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October 27, 2022 Pamela J. Larson, Authorized Agent Hutchinson Health 1095 Highway 15 South Hutchinson, Minnesota 55350 License Number: 1049920 CORRECTION ORDER Dear Pamela J. Larson; On August 30, 31, September 1, 2, 5, and 8, 2022 , a licensing review of Hutchinson Health, located at 1071 Highway 15 South, Hutchinson, Minnesota 55350 was conducted to determine compliance with state and federal laws and rules governing the provision of substance abuse treatment under Minnesota Statute, chapter 245G. As a result of this review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statute, 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 re-inspection. Corrective action for each violation is required by Minnesota Statute, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Policy and Procedures 1. Citation: Minnesota Statutes, section 245G.15, subdivision 2. Violation: The license holder’s grievance procedure did not meet requirements in the following ways: a) The policy was combined with their hospital policies which provided conflicting information related to the requirements specific to the 245G program and referenced Rule 31 which was repealed; b) The policy did not include the correct contact information for the Minnesota Board of Behavioral Health and Therapy; and c) The policy did not clearly identify the highest level of authority in the program the client may bring the grievance to if not resolved by another staff member. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance policy and procedures meet all applicable requirements. 2. Citation: Minnesota Statutes, sections 245G.07, subdivisions 1, and 245G.12, clause (10). Violation: The license holder’s description of treatment services did not meet requirements. The description did not specifically identify services the license holder provides to include the amount and type of services provided, including which services met the definition of group counseling. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the description of treatment services meet all applicable requirement. Within 30 days of receipt of this order, submit revised description of treatment services specific to the 245G program that meet all applicable requirements. 3. Citation: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b). Violation: The license holder did not have a policy or procedure that identified how the program will track and record client attendance at treatment activities, including the date, duration, and nature of each treatment service provided to the client. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that there is a policy and procedure that tracks and records client attendance that meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of the policy and procedure that demonstrates compliance. 4. Citation: Minnesota Statutes, section 245A.65, subdivision 2, clauses (2) and (5). Violation: The license holder’s program abuse policy did not meet the requirements in the following ways: a) The license holder did not identify specific reduction measures for areas that are difficult to supervise in order to minimize the risks of abuse of vulnerable adults within the scope or control of program services; and b) The license holder’s governing body did not provide documentation that the program abuse policy and plan were reviewed annually in 2020 and 2022. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that the program abuse policy identifies reduction measures to minimize risks and the policy reviews meet the annual applicable requirements. 5. Citation: Minnesota Statutes, section 245G.12, clause (9). Violation: The license holder’s maltreatment of minor’s policy did not meet the requirements in the following ways: a) The policy identified a process for reporting maltreatment of minors for the program, and defers the responsibility to the social work department within the hospital that did not meet 260E; and b) The policy did not identify the primary and secondary persons or positions that will ensure that when required an internal review will be completed. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of minor’s policy meets the applicable requirements. Within 30 days of receipt of this order, submit a revised maltreatment of minor’s policy that demonstrates compliance. Personnel Files 6. Citation: Minnesota Statutes, sections 245C.03, subdivision 1, and 245C.04, subdivision 4a. Violation: Two of three personnel files reviewed for requirements governing background studies did not meet requirements in the following ways: a) The personnel file did not contain documentation that the license holder submitted a background study for the staff person following a legal name change (personnel file number 1); and b) The staff were not affiliated on the 245G programs active Net study 2.0 roster (personnel files numbered 1 and 3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure background studies are completed as required and meet all applicable requirements. 7. Citation: Minnesota Statutes, section 245G.11, subdivision 3. Violation: One of three personnel files reviewed for the requirements governing staff qualifications did not meet requirements (personnel file numbered 1) as the license holder failed to demonstrate that the treatment director knew and understood the implications of Minnesota Statutes, chapter 245G, chapter 245A, and sections 626.556, 626.557, and 626.5572. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that the treatment director demonstrates knowledge and understanding of the requirements governing the licensed 245G program. Within 30 days of receipt of this order, submit a plan detailing how this will be met and monitored on an ongoing basis to meet all applicable requirements. 8. Citation: Minnesota Statutes, section 245G.13, subdivision 1, clause (7). Violation: One of three personnel files reviewed for the requirements governing orientation (personnel file number 1) did not meet the requirements of receiving orientation within 24 working hours of starting their position. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure and document all staff received orientation within 24 working hours of starting. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in Correction Order dated March 19, 2019. 9. Citation: Minnesota statutes, section 245G.13, subdivision 3. Violation: Three of three personnel files reviewed for requirements governing inquiries required by sections 604.20 to 604.205, (personnel files numbered 1 through 3) did not contain documentation that inquiries were sent to the staff person’s former employers regarding substantiated sexual contact with a client. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure and document that all required inquiries were made to former employers and meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated March 19, 2019. Client Files 10. Citation: Minnesota Statutes, section 245G.15 subdivision 1. Violation: Three of three client files reviewed for requirements governing the initial services plans (client files numbered 1 through 3) did not meet the requirements in the following ways: a) The initial services plans were not person-centered and client specific; and b) The initial services plans did not identify the client’s needs to be addressed between day of service initiation and the development of the individual treatment plans. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all initial services plans meet all applicable requirements. Within 30 days of receipt of this order, submit an initial services plan for one client that demonstrates compliance. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated March 19, 2019. 11. Citation: Minnesota Statutes, section 245G.05, subdivision 1. Violation: Three of three client files reviewed for requirements governing the comprehensive assessments (client files numbered 1 through 3) did not meet the requirements. The comprehensive assessments were not reviewed and updated by an alcohol and drug counselor within 3 calendar days on which a treatment session was provided from the day of service initiation. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for one client that demonstrates compliance. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated March 19, 2019. 12. Citation: Minnesota Statutes, sections 245G.05, subdivision 1, 245G.09, subdivision 3, and 245G.18. Violation: Three of three client files reviewed for requirements governing the individual treatment plans did not meet the requirements in the following ways: a) The treatment plan goals were not person-centered (client files numbered 1 through 3); b) The treatment plans did not contain specific goals and methods that included the amount, frequency, and anticipated duration of services (client files numbered 1 through 3); and c) A treatment plan did not include documentation of coordination with the school system to assure client’s academic needs were addressed (client file numbered 2). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all treatment plans meet applicable requirements. Within 30 days of receipt of this order, submit documentation for one client that demonstrates compliance. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated March 19, 2019. 13. Citation: Minnesota Statutes, sections 245G.06, subdivision 3, paragraph (c), and 245G.09, subdivision 3. Violation: Three of three client files reviewed for the requirements governing documentation of treatment services and treatment plan reviews, (client files numbered 1 through 3) did not meet the requirements in the following ways: a) The treatment plan reviews had conflicting documented amounts of treatment services when compared with the group duration in the individual group notes and duration of individual sessions; b) The treatment plan reviews did not include the client’s response to each service; and c) The treatment plan reviews did not document participation of others. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all documentation of treatment services and treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of a treatment plan review for one client that demonstrates 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 your Licensor at: 1. By secure email to: Alex.Stolis@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Alex Stolis 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, Kristi Strang, Human Services Supervisor Licensing Division Office of Inspector General 651-431-6611
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