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December 28, 2022 Teresa Hayden, Authorized Agent Pride Institute Inc. 14400 Martin Drive Eden Prairie, MN 55344 License Number 1030116 (245G) License Report Number: 202207792 CORRECTION ORDER Dear Teresa: On October 5 and 6, 2022, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility located at 2101 Hennepin Avenue, Suite 202, Minneapolis, MN 55408. As a result of this visit, DHS determined that you are in violation of thirteen of the Substance Use Disorder rules and statutes. As a result, DHS is issuing this order which requires you to take the correction action as described below each violation. 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. Policy, Procedure and Practice 1. Violation: The license holder failed to document that services for which they billed were provided as required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b), clause (1): One hour of individual treatment was billed on August 10, 2022, and the documentation of the service did not include an amount (client file numbered 1).
Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type 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 public funding Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG. 2. Violation: The license holder provided services off-site via telehealth and did not include a policy and procedure detailing the off-site location as part of the treatment service description and the program abuse prevention plan, including the reason for the provision of services remotely. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan, and description of treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit revised policies which meets all applicable requirements. 3. Violation: The license holder failed to follow their policy to track and record client attendance (client file numbered 1): a. A group note was not completed for a group treatment service on August 24, 2022; and b. Group notes did not document the nature of the services. The notes included a topic; however, the topics were not included in the license holder’s treatment services description, and the notes did not identify the type of service that was provided on the following dates: August 15, 17, 18, 22, and 25, 2022. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14a, and 245G.09, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policy to track and record client attendance is followed and meets all applicable requirements. 4. Violation: The license holder’s tuberculosis policy did not include the resources used to provide information on tuberculosis and tuberculosis screening for each client. Statute Violated: Minnesota Statutes, section 245G.12, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the tuberculosis policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy which meets all applicable requirements. 5. Violation: The license holder had two vulnerable adult maltreatment reporting policies, which contained conflicting primary and secondary persons or positions for: a. To whom internal reports may be made; and b. Who will ensure that internal reviews are completed when required. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, and 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that there is a policy and procedure for vulnerable adult maltreatment reporting that meets all applicable requirements. Within 30 days of receipt of this order, submit a description of how this violation has been corrected. Repeat Violation: In a Correction Order that DHS issued on August 13, 2021, you were previously found in violation of this same statute. Client Files 6. Violation: One of two client files reviewed for requirements governing protection of client records from unauthorized disclosure (client file numbered 1) contained Authorizations for Releases of Information which did not identify the purpose of the disclosure to be made. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, and paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all releases of information meet all applicable requirements. 7. Violation: One of two client files reviewed for requirements governing vulnerable adult determinations (client file numbered 1) did not contain a determination whether the client was a vulnerable adult. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all vulnerable adult determinations are completed and meet all applicable requirements. 8. Violation: Two of two 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 2); b. Frequency and amount of substances used (client files numbered 1 and 2). The substance use history’s frequency and amount were limited to only the most recent use; and c. A description of how use affected client’s ability to function in an educational setting (client file numbered 2). 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 all comprehensive assessments meet all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on August 13, 2021, you were previously found in violation of this same statute. 9. Violation: Two of two client files reviewed for requirements governing individual treatment plan reviews (client files numbered 1 and 2) did not include resources to refer the clients to when needs were to be addressed concurrently by another provider. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all individual treatment plans meet all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on August 13, 2021, you were previously found in violation of this same statute. 10. Violation: One of two client files reviewed for requirements governing client record documentation (client file numbered 2) did not meet the requirements in the following ways: a. A treatment plan review was unsigned; b. A correction to the initial services plan was made in a way in which the original entry could not still be read; and c. Entries contained inaccurate information: 1) The admit dates on the DAANES, admission checklist, and client audit checklist were inaccurate; and 2) The discharge summary stated the client did not meet with a psychiatrist; however, a treatment plan review documented the client did meet with a psychiatrist. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all client record documentation meets all applicable requirements. 11. Violation: One of two client files reviewed for requirements governing discharge summaries (client file numbered 1) did not include: a. Continuing care recommendations; and b. A risk rating in dimension two. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all discharge summaries meet all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on August 13, 2021, you were previously found in violation of this same statute. Personnel Files 12. Violation: Two of three personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. Orientation to policies and procedures was not provided within 24 working hours of starting (personnel file numbered 2); and b. The license holder did not document the date staff persons first provided direct contact services to a vulnerable adult; therefore, it could not be determined if orientation was provided within 72 hours of first providing direct contact services to a vulnerable adult as required on: 1) The program abuse prevention plan (personnel files numbered 1 and 2); and 2) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 1, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure and document that all staff orientation is completed and meets all applicable requirements. 13. Violation: Two of two personnel files reviewed for requirements governing inquiries required under sections 604.20 to 604.205 for staff member who provides psychotherapy services (personnel files numbered 1 and 3), did not contain documentation that inquiries were sent to the staff persons’ former employers regarding substantiated sexual contact with a client. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3, clause (3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure and document that all inquiries are made to former employers and meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that required inquiries have been made for personnel files numbered 1 and 3. You must correct the violations cited above. 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: 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 Program must maintain compliance with the licensing statutes and rules, specifically 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 651-431-6614. Sincerely, Leah Wachter, Senior Licensor Licensing Division Office of Inspector General
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