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February 3, 2023 Martha Paulson-Strommen, Authorized Agent Reverence For Life & Concern For People dba Project Turnabout 660 18th Street Granite Falls, MN, 56241 License Number: 1098948 (245F) CORRECTION ORDER Dear Martha: On December 12, 13, and 14, 2022, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 660 18th Street, Granite Falls, MN, 56241. As a result of this visit, DHS determined that you are in violation of 16 of the Withdrawal Management rules and statutes. As a result, DHS is issuing this order which requires you to take the correction action as described under 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. Practices, Policies, and Procedures 1. Violation: The license holder failed to maintain an active roster in the NETStudy 2.0 system to document when background study subjects were affiliated with multiple entities. Statute Violated: Minnesota Statutes, section 245C.07, subdivision 14, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the background study roster in the NETStudy 2.0 system meets all applicable requirements. 2. Violation: The license holder failed to follow their system for accounting for all scheduled drugs each shift, as described in the policy Accounting for Scheduled Narcotics/Schedule II Medications. The license holder did not include controlled substances which were stored but not currently being taken by patients when accounting for scheduled drugs. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245F.13, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the system for accounting for all scheduled drugs each shift is followed and meets all applicable requirements. 3. Violation: The license holder did not document the medical director’s annual approval, in 2021 and 2022, of the following procedures: a. Admission, discharge, and transfer criteria and procedures; b. A health services plan; c. Physical indicators for a referral to a physician, registered nurse, or hospital, and procedures for referral; d. Procedures to follow in case of accident, injury, or death of a patient; e. Formulation of condition-specific protocols regarding the medications that require a withdrawal regimen that will be administered to patients; f. An infection control program; and g. A medication control plan. Statute Violated: Minnesota Statutes, section 245F.14, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all medical director annual approval documentation requirements are met. Within 30 days of receipt of this order, submit documentation of the medical director’s current approval of the procedures identified above. 4. Violation: The license holder did not meet requirements governing patient property management in the following ways: a. The license holder’s practice was to assist patients with the safekeeping of property by keeping the patients’ hygiene property in locked storage; however, the license holder did not document each receipt and disbursement of the property; and b. The license holder did not document disbursement of patient property at the time of disbursement (patient files numbered 1 and 2). Statute Violated: Minnesota Statute 245A.04, subdivision 13, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure patient property management meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of patient property management from one recently discharged patient file that meets all applicable requirements. 5. Violation: The policy manual did not contain a description of patient education services. The policy titled Patient Education Services listed the education topics required by section 245F.08, subdivision 4; however, it did not describe the program’s education services. Statute Violated: Minnesota Statutes, sections 245F.08, subdivision 4, and 245F.18. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a description of patient education services is included in the policy manual and meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy that meets all applicable requirements. Patient Files 6. Violation: Three of three patient files reviewed for requirements governing individual abuse prevention plans (IAPPs) did not meet requirements in the following ways: a. The IAPPs were not reviewed and evaluated by the interdisciplinary team as part of the service plan reviews (patient files numbered 1, 2, and 3); and b. The IAPP did not include a statement of the specific measures that would be taken to minimize the risk of abuse to that person, including specific actions the program would take within the scope of the licensed services, or document the determination that the vulnerable adult did not need specific risk reduction measures in addition to those identified in the program abuse prevention plan (patient file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), and 245F.19, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual abuse prevention plans meet all applicable requirements. 7. Violation: Three of three patient files reviewed for requirements governing medical services did not meet requirements in the following ways: a. Follow-up screenings were not conducted between 4 and 12 hours after service initiation to collect information relating to acute intoxication, other health complaints, and behavioral risk factors that the patients may not have communicated at service initiation (patient files numbered 1, 2, and 3); b. Hourly observations were not documented (patient files numbered 1, 2, and 3); and c. Initial health assessments were not conducted upon admission (patient files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245F.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medical services meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of a follow-up screening from one recently admitted patient file that meets all applicable requirements. 8. Violation: Three of three patient files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. It could not be determined which staff administered the comprehensive assessments (patient files numbered 1, 2, and 3). Multiple staff members contributed to the comprehensive assessments and the assessments did not document which sections were completed by each staff member and did not contain dated signatures of each of the staff members; b. Comprehensive assessments were not completed within 72 hours of admission (patient files numbered 1, 2, and 3); and c. Comprehensive assessments did not include information about the patients’ needs that relate to substance use and personal strengths that support recovery, including: 1) A description of the circumstances on the day of service initiation (patient file numbered 1); 2) Amounts, frequency, and duration of each type of substance used (patient files numbered 1 and 2); 3) Circumstances of relapse (patient file numbered 3); 4) Effects of mental health on the patient’s ability to function (patient file numbered 3); and 5) A mental health screening tool approved by the commissioner (patient files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 9. Violation: Three of three patient files reviewed for requirements governing progress notes (patient files numbered 1, 2, and 3) did not meet requirements. The license holder identified the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) forms as the progress notes, and the CIWA-ARs did not: a. Include documentation of patients’ involvement in the stabilization services, including the type and amount of each stabilization service; b. Include documentation of referrals made to other services or agencies; and c. Specify the participation of others. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of one daily progress note from one recently admitted patient file that meets all applicable requirements. 10. Violation: Three of three patient files reviewed for requirements governing discharge plans (patient files numbered 1, 2, and 3) did not include final evaluations of the patients’ progress toward treatment objectives. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge plans meet all applicable requirements. 11. Violation: One of three patient files reviewed for requirements governing patient record entries (patient file numbered 2) contained entries that did not include a staff member’s signature. Statute Violated: Minnesota Statutes, section 245F.19, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure patient record entries meet all applicable requirements. Personnel Files 12. Violation: The license holder failed to comply with conditions of a background study variance (personnel file numbered 1). The license holder jointly operated the withdrawal management program with a detoxification program, and utilized the same staff persons for both programs. A background study variance was granted for personnel file numbered 1 to provide direct contact services in the detoxification program; however a variance was not requested for the staff person to provide direct contact services in the withdrawal management program. Statute Violated: Minnesota Statutes, section 245C.30, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all staff background studies meet all applicable requirements. 13. Violation: Four of seven personnel files reviewing for requirements governing staff qualifications did not contain documentation of the following staff qualifications: a. Competency in visual observation of a patient’s health status, including monitoring a patient’s behavior as it relates to health status, as required for technicians (personnel files numbered 1 and 7); b. Knowledge of and ability to perform basic activities of daily living and personal hygiene, as required for technicians (personnel files numbered 1 and 7); c. Knowledge of and understanding of the requirements of Minnesota Statutes, chapters 245F and 253B.04, as required for responsible staff persons (personnel file numbered 4); and d. A minimum of one year in recovery from substance use disorder, as required for recovery peers (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245F.15, subdivisions 5, 6, and 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff qualifications are documented and meet all applicable requirements. 14. Violation: One of five personnel files reviewed for requirements governing staff orientation (personnel file numbered 4) did not meet requirements in the following ways: a. Orientation to patient rights under Minnesota statutes, chapter 253B was not completed within 72 hours of beginning of employment; b. Orientation to HIV minimum standards was not completed within 72 hours of beginning of employment; c. Orientation to infection control procedures was not completed within 72 hours of beginning of employment; and d. Orientation to program policies and procedures was not documented as completed in accordance with the programs policy. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245F.16, subdivisions 1 and 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. 15. Violation: Four of five personnel files reviewed for requirements governing annual and biennial training did not meet the requirements in the following ways: a. Training on infection control procedures was: 1) Not completed in 2022 (personnel files numbered 3 and 4); and 2) Completed late in 2022 (personnel file numbered 7); b. Training on the license holder’s vulnerable adult maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 was not completed in 2022 (personnel files numbered 3 and 4); c. Training on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was not completed in 2022 (personnel files numbered 3 and 4); d. Training on the facility’s polices for obtaining patient releases of information required by 626.557, subdivision 3a, paragraph (a) was completed late in 2022 (personnel file numbered 3); e. Training on mandatory reporting of maltreatment of minors under chapter 260E was completed late in 2022 (personnel file numbered 3); f. Training on HIV minimum standards as required in section 245A.19 was completed late: 1) In 2021 (personnel file numbered 6); and 2) In 2022 (personnel file numbered 7); g. Training on motivational counseling techniques and identifying stages of change: 1) Was not completed in 2021 (personnel file numbered 6); 2) Was not completed in 2022 (personnel file numbered 7); and 3) Was completed late in 2022 (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245F.16, subdivision 2, paragraphs (a) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the trainings identified above as not completed in 2022 have now been completed for the corresponding staff persons. 16. Violation: Two of seven personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. The file did not contain a completed application signed by the staff member (personnel file numbered 1); and b. The annual job performance evaluation was completed late in 2021 (personnel file numbered 3). Statute Violated: Minnesota Statutes, section 245F.17. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel file content meets all applicable requirements. Corrective Action Required 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: 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 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 20 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Withdrawal Management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, chapter 245F. · 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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