five days of the client’s service termination. Corrective Action Required: Immediately and on an ongoing basis the, the license holder must ensure discharge summaries meet all applicable requirements of the statute. 9. Citation: Minnesota Statute 245A.04, subdivision 13, paragraph (c) Violation: One of three client files reviewed for client property management (client file numbered 3) did not meet requirements. The license holder failed to document receipt of the client’s property, including the client’s signature. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client property management meets all requirements Personnel Personnel files reviewed are identified in the following manner: · Fergus Falls: Personnel files numbered 1 through 4 · Geneva: Personnel files numbered 5 through 8 · Cranberry Acres: Personnel files numbered 9 through 11 · Geneva and Cranberry Acres: Personnel files 12 and 13 10. Citation: Minnesota Statutes, sections 245C.07, subdivision 2, paragraph (f) and 245G.13, subdivision 3. Violation: Three of thirteen personnel files reviewed for requirements governing background studies did not meet requirements. The license holder failed to affiliate the staff person on all active rosters: a. A background study was submitted under license number 108860, however, the staff were not affiliated to license 1096260 (personnel files numbered 7 and 8); and b. A background study was submitted under license 1079088, however, the staff was not affiliated to licenses 1096260 and 1083755 (personnel file numbered 13). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all background studies meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 28, 2020. 11. Citation: Minnesota Statute, section 245G.11, subdivision 11. Violation: One of two personnel files reviewed for supervision requirements governing individuals with a temporary permit to provide chemical dependency treatment service (personnel file numbered 9) did not meet requirements in the following ways: a. The personnel file did not contain documentation of supervision for the following timelines: 1. Weeks of July 3, 2021 to August 21, 2021; 2. Weeks of March 12, 2022 to April 2, 2022; 3. Weeks of June 11, 2022 to June 25, 2022; and 4. Week of August 23, 2022 b. The personnel file supervision documentation did not contained the date or amount of time of supervision for the followings dates: 1. Week of May 30, 2022 to June 3, 2022; 2. Week of June 27, 2022; 3. Week of August 3, 2022; and 4. Week of August 11, 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that supervision of an individual with temporary permit meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 28, 2020. 12. Citation: Minnesota Statutes, section 245G.13, subdivision 1, clause (8). Violation: One of five personnel files reviewed for requirements governing orientation training (personnel file numbered 1) did not meet requirements. Staff did not receive orientation to the staff member’s specific job responsibilities within 24 working hours. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel files include documentation of orientation that meets all applicable requirements. 13. Citation: Minnesota Statutes, sections 245G.13, subdivision 2, paragraph (c) and 626.557, subdivision 3. Violation: One of five personnel files reviewed for requirements governing annual training (personnel file numbered 6) did not meet requirements. The personnel file did not contain documentation of annual training for obtaining a release of information for calendar year 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual training meets all applicable requirements. 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: 1. By secure email to: Leah.Wachter@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: NAME OF LICENSOR Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. 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 me as soon as possible. Sincerely, Sue Schill-Grotte, Human Services Licensor Licensing Division Office of Inspector General 651-431-6604
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