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December 14, 2022 CERTIFIED MAIL Carmen Wilson, Authorized Agent Tomorrow LLC dba Anchorage PO Box 128 Pillager, MN 56473 License Number: 1044799 (245G) Licensing Report Number: 202201590 ORDER OF CONDITIONAL LICENSE Dear Carmen: The Department of Human Services (DHS) is placing your license to provide services at Tomorrow LLC dba as Anchorage, located at 3027 South Frontage Road Moorhead, MN 56560, on conditional status for two years, beginning December 21, 2022. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Substance Use Disorder Treatment licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On October 10 through 13, 2022, DHS licensors conducted a licensing review and licensing investigation at your facility located at 3027 South Frontage Road Moorhead, MN 56560. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Substance Use Disorder Treatment programs, citing 38 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature and Severity: Your program failed to follow requirements which affected the health, safety, and rights of persons served: o The program failed to comply with background studies requirements (violations numbered 1 and 2). o The program failed to ensure staff were qualified (violation numbered 3). o The program failed to meet requirements for billing for services (violation numbered 4). o The program failed to ensure that staff requirements for first aid certification were met (violation numbered 5). o The program failed to account for all scheduled drugs each shift (violation numbered 6). o The program failed to complete internal reviews of suspected vulnerable adult maltreatment (violation numbered 7). o The program failed to provide training related to duties in implementing policies and procedures (violation numbered 8). o The program failed to provide staff orientation and training (violations numbered 9 and 10). o The program failed to provide required staff supervision (violation numbered 11). o The program failed to complete a treatment plan for 115 days (violation numbered 15). o The program failed to comply with requirements for confidentiality of client records (violations numbered 16 and 17). o The program failed to complete individual abuse prevention plans as required (violation numbered 20). · Chronicity: Your program failed to correct prior violations cited in a Correction Order issued on December 20, 2019. Of the 38 violations in this order, 25 are repeat violations. Due to the serious and chronic nature of these violations, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder treatment is being placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder failed to comply with background studies requirements. a. The license holder failed to initiate background studies on individuals before they began in positions of direct contact with persons served by the program. At the time of the review, background studies had not been initiated for staff persons who began direct contact positions on: 1) July 29, 2020 (personnel file numbered 4); and 2) November 10, 2021 (personnel file numbered 10); b. The license holder failed to comply with notices to immediately remove individuals from positions requiring background studies. Background studies were initiated prior to when the individuals began positions of direct contact with persons served by the program; however, notices were issued which stated the individuals must be immediately removed from their positions and that the license holder was required to submit new background study requests for the individuals. The license holder did not submit new requests prior to hiring the individuals in positions allowing direct client contact on: 1) December 6, 2021 (personnel file numbered 15); and 2) December 29, 2021 (personnel file numbered 8); c. The license holder failed to provide continuous, direct supervision of individuals who provided direct contact services to persons served by a program while the individuals’ background studies were in process, but not yet completed (personnel files numbered 11 through 14); and d. The license holder failed to transfer a background study (personnel file numbered 2). The background study was initially submitted under another license owned by the license holder, which closed December 31, 2020, and the license holder did not notify DHS to transfer the background study to an active license. Statute Violated: Minnesota Statutes, sections 245C.03, subdivision 1, paragraph (a), 245C.04, subdivision 1, paragraph (g), 245C.07, paragraph (b), and 245C.13, subdivision 2. 2. Violation: The license holder failed to comply with conditions of background study variances. a. The license holder allowed staff persons to remain in positions of direct contact with persons served by the program following the expiration of background study variances (personnel files numbered 11 and 13); b. The license holder failed to ensure the staff person remained under continuous supervision by another staff person whenever s/he direct contact with, or access to, the persons served by the program (personnel file numbered 12); c. The license holder failed to ensure the staff persons did not have access to client valuables (personnel files numbered 12, 13, and 14); d. The license holder failed to ensure the staff person did not have access to client medications (personnel file numbered 14); and e. The license holder failed to report grievances or complaints from staff or clients about the work of the staff persons to DHS central intake within 72 hours (personnel files numbered 12 and 13). Statute Violated: Minnesota Statutes, section 245C.30, subdivision 1. 3. Violation: The license holder failed to ensure staff were qualified. a. A staff person (personnel file numbered 1) provided treatment coordination and was not qualified. The license holder was aware the staff person did not meet treatment coordinator qualifications and used a different title for the staff person until qualified; however, still allowed the staff person to provide treatment coordination services during the time period July 15, 2021 through May 26, 2022. During that time, the staff person did not meet the following qualifications: 1) Successfully completed 30 hours of classroom instruction on treatment coordination for individuals with substance use disorder; 2) 2,000 hours of supervised experience working with individuals with substance use disorder; 3) Skilled in the process of identifying and assessing a wide range of client needs; and 4) Knowledgeable about local community resources and how to use those resources for the benefit of the client; b. The Alcohol and Drug Counselor Supervisor (personnel file numbered 2) did not meet the requirement to have three or more years' experience providing individual and group counseling to individuals with substance use disorder. The license holder was unaware of the qualification requirements for this position; and c. A peer recovery specialist (personnel file numbered 9) facilitated a group treatment session on January 13, 2022 and was not qualified to do so, as peer recovery services may only be provided one-to-one. Statute Violation: Minnesota Statutes, sections 245G.07, subdivisions 2 and 3, 245G.11, subdivisions 4 and 7, paragraph (a), and 245G.13, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 4. Violation: The license holder failed to meet requirements for receiving public funding reimbursement from the commissioner for services provided: a. The license holder did not document that all of the clinical services hours required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b), clause (8) were provided to clients receiving public funding reimbursement for high intensity residential treatment. The clients did not receive the required 30 hours of services per week during the weeks ending: 1) February 6, 2022 (client files numbered 1 and 5); and 2) January 30, 2022 (client file numbered 1); b. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (4), for services provided to individuals with co-occurring mental health and chemical dependency problems: 1) Co-occurring counseling staff did not receive 8 hours of co-occurring training in the past year (personnel files numbered 2 and 4); 2) The license holder did not complete a diagnostic assessment within 10 days of admission (client file numbered 1); and 3) Multidisciplinary case reviews were not completed monthly (client file numbered 1). The client was in the program for 4 months and no reviews were documented; c. Documentation of two group treatment services on February 7, 2022 and two groups on February 9, 2022 services did not identify who provided the services; therefore it could not be determined if the services were provided by a qualified staff person (client file numbered 3); d. Documentation of services did not accurately identify the duration of the services (client file numbered 1): 1) The file documented that the client was in two services at the same time on January 21, 2022, January 24, 2022, March 10, 2022, April 20, 2022, April 28, 2022, and May 2, 2022; and 2) Documentation of groups identified that breaks occurred and did not identify the duration of the breaks on January 20, 2022 and March 10, 2022; e. Documentation of services did not identify the nature of the service (client file numbered 1). The file contained documentation for Art Therapy group and Treatment Coordination, which were not consistent with the program’s treatment services description or with the treatment services defined in Minnesota Statutes, section 245G.07, subdivisions 1 and 2. Statute Violation: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 5. Violation: The license holder failed ensure that when clients were present at least one staff person was on the premises that had a current American Red Cross standard first aid certificate or an equivalent certificate. The license holder was unable to provide documentation that the requirement was met during the following time periods: a. 11pm September 26, 2022 to 7am September 27, 2022; b. 11pm September 27, 2022 to 7am September 28, 2022; c. 11pm October 2, 2022 to 7am October 3, 2022; d. 11pm October 3, 2022 to 7am October 4, 2022; and e. 9:30pm October 4, 2002 to 7am October 5, 2022. Statute Violation: Minnesota Statutes, section 245G.10, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 6. Violation: The license holder failed to follow their policy and procedure to account for all scheduled drugs each shift. A controlled substance was not included in the shift count of scheduled drugs October 7, 2022 through October 10, 2022. Statute Violation: Minnesota Statutes, sections, 245A.04, subdivision 14, and 245G.08, subdivision 6. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 7. Violation: The license holder failed to complete internal reviews when the facility had reason to know that reports of alleged or suspected maltreatment had been made on: a. August 27, 2021; b. January 18, 2022; and c. July 29, 2022. Statute Violation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 8. Violation: The license holder failed to provide and document training to program staff related to their duties in implementing the program's policies and procedures, and to monitor implementation of policies and procedures, as evidenced by the violations identified in this order: a. During an interview with the staff person identified by the license holder as the compliance officer (personnel numbered 17) it was determined that the staff person was unaware s/he was designated as the compliance officer, was unaware of the duties required, and did not receive training on them; and b. During an interview with the treatment director (personnel file numbered 16), it was identified that the staff person was unaware of the duties related to personnel training and monitoring that were in the treatment director job description, and did not receive training on them. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b). 9. Violation: Four of four personnel files reviewed for requirements governing orientation did not contain documentation orientation was completed on: a. The staff member’s specific job responsibilities (personnel files numbered 1, 3, 8, and 10); b. Policies and procedures (personnel files numbered 3, 8, and 10); c. Client needs (personnel files numbered 1, 3, 8, and 10); d. HIV minimum standards (personnel files numbered 1 and 3); e. Vulnerable adult maltreatment reporting requirements and definitions in sections 626.557 and 626.5572, and 245A.65 (personnel files numbered 3, 8, and 10); f. The license holder's program abuse prevention plan (personnel files numbered 1, 3, 8, and 10); g. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 3, 8, and 10); and h. The program’s drug and alcohol policy (personnel file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivisions 1, 2, paragraph (d), and 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 10. Violation: Six of six personnel files reviewed for requirements governing annual and biennial staff training did not include documentation the staff persons received training as required: a. Training on Vulnerable Adults Maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572 was not received in: 1) 2021 and 2022 (personnel files numbered 2 and 4); and 2) 2022 (personnel files numbered 1 and 3); b. Training on internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was not received in: 1) 2021 and 2022 (personnel files numbered 2 and 4); and 2) 2022 (personnel files numbered 1 and 3); c. Training on the facility’s policies for obtaining releases of information required by Minnesota Statutes, section 626.557, subdivision 3a, paragraph (a) was not received in: 1) 2021 and 2022 (personnel files numbered 2 and 4); and 2) 2022 (personnel files numbered 1 and 3); d. Training on the program abuse prevention plan was not received in: 1) 2021 and 2022 (personnel files numbered 2, 4, and 9); and 2) 2022 (personnel files numbered 1 and 3); e. Training on mandatory reporting of maltreatment of minors, including reporting of prenatal exposure to controlled substances was not received in: 1) 2021 and 2022 (personnel files numbered 2 and 4); and 2) 2022 (personnel files numbered 1 and 3); f. Training on HIV minimum standards was not received in: 1) 2021 and 2022 (personnel files numbered 2 and 4); 2) 2022 (personnel file numbered 3); and 3) 2021 (personnel file numbered 9); g. Training on client confidentiality rules and regulations: 1) Was not received within the past two years (personnel file numbered 4); and 2) Was not documented (personnel file numbered 2). Training titled HIPPA for Behavioral Health was completed within the past two years; however, the license holder identified that the training was provided through a training company and was unable to identify if all applicable confidentially rules and regulations were including in the training, and stated the content of the training was no longer available; h. Training on emergency procedures: 1) Was not received within the past two years (personnel file numbered 4); and 2) Was not documented (personnel file numbered 2). Training titled Emergency Preparedness for Healthcare Workers was completed within the past two years; however, the license holder identified that the training was provided through a training company and was unable to identify if the program’s emergency procedures were including in the training, and stated the content of the training was no longer available; i. Training on client ethical boundaries was not received within the past two years (personnel file numbered 4); and j. Training on client rights was not received within the past two years (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivisions 2, paragraphs (b), (c), and (d), and 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 11. Violation: Four of five personnel files reviewed for requirements governing staff supervision did not meet requirements in the following ways: a. Supervision for individuals with Alcohol and Drug Counselor temporary permits was not documented at least on a weekly basis, including the amount and type of the supervision: 1) Supervision was not documented: (i) January 1, 2021 through May 21, 2022 and the weeks ending May 28, June 4, 18, and 25, July 2, 16, 23, and 30, August 6, 13, and 27, September 10, 17, and 24, and October 1 and 8, 2022 (personnel file numbered 6); (ii) The weeks ending May 28, June 4, 11, and 25, July 2, 9, 23, and 30, August 6, 13, 20, and 27, September 17 and 24, and October 1 and 8, 2022 (personnel file numbered 7); and (iii) The weeks ending August 13, 20, and 27, September 24, and October 8, 2022 (personnel file numbered 5); 2) Supervision documentation did not identify the amount (personnel files numbered 5, 6, and 7); b. Supervision for a treatment coordinator (personnel file numbered 1) was not provided from an alcohol and drug counselor or a mental health professional who has substance use treatment and assessments within the scope of their practice at least one hour monthly: 1) Supervision was not documented August, 2021 through April 2022, and July 2022; and 2) Documentation of supervision did not identify the amount of supervision provided. The form stated “Meeting are approximately one hour (60 minutes) in length.” Statute Violated: Minnesota Statutes, section 245G.11, subdivision 7, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 12. Violation: The license holder failed to designate a responsible staff member present in the facility during all hours of operations. During an interview with a staff person (personnel numbered 16), it was identified that the treatment director did not designate a responsible staff member on any overnight shifts and weekends. It was identified that those shifts were usually staffed by two behavioral health technicians only, and one was not designated as the responsible staff member, and staff in that position do not meet the requirement of a responsible staff person to know and understand the implications of Minnesota Statutes, chapter 245G. Statute Violation: Minnesota Statutes, section 245G.10 subdivision 3. 13. Violation: Two of two personnel files reviewed for requirements governing staff development (personnel files numbered 2 and 8) did not contain documentation that a minimum of 12 hours of training in co-occurring disorders was obtained within six months of employment. Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 2, paragraph (e), and 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 14. Violation: Six of ten personnel files reviewed for requirements governing personnel file contents did not contain: a. Completed applications for employment signed by the staff members (personnel files numbered 8 and 10); b. Documentation that the staff members met the qualification requirements of their positions (personnel files numbered 2, 3, 4, and 9); and c. Written annual reviews of the employees’ job performance: 1) In 2021 and 2022 (personnel file numbered 4); 2) In 2022 (personnel file numbered 3); and 3) In 2021 (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 15. Violation: Four of four client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. The individual treatment plans were not completed within 10 calendar days from the day of service initiation. The plans were completed: 1) 115 days after service initiation (client file numbered 1); and 2) 12 days after service initiation (client files numbered 2 and 4); b. The individual treatment plan was not signed by the client and did not document the client’s involvement in the development of the plan (client file numbered 1); c. The individual treatment plans were not updated based on new information gathered about the clients’ condition on whether methods identified had the intended effect (client files numbered 1 and 3); and d. Treatment services were not provided according to the individual treatment plans (client files 1 and 3). The treatment plan goals and methods did not include amount, frequency, and anticipated duration of each type of treatment service provided to the clients. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 2, 245G.07, subdivision 1, paragraph (b), and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 16. Violation: Four of four client files reviewed for requirements governing protection of client records from unauthorized disclosure (client files numbered 1 through 4) contained Authorizations for 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). Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 17. Violation: Two of four client files reviewed for requirements governing consent to disclose suspected maltreatment (client files numbered 1 and 3) did not contain documentation the license holder sought consent to disclose maltreatment upon admission. Statute Violated: Minnesota Statutes, section 626.557, subdivision 3a. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 18. Violation: One of four client files reviewed for requirements governing orientation (client file numbered 3) did not contain documentation that: a. The client was given a written statement of client rights and responsibilities on the day of service initiation and that staff reviewed the statement with the client; b. The license holder explained the grievance procedure to the client on the day of service initiation; c. The client received orientation to the HIV minimum standards within 72 hours of admission to the program; d. The client received information on tuberculosis and tuberculosis screening; and e. The client received orientation within 24 hours of admission to the program to: 1) The license holder’s internal and external reporting policies, including telephone number for the Minnesota Adult Abuse Reporting Center; and 2) The license holder’s program abuse prevention plan. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivisions 1, paragraph (c), and 2, paragraph (a), 245G.09, subdivision 3, and 245G.15, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 19. Violation: One of four client files reviewed for requirements governing initial service plans (client file numbered 1) did not contain an initial service plan completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 20. Violation: Four of four client files reviewed for requirements governing individual abuse prevention plans (IAPPs) did not meet requirements in the following ways: a. The IAPP was not developed within 24 hours of the day of service initiation (client file numbered 1). It was developed 118 days after service initiation; b. The IAPPs did not include assessments of the persons’ risk of abusing other vulnerable adults (client files numbered 1 through 4); c. The IAPPs did not include complete assessments of the persons’ susceptibility to abuse by other individuals (client files numbered 1 through 4). The IAPP form limited the assessment to the categories of sexual abuse, physical abuse, self-abuse, and financial exploitation, and did not include all types of abuse defined in Minnesota Statutes, section 626.5572; d. The IAPPs did not detail the measures to be taken to minimize the risk that the vulnerable adults might reasonably be expected to pose to visitors to the facility and persons outside the facility, if unsupervised, when the facility knew that the vulnerable adults had committed a violent crime or an act of physical aggression towards others (client files numbered 3 and 4); and e. The client receiving services did not participate in the development of the IAPP (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (b), and 245G.09, subdivision 3. 21. Violation: Three of four client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessments were not completed within three calendar days from the day of service initiation and the person-centered reason for the delays and the planned completion were not documented in the clients’ files: 1) The assessment was completed 115 days after service initiation (client file numbered 1); and 2) The assessment was completed four days after service initiation (client file numbered 2); b. The assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: 1) A description of the circumstances on the day of admission (client files numbered 1 and 3); 2) Circumstances of relapse (client file numbered 3); 3) A mental health screening tool (client files numbered 1 and 3); and 4) A description of how the clients’ use affected ability to function appropriately in a work and educational setting; (client files numbered 1 and 3); c. The substance use histories were not complete: 1) The assessment identified that the client used opiates, which was not in the list of substance use history (client file numbered 1); and 2) The amounts and frequency of substances used were limited to the most recent period of use, and did not cover the clients’ history of use (client files numbered 1 and 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a), and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 22. Violation: Two of four client files reviewed for requirements governing assessment summaries (client files numbered 1 and 2) contained summaries which were not completed within three calendar days from the day of service initiation: a. The summary was completed 115 days after service initiation (client file numbered 1); and b. The summary was completed four days after service initiation (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 2, and 245G.09, subdivision 3. 23. Violation: Three of three client files reviewed for requirements governing combined treatment services reviews and treatment plan reviews did not meet requirements in the following ways: a. A review of all treatment services was not documented the weeks ending January 2, 9, 16, 23, and 30, February 6, 13, 20, and 27, March 6, 13, 20, and 27, April 3 and 10, 2022; and b. Treatment plan reviews were not completed the weeks ending: 1) July 17, 24, and 31, 2022 (client file numbered 3); and 2) September 18, 2022 (client file numbered 4); c. Treatment plan reviews did not: 1) Address each goal in the treatment plan (client file numbered 1); 2) Address whether the methods to address the goals were effective (client file numbered 4); and 3) Include monitoring of physical and mental health problems (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 24. Violation: One of three client files reviewed for requirements governing medication administration (client file numbered 1) did not record the client’s use of medication. The Medication Administration Record did not document whether or not medications were administered as prescribed on ten occasions. Statute Violated: Minnesota Statutes 245G.08, subdivision 5, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 25. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. The discharge summaries were not completed within five days of the clients’ service termination. They were completed: 1) 31 days late (client file numbered 3); 2) 5 days late (client file numbered 1); and 3) 2 days late (client file numbered 4); b. The discharge summary did not include continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 4, and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this same statute. 26. Violation: Two of four client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Client responses to each treatment services were not documented (client file numbered 1); b. Concerns related to attendance for treatment services, including the reason for any client absence from the treatment service were not documented (client file numbered 1); c. Client record entries were not signed: 1) Individual treatment plan (client file numbered 1); and 2) Two group notes (client file numbered 2); d. Client record entries were not accurate: 1) Four weekly reviews listed total amount of service hours provided which were not accurate based on service notes (client file numbered 1); 2) Five weekly reviews listed amounts of treatment coordination which were not accurate based on treatment coordination notes (client file numbered 1); and 3) The discharge summary inaccurately stated the client met all treatment plan goals (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and b. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 27. Violation: The license holder failed to ensure that client property policies and procedures were followed and met all applicable requirements: a. The license holder failed to immediately document receipt and disbursement of clients’ property at the time of receipt and disbursement, including the clients’ signatures, or the signatures of the conservators or payees: 1) The license holder stored client cell phones in a locked area, and provided them to clients to use as needed. The Client Personal Property policy required documentation of cell phone storage; however, the license holder failed to follow the policy, and the practice at the time of the review was that receipt and disbursement was not documented; 2) The license holder stored client car keys in a locked area, and provided them to clients for passes. The Client Personal Property policy stated car keys are required to be kept in the main office; however, neither the policy nor the license holder’s practice at the time of the review required this to be documented; and 3) Documentation of disbursement of property did not include the client’s signature (client file numbered 1); b. The policy manual contained conflicting policies regarding client medication property. The Client Personal Property policy included procedures for returning client medication at discharge except for a medication that was determined by a physician to be harmful after examining the client, which were consistent with the requirements in Minnesota Statutes, section 245G.21, subdivision 3. However, the Behavior Contract/Recovery Agreement policy included procedures for not returning medication at discharge based on staff judgement, and the Psychotropic Medications policy indicated MD approval was required in order to release medications upon discharge. Statute Violation: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c), 245A.04, subdivision 14, paragraph (b), and 245G.21, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 28. Violation: The license holder had two vulnerable adult maltreatment reporting policies, which contained conflicting primary and secondary persons or positions: a. To whom internal reports may be made; b. Responsible for forwarding internal reports to the common entry point; and c. Who will ensure that, when required, internal reviews are completed. Statute Violation: Minnesota Statutes, sections 245A.65, subdivision 1. 29. Violation: The policy and procedure for reporting maltreatment of minors were not in accordance with Minnesota Statutes, chapter 260E. The policy included procedures and definitions from Minnesota statutes, sections 626.556 and 626.5561, which are repealed. In addition, several other policies in the policies and procedures manual also referenced sections 626.556 and 626.5561. Statute Violation: Minnesota Statutes, section 245G.12. 30. Violation: The medical services policies did not meet requirements in the following ways: a. The policies did not include a provision that if a client self-administers medication when the client is present in the facility, the client must self-administer medication under the observation of a trained staff member; b. The policies did not include requirements for recording the client’s use of medication, including staff signatures with date and time; c. The policies did not include a statement that only authorized personnel are permitted access to the keys to the locked compartments; and d. The policies included conflicting procedures to destroy a discontinued, outdated, or deteriorated medication. Statute Violation: Minnesota Statutes, section 245G.08, subdivisions 5, paragraph (c), and 6. 31. Violation: The service termination policies did not meet requirements in the following ways: a. The description of client behaviors that constitutes reason for staff-member requested service termination was incomplete: 1) The list did not include behaviors that were listed in other policies as things that would result in discharge; and 2) The policy included a section for prohibited behaviors and did not identified if these behaviors would result in at staff request discharge; b. The policies did not include procedures for communicating staff-approved service termination criteria to a client, including the expectations in the client’s individual treatment plan according to section 245G.06; c. The policies included two lists of staff members authorized to terminate a client’s service which did not match; and d. The policies included discharge summary requirements which were not consistent with the requirements in Minnesota statutes, section 245G.06. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3. 32. Violation: The grievance procedure did not meet requirements in the following ways: a. The grievance procedure in the policy manual and used for client orientation included incorrect contact information for the Board of Behavioral Health and Therapy and the Ombudsman for Mental Health and Developmental Disabilities; and b. The license holder did not document the date a grievance was received or the date of the response; therefore, it could not be determined if the license holder responded to the grievance within three days as required. The grievance had an occurrence date of December 6, 2021. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 33. Violation: The visiting policy did not meet requirements in the following ways: a. The policy identified that restrictions on visiting may be imposed due violation of rules; however, limitations may only be imposed as necessary for the welfare of a client provided the limitation and the reasons for the limitation are documented in the client's file; and b. The visiting hours in the policy manual and posted at the facility did not include evening hours. Statute Violation: Minnesota Statutes, section 245G.21, subdivision 2. 34. Violation: The description of treatment services did not meet requirements in the following ways: a. The description of treatment services was not current. The policy stated that low intensity treatment is offered; however, the license holder stated at the time of the review that it is not offered; and b. The description of group services did not include the type and amount of each service provided, including identifying which services meet the definition of group counseling. Statute Violation: Minnesota Statutes, sections 245G.07, subdivisions 1, 2, and 4, and 245G.12. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 35. Violation: The policy that identified how the program will track and record treatment activities did not identify that the record of treatment activities would include the date, duration, and nature of each treatment service. Statute Violation: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b). 36. Violation: The plan for transfer of clients and records upon closure did not meet requirements in the following ways: a. The plan was not reviewed and signed by a controlling individual of program annually. It was not signed in 2021 and 2022; and b. The policy contained conflicting information. It stated both that records would be transferred to another program upon closure and that records would be maintained by the license holder upon closure. Statute Violation: Minnesota Statutes, section 245G.10, subdivision 15a, paragraph (a). 37. Violation: The written policy for reporting the death of an individual served by the program did not meet requirements in the following ways: a. The policy did not require that within 24 hours of receiving knowledge of the death of an individual served by the program, the license holder shall notify the commissioner of the death; and b. The policy stated records of deceased clients shall be retained both for 5 years and for 7 years. Statute Violation: Minnesota Statutes, sections 245A.04, subdivision 16, and 245G.09, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. 38. Violation: The personnel policies did not meet requirements in the following ways: a. The description of behavior that constitutes grounds for disciplinary action, suspension, or dismissal policies did not include policies prohibiting client abuse described in sections 245A.65, 260E, 626.557, and 626.5572; b. The policies did not include a chart or description of the organization structure indicating lines of authority and responsibilities; c. The policies did not prohibits license holders, employees, subcontractors, and volunteers from being in any manner under the influence of a chemical that impairs the individual’s ability to provide services or care. The policy was limited to being under the influence of controlled substances and alcohol; and d. The policies did not contain a job description for each staff member, specifying responsibilities, the degree of authority to execute job responsibilities; and qualification requirements: 1) Job descriptions were not included for the Intern and Administrator positions; 2) Degree of authority was not included on job descriptions for: (i) Medical Director; (ii) Alcohol and Drug Counselor Supervisor (iii) Registered Nurse; (iv) Administrative Assistant; (v) Behavioral Health Technician Supervisor; (vi) Behavioral Health Technician; and (vii) Office Manager; 3) Degree of Authority was not clear on job descriptions. The descriptions listed multiple positions to whom the position reported and conflicted with each other: (i) Alcohol and Drug Counselor; (ii) Office Manager; (iii) Case Manager; and (iv) Peer Recovery Specialist 4) The Case Manager job description included job responsibilities for Treatment Coordination, as identified in Minnesota Statutes, section 245G.07, subdivision 1, and did not contain qualifications required to provide that service; and 5) The Mental Health Professional job description stated the position does not have client contact, which was not accurate at the time of the review. Statute Violation: Minnesota Statutes, section 245G.13, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on December 20, 2019, you were previously found in violation of this statute. Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to the DHS Licensor within 30 days the effective date of this conditional license order explaining how you are correcting the violations. If you fail to demonstrate substantial compliance with Substance Use Disorder treatment requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Additionally, DHS will not approve a request to open a new licensed program from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the Substance Use Disorder treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from the effective date of this conditional license order, you must notify current clients and all parties who refer clients to the program of the conditional status of the license. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. The notification must be approved by DHS Licensing prior to being sent to clients and all other parties. Therefore, the draft notice must be submitted to the DHS Licensor for approval within 10 days of receipt of the order. While the license is on conditional status, you must notify new clients that the license is on conditional status before they begin receiving treatment services. Documentation of notification of the conditional status must be maintained in in each client’s file and in a central file for referral sources. 2. Within 15 days from the effective date of this conditional license order, you must identify a Compliance Officer who will be responsible for correcting the violations identified in this order, monitoring and ensuring the terms identified in this order are met, and monitoring ongoing compliance with requirements for Substance Use Disorder treatment programs. The Compliance Officer cannot also hold the position of Treatment Director or Alcohol and Drug Counselor Supervisor, and must know and understand the requirements of Minnesota Statutes, chapters 245A, 245G, and 260E, and sections 626.557 and 626.5572. The Compliance Officer must be approved by the DHS Licensor. 3. Within 30 days from the effective date of this conditional license order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the DHS Licensor and must include: a. A description of how you will ensure that background study requirements are met on an ongoing basis, including identifying who will be responsible for managing staff background studies, and documentation that the responsible person has received training on these duties; b. A description of how you will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; c. A description of how you will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation the person has received training on these duties. The procedures must identify the material which will be used to complete each required orientation and training item, and include forms which will be used to document staff orientation and training; and d. A list of all current staff which identifies each staff person’s name, position, qualifications, and background study status must be submitted with the plan. 4. Within 30 days of approval of the personnel training plan required in Term 3, you must provide training to all staff persons missing any of the required trainings, and submit documentation of those trainings on the approved forms to the DHS Licensor. Upon approval, training documentation must be maintained in each staff person’s personnel file. 5. Within 30 days from the effective date of this conditional license order, you must submit a description of how a registered nurse will provide supervision as defined in section 148.171, subdivision 23 to staff members who have been delegated the task of administration of medication or assisting with self-medication. The description must identify how supervision will be provided, including a minimum of monthly on-site supervision or more often if warranted by a client's health needs. The description must also address how supervision will be documented, including documenting review of medication administration records and documenting supervision provided to address missing documentation. The description must be approved the DHS Licensor, and included in the policies and procedure manual upon approval. 6. Within 30 days from the effective date of this conditional license order, you must schedule a meeting with the DHS Licensor to develop a self-monitoring plan that includes procedures for an ongoing, systematic approach for monitoring compliance with applicable rules and statutes. The meeting must include the Compliance Officer identified in Term 2 above at a minimum. The plan must identify how you will complete sample reviews of client and personnel files on a monthly basis and must be approved the DHS Licensor. 7. While the license is on conditional status, the self-monitoring procedure approved in Term 6 must be completed on a monthly basis, within 15 days following the end of the month, and results submitted to the DHS Licensor. The results of the first monthly review must be submitted within 10 days following completion of the first review. Following that, the results must be submitted on a quarterly basis, within 10 days following completion of the last monthly review of the quarter. The results must include the corrective action implemented to address any violations or deficiencies identified. The DHS Licensor may request copies of client and personnel files reviewed for the self-monitoring procedures on an as-needed basis in order to evaluate understanding and compliance. 8. Within 60 days from the effective date of this conditional license order, you must submit revised policies and procedures to the DHS Licensor for violations numbered 27 through 38 above. The revised policies and procedures must correct the violations identified and meet all applicable requirements, and must be approved by DHS Licensing. Within 30 days following approval of the revised policies and procedures, you must provide training on them to all staff, and submit documentation of the training to the DHS Licensor. 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below 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. 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 Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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 Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all Substance Use Disorder Treatment laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Substance Use Disorder treatment programs are required to follow Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. 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 Office of Inspector General, Licensing Division
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