|
December 1, 2022
Emily Peach, Authorized Agent Beauterre Recovery Institute 550 Main Street Suite 230 New Brighton, Minnesota, 55112 License Number: 1075930 Report Numbers: 202202155 and 202203895 CORRECTION ORDER Dear Emily: On September 12, 13, 14, and 15, 2022, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility located at 2480 South County Road 45, Owatonna, Minnesota 55060. As a result of this visit, DHS determined that you are in violation of 18 of the Substance Use Disorder Treatment rules and statutes. As a result, DHS is issuing this order which requires you to take the correction action as described below. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Practices, Policies, and Procedures 1. Violation: The license holder allowed treatment services to be provided by unqualified persons: a. A group treatment service, Community Group, was peer-led. The treatment services description stated Community Group is “facilitated by licensed professionals, program assistants, and senior peer leaders”, and a note for the group on 3/21/2022 documented it was led by a peer; and b. Treatment coordination was provided on 3/2/22 and 3/7/22 by a Resource Coordinator (personnel file numbered 11) who did not meet the qualifications of a treatment coordination provider. In addition, the Resource Coordinator job description included job responsibilities consistent with the description of treatment coordination in Minnesota Statutes, section 245G.07, subdivision 1, and did not require the position to meet the qualifications of a treatment coordination provider. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3, and 245G.11, subdivision 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment services are provided by qualified professionals. 2. Violation: The license holder did not respond to a client grievance received on 11/7/2021 within three days of the staff member’s receipt of the grievance. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure grievances are responded to within three days of a staff member’s receipt of the grievance. 3. Violation: The license holder had two policies for reporting maltreatment of vulnerable adults which included conflicting primary and secondary persons or positions to whom internal reports will be made. Statutes Violated: Minnesota Statutes, section 245A.65, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policies for reporting maltreatment of vulnerable adults are consistent and meet all applicable requirements. Within 30 days of receipt of this order, submit a policy that meets all applicable requirements. 4. Violation: The license holder did not follow their tuberculosis policy, which stated that client orientation packets will include the Minnesota Department of Health Tuberculosis Fact Sheet, which is the required form approved by the Department of Human Services Commissioner. At the time of the review, the orientation packet only included tuberculosis information from the Centers for Disease Control. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the tuberculosis policy is followed and meets all applicable requirements. 5. Violation: The treatment services policy and practices did not meet requirements in the following ways: a. The policy identified that Group Therapy services meet the definition of group counseling under section 245G.01, subdivision 13a. However, during the licensing review, the license holder stated the policy was not accurate, and that Primary Group was the only type of group therapy which meets the definition of group counseling; b. The license holder did not ensure that group counseling did not exceed 16 clients. A group counseling session had 17 clients on 8/12/22; c. The policy included a description of a service to help the client integrate gains made during treatment into daily living and to reduce the client's reliance on a staff member for support, which is a required treatment service; however, the description indicated it was not a treatment service and stated it may be provided by staff who are not qualified to provide treatment services; d. The policy did not include a description of peer recovery support services; however, the program had a Patient Services Coordinator, and the job description for the position stated the position works as a Peer Recovery Support Specialist; e. The license holder’s practice was to complete “group notes” for both treatment services and other activities that are not treatment services. Multiple notes did not identify whether or not the groups were treatment services; therefore, it could not be determined if treatment services were provided in accordance with the descriptions of treatment services in Minnesota Statutes, section 245G.07 and in the license holder’s policy; and f. Therapeutic recreation group notes did not reflect that a group treatment service was provided. Notes for group on 2/28/22 and 9/12/22 stated clients were given an option to attend one of various activities offered, and did not identify which activity each client did, and did not reflect that the clients participated in an activity together as a group. Statutes Violated: Minnesota Statutes, sections 245G.07, 245G.10, subdivision 4, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services policy and practices meet all applicable requirements. Within 30 days of receipt of this order, submit a revised policy which meets all requirements. 6. Violation: The service termination policy did not include a requirement that before discharging a client from a residential setting for not reaching treatment plan goals the license holder must confer with other interested persons to review issues involved in the decision. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service termination policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy which meets all requirements. 7. Violation: The personnel policies did not meet the requirements in the following ways; a. The policies did not include a job description the following positions, identified as program staff: 1) Utilization Review/Financial Counselor; 2) Admissions Coordinator; 3) Program Assistant 4) Housekeeping; 5) Vice President of Clinical Services; 6) Intern; 7) Maintenance; and 8) Receptionist (Office Tech)/Administrative Assistant; b. The organizational chart did not include the following positions, identified as program staff: 1) Utilization Review/Financial Counselor; 2) Admissions Coordinator; 3) Program Assistant; 4) Housekeeping; and 5) Vice President of Clinical Services; c. The degree of authority to execute job responsibilities was not clear in the Resource Coordinator job description. The description stated the position reports to the Counselor Supervisor or the Treatment Director, and the organizational chart indicated the position directly reports to the Treatment Director; and d. The problematic substance use policy did not include circumstances under which an individual who participates in monitoring by the health professional services program is able to provide services to the program’s clients. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies meet all applicable requirements. Within 30 days of receipt of this order, submit a list of all staff positions in the program, and job descriptions for each position and an organizational chart which reflects the current positions. Client Files 8. Violation: Four out of five client files reviewed for requirements governing protection of client records from unauthorized disclosure (client files numbered 1, 3, 4 and 5) contained releases of information which did not identify the names of the individuals or entities to which disclosures were to be made. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client records are protected from unauthorized disclosure, and that written consents to disclosure meet all requirements of Code of Federal Regulations, title 42, chapter 1, part 2, section 2.31. 9. Violation: Five out of five client files reviewed for requirements governing client rights protection (client files numbered 1 through 5) did not contain documentation that the license holder informed each client of the client’s right to refuse being photographed or recorded. The Patient Photographs policy stated “Clients must be informed when their actions are being recorded by camera or tape, and have the right to deny any taping or photography, except when it is to be used for identification purposes or for enhancing either therapy or staff supervision of the client”; however, clients were not informed of this policy. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, and 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clients are informed of the right to refuse being photographed or recorded in accordance with the program policy and Minnesota statute requirements. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 10. Violation: Four out of four client files reviewed for requirements governing comprehensive assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: a. A description of the circumstances on the day of service initiation (client file numbered 1); b. A list of substance use history including types, amount, frequency, and duration of substances used: 1) The histories did not include alcohol (client files numbered 2, 4, and 5); and 2) The history did not include duration of opiate use (client file numbered 5); c. The absence or presence of previous withdrawal symptoms for each substance used in the previous 30 days (client files numbered 2, 4 and 5); and d. Whether or not physical concerns need to be referred to an appropriate health care professional (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements.
11. Violation: Four out of four client files reviewed for the requirements governing individual treatment plans did not meet requirements in the following ways: a. The plan was not signed by client and did not document that the client was involved in the development of the plan (client file numbered 4); b. The plan did not include how the family the client chose to have involved in treatment services would be involved in the client’s treatment (client file numbered 5); c. The plans did not include amount, frequency, and anticipated duration of treatment services to be provided (client files numbered 1, 2, 4, and 5); and d. The plans were not updated based on new information gathered about clients’ condition and on whether methods identified had the intended effect (client files numbered 1 and 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans are completed within the required timeframe that meets all applicable requirements. 12. Violation: Two out of four client files reviewed for the requirements governing reviews of treatment services did not meet the requirements in the following ways: a. A review was not documented the week ending 10/25/20 (client file numbered 3); and b. Reviews did not include the reasons for absences from a treatment service (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, the license holder was cited for a similar violation. 13. Violation: Three out of four client files reviewed for the requirements governing treatment plan reviews did not meet the requirements in the following ways: a. The reviews did not indicate the dates of each service provided (client files numbered 1, 4 and 5); b. The reviews did not indicate the amount of each service provided (client file numbered 5); c. The reviews did not indicate the client’s response to each service provided (client file numbered 1); and d. The reviews documented that all methods to address treatment plan goals were effective; however, the dimension narratives on the reviews indicated they were not effective, as the client was not attending programming as required and was isolating and struggling with “overwhelming” mental health symptoms (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 14. Violation: Two of four client files reviewed for requirements governing medication administration did not record the clients’ use of medication. The Medication Administration Records did not document whether or not medications were administered as prescribed on: a. Thirteen occasions (client file numbered 4); and b. Seven occasions (client file numbered 1). Statute Violated: Minnesota Statutes 245G.08, subdivision 5, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration records meet all applicable requirements. 15. Violation: Two out of five client files reviewed for the requirements governing record keeping did not meet the requirements in the following ways: a. An entry in the client record was not accurate (client file numbered 3). A note for a group on 11/7/20 stated the client was present and engaged; however, the client discharged from the program on 11/5/2020 and was not present; and b. An entry in the client record was not signed (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 16. Violation: Two out of four client files reviewed for the requirements governing discharge summaries did not meet the requirements in the following ways: a. The continuing care recommendations did not include referrals (client files numbered 3 and 4); and b. The summary did not include the client’s living arrangements at service termination (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. Personnel Files 17. Violation: Two out of seven personnel files reviewed for the requirements governing medication administration training (personnel files numbered 5 and 10) did not receive training taught by a registered nurse and offered by the license holder on the process for administration of naloxone. The staff received computer-based training through an online agency. Statute Violated: Minnesota Statutes, section 245G.08, subdivisions 3 and 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure naloxone training is provided and meets all applicable requirements. 18. Violation: One out of seven personnel files reviewed for the requirements governing annual training (personnel file numbered 2) documented that the staff person received annual training on HIV minimum standards late in 2021. Statutes Violated: Minnesota Statutes, sections 245A.19, paragraph (b), and 245G.13, subdivision 2, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff training is annually and meets all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. Recommendations The following recommendations are being made to assist with achieving and maintaining compliance with applicable requirements on an ongoing basis. Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow recommendations result in a violation of statutes or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license. You may contact your licensor for more information if you choose to implement these recommendations. DHS is recommending that you: 1. Develop a process to inform potential clients prior to admission that medications they bring to the facility which are determined by a medical professional to be harmful to the client may be destroyed, unless they are approved to be returned to the client by the client’s personal medical professional. It is recommended the process include procedures to document: a. The client was informed; b. The client was examined by a medical professional and the medication was determined to be harmful to the client, as applicable; and c. The client was given the opportunity to have their personal medical professional approve return of the medication. 2. Include qualifications consistent with the definition of Mental Health Professional in Minnesota Statutes, section 245I.04, subdivision 2, in the Mental Health Professional job description. 3. Determine the highest level of authority for purposes of responding to client grievances, and revise the grievance procedure as necessary. At the time of the review, the procedure stated the treatment director is the highest level of authority; however, it was identified during the review that there is a corporate compliance division which may also address grievances. 4. Document how client orientation is provided to items that are not included in the client intake packet. Client files reviewed included an Acknowledgments form which stated clients were oriented to “Vulnerable Adult Reporting” and the Program Abuse Prevention Plan. However, the intake packet, which was identified as the material used to provide the orientation, did not include these items. Corrective action required
You must correct the violations cited above. If you fail to correct the violations identified in the Correction Order within the specified time lines DHS 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 must be sent: 1. By secure email to: Leah.Wachter@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Leah Wachter Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began 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 20 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Substance Use Disorder Treatment program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at leah.wachter@state.mn.us or 651-431-6614. Sincerely, Leah Wachter, Senior Licensor Licensing Division Office of Inspector General
|
