February 24, 2023                  CERTIFIED MAIL

Dana Nelson, Authorized Agent

American Indian Community Development Corporation (AICDC)

1800 Chicago Avenue

Minneapolis, MN 55404

License Number: 1100408

Licensing Report Number: 202207106

ORDER OF CONDITIONAL LICENSE

Dear Dana:

The Department of Human Services (DHS) is placing your withdrawal management license at AICDC, located at 1800 Chicago Avenue, Minneapolis, MN 55404, on conditional status for two years, beginning March 7, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with 245F 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 November 15, 16, 17, 2022, DHS licensors conducted a licensing review and investigation at your facility located at 1800 Chicago Avenue, Minneapolis, MN 55404. 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 Withdrawal Management programs, citing 23 violations. DHS has considered the nature 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 (violation numbered 1).

o The program failed to ensure a licensed registered nurse was on duty each shift for the services being provided (violation numbered 2).

o The program failed to ensure a Program Director knew and understood licensing requirements (violation numbered 3).

o The program failed to provide orientation to patients (violation numbered 4).

o The program failed to identify patients in need of stabilization services and implement stabilization plans (violation numbered 5).

o The program failed to monitor for patients safety (violation numbered 6).

o The program failed to complete individual abuse prevention plans as required (violation numbered 7).

o The program failed to comply with requirements for comprehensive assessments (violation numbered 8).

o The program failed to meet standards related to documentation (violations numbered 9, 10, and 12).

o The program failed to follow their discharge policy (violations numbered 11 and 17).

o The program failed to provide staff orientation and training (violations numbered 14 and 15).

Due to the nature and severity of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Withdrawal Management services is 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. Staff person (personnel file numbered 8) was hired on 7/5/22. On 8/21/22 the license holder received notice from the commissioner that more time was needed to complete the study. However, the individual was required to be under continuous direct supervision until the completion of the background study. The license holder allowed SP8 to continue providing services but failed to provide the required supervision.

Statute Violated: Minnesota Statutes, section 245C.13, subdivision 2, paragraph (a).

2. Violation: The license holder failed to have a licensed registered nurse on each shift while providing medically monitored services to patients in the program. Through staff interviews, patient record documentation, and payroll records, it was identified that the license holder did not have a licensed registered nurse on duty as required on the following dates:

a. The evening of March 7, 2022 into the morning of March 8, 2022;

b. April 4, 2022;

c. April 6, 2022;

d. April 8, 2022;

e. April 11, 2022;

f. April 13, 2022;

g. Four hours on April 18, 2022;

h. April 19, 2022;

i. Five and one half hours on April 20, 2022;

j. April 25, 2022; and

k. April 26, 2022.

Statute Violated: Minnesota Statutes, section 245F.12, subdivision 3.

3. Violation: The license holder failed to ensure that the Program Director knew and understood the licensing standards under Chapter 245F. Through interviews and as evidenced by the number and nature of citations in this order, it was evident the program director did not know and understand the requirements of Chapter 245A, 245C, 245F, and sections 626.557, and 626.5572 (personnel file numbered 1).

  Statute Violated: Minnesota Statutes, sections 245F.14, subdivision 1, and 245F.15, subdivision 3 (3).

4.  Violation: Six of six patient files reviewed for requirements governing patient orientation (patient files   numbered 1 through 6) failed to document that the license holder provided orientation on the internal   and external maltreatment reporting policies.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c).

5.  Violation: The license holder failed to develop a policy and procedure for the implementation of stabilization services and plans.

a. Although the license holder identified a form titled 245F Physician Orders & Stabilization Plan, the form was a signed physician order and did not:

1) Identify the medical needs and goals to be achieved while the patient is receiving services;

2) Specify stabilization services to address the identified medical needs and goals, including amount and frequency of services;

3) Specify the participation of others in the stabilization planning process and specific services where appropriate;

4) Identify the staff person responsible for each care coordination service;

5) The duration a patient is to remain in care; and

6) Documentation encouraging patients to enter programs for ongoing recovery;

b. The license holder could not clearly identify the stabilization services offered to clients who remained in care who no longer identified as needing withdrawal management services.

Statute Violated: Minnesota Statutes, sections 245F.07, subdivision 1, and 245F.08, subdivisions 1 through 5; and 245A.04, subdivision 14.

6.   Violation: Six of six patient files reviewed for requirements governing hourly observations (patient files numbered 1 through 6) did not meet requirements. Hourly observations were not documented on the following dates:

a. Eight hours on October 24, 2022 (patient file numbered 5);

b. One hour on October 22, 2022 and October 27, 2022 (patient files numbered 1 and 2);

c. One hour on October 6, 2022, two hours on October 7, 2022, one hour on October 9, 2022, eight hours on October 8, 2022 (patient file numbered 3);

d. One hour on October 14, 2022 (patient file numbered 4); and

e. Three hours on September 22, 2022 and one hour on September 24, 2022 (patient file numbered 6).

  Statute Violated: Minnesota Statutes, sections 245F.12.

7.  Violation: Six of six patient files reviewed for requirements governing vulnerable adult assessments and individual abuse prevention plans (IAPPs) failed to meet requirements in the following ways:

a. The files did not include an assessment of the persons’ risk of abusing other vulnerable adults or the persons susceptibility to abuse by other individuals according to Minnesota statute 626.557, subdivision 14, paragraph (b), (patient files numbered 1 through 6). The 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;

b. The IAPP’s did not include the specific actions the program will take to minimize the risk of abuse within the scope of their program when the program abuse prevention plan did not address the risk reduction measure (patient files numbered 1 and 3);

c. The license holder did not ensure that the person receiving services participated in the development of the IAPP to the full extent of their abilities (patient file numbered 6); and

d. The IAPP’s did not include an interdisciplinary team review and evaluation as part of the service plan review (patient files 1 through 6).

Statute Violated: Minnesota Statutes, section 245A.65, subdivisions 2, paragraph (b) and 14, paragraph (b).

8.  Violation: Four of four patient files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways:

a. The license holder failed to review the previous comprehensive assessment in the patient’s record and verify that it was accurate and complete (patient file numbered 6);

b. The assessments did not include information about the patient’s needs that relate to substance use and personal strengths that support recovery, including:

i. A description of the circumstances on the day of service initiation (patient files numbered 1 and 6);

ii. A list of previous attempts at treatment for substance misuse or substance use disorder (patient files numbered 1, 3, and 6);

iii. Previous attempts at treatment for mental illness (patient files numbered 1, 3, and 6);

iv. Circumstances of relapse (patient file numbered 6);

v. Family history, including history of substance use and misuse (patient file numbered 6);

vi. Whether or not the concerns need to be referred to an appropriate health care professional (patient file numbered 3);

vii. Mental health history, including symptoms, and the effect on the patient’s ability to function (patient files numbered 1, 3, and 6);

viii. Current mental health treatment (patient files numbered 1 and 6);

ix. Psychotropic medications needed to maintain stability (patient files 1 and 6);

c. Substance use history including amounts and types of substances used were not complete:

i. Alcohol use was noted in the progress notes but was not listed in the assessment (patient file numbered 6);

ii. The assessment identified other substance use history but only listed alcohol (patient file numbered 1);

iii. The assessment states that patient has DWI/DUI but did not list the substance that was used (patient file numbered 3); and

iv. The amounts and types of substances used including frequency and duration did not cover the client’s history of use (patient files numbered 1, 3, 4, and 6).

Statute Violated: Minnesota Statutes, sections 245F.06, subdivision 2.

9.   Violation: One patient file reviewed for requirements governing progress notes failed to meet   requirements. A patient was given medication for uncontrolled behavior on October 6, 2022 but there   was no progress note documentation (patient file numbered 3).

Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2.

10.  Violation: Two of four patient files reviewed for requirements governing medication administration   failed to meet requirements in the following ways:

a. Medications ordered but were not documented as administered for Thiamine September 24, 2022 through November 4, 2022 (patient file numbered 2); and

b. Medications were not documented as administered for Thiamine and Folic Acid on October 7, 2022 (patient file numbered 3).

Statute Violated: Minnesota Statutes, section 245F.13, subdivision 2, paragraph (3).

11.  Violation: Five of five patient files reviewed for requirements governing discharge plans failed to meet requirements in the following ways:

a. The license holder failed to conduct discharge planning for the patient prior to discharge. The plan was completed after the patient was discharged and did not document their signature (patient file numbered 3);

b. The discharge plans did not include:

i. Referrals made to other services or agencies at the time of transition (patient files numbered 2, 3, and 6);

ii. The patients plan for follow up, aftercare, or other post-stabilization services (patient files numbered 2, 3 and 6); and

iii. A stabilization summary and final evaluation of the patients’ progress toward treatment objectives (patient files numbered 2 through 6).

Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3.

12. Violation: Four of six patient files reviewed for requirements governing patient records failed to meet   requirements in the following ways:

a. Each entry was not signed and dated by the staff person making the entry (patient files numbered 1, 2, 3, and 6); and

b. Patient records were not protected against unauthorized disclosure in compliance with Minnesota Statutes, section 254A.09. A patient release of information did not identify the type of records to be disclosed (patient file numbered 2).

Statute Violated: Minnesota Statutes, section 245F.19, subdivisions 1 and 3.

13. Violation: One of six patient files reviewed for requirements governing funds and property (patient file   numbered 3) failed to obtain the patient’s signature after property was returned at discharge.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c).

14. Violation: Six of eleven personnel files reviewed for requirements governing orientation did not contain documentation of orientation before providing direct patient care on the following:

a. The staff member’s specific job responsibilities (personnel file numbered 6);

b. Policies and procedures (personnel files numbered 1, 2, 3, and 4);

c. Patient needs (personnel files numbered 3 and 4);

d. HIV minimum standards (personnel file numbered 1);

e. Vulnerable adult maltreatment reporting requirements and definitions in sections 626.557 and 626.5572, and 245A.65 (personnel files numbered 3 and 4);

f. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1, 3, 4 and 6);

g. The specific license holder and staff responsibilities for patient confidentiality (personnel file numbered 3);

h. Motivational counseling techniques and identifying stages of change (personnel files 3, 4, 5, and 10);

i. Standards governing the use of protective procedures (personnel file numbered 4);

j. Infection control procedures (personnel file numbered 4); and

k. Eight hours of training on the program’s protective procedures policy (personnel file numbered 4).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3; and 245F.16 subdivisions 1 and 2 paragraph (a) and (b).

15. Violation: One of four personnel files reviewed for requirements governing annual staff training did not include documentation the staff persons received training on the following (personnel file numbered 5):

a. Mandatory reporting under sections 245A.65 and 626.557 and chapter 260E, including specific training covering the facility’s policies concerning obtaining patient releases of information;

b. HIV minimum standards for calendar year 2022; and

c. Motivational counseling techniques and identifying stages of change for calendar year 2022.

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245F.16, subdivision 2, paragraphs (a) and (c).

16.  Violation: Five of eleven personnel files reviewed for requirements governing personnel file contents did not contain:

a. Documentation related to the applicant’s background study data, including the documentation related to required supervision according to chapter 245C (personnel files numbered 4 and 8);

b. Documentation verifying that staff members met the qualification requirements of their positions including:

i. A licensed professional’s license on file expired October 31, 2022 (personnel file numbered 5);

ii. A licensed professional’s license expired March 31, 2022, and was not shown as active again until July 5, 2022 (personnel file numbered 11). SP11 continued to perform duties requiring an active license until the license holder was made aware on May 19, 2022.

c. Required written annual job performance evaluation including:

i. Evaluation due November 30, 2021 was not completed (personnel file numbered 5); and

ii. Evaluation completed late on May 24, 2021, and no evaluation was completed for May of 2022 (personnel file numbered 7).

Statute Violated: Minnesota Statutes, section 245F.17, (1), (2), and (5).

17. Violation: The license holder’s discharge and denials of admission policies and practices did not meet   requirements in the following ways:

a. The license holder failed to designate which staff members are authorized to discharge clients;

b. The license holder failed to clearly describe the programs guidelines for determining when a patient is medically stable; and when a patient needs a transfer to a higher level of care including a transfer to a medically monitored program, hospital, or other acute care facility; and

c. The license holder failed to document why a referral was not made when the program denied an individuals’ admission. Through review of documentation, it was noted that often times this area was left blank.

  Statute Violated: Minnesota Statutes, section 245F.05, subdivisions 3 through 5.

18.  Violation: The license holder failed to update the programs policy and procedures governing   maltreatment reporting. The posted internal policy identified individuals who were no longer employed   as the person to whom internal reports be made.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d).

19.  Violation: The license holder failed to follow the requirements for protective procedures in the following   ways:

a. Through staff interviews (personnel numbered 1 and 5), and the authorized agent, it was noted staff failed to understand what a protective procedure was and could not definitively say whether the program utilized protective procedures.

b. The program did not maintain a central log documenting each incident involving the use of law enforcement including:

i. The date and time law enforcement arrived and left the program;

ii. The reason for the use of law enforcement;

iii. If law enforcement used force or a protective procedure;

iv. Which protective procedure was used;

v. Whether any injuries occurred;

c. An administrative review of each use of a protective procedure did not include:

i. A date that the review was completed within the 72 hour time frame for December 14, 2021 and July 29, 2022 use of protective procedures; and

ii. Documentation whether law enforcement was involved.

Statute Violated: Minnesota Statutes, section 245F.09, subdivisions 4 and 5, paragraph (a) and (b).

20.  Violation: The license holder’s policy and patient handbook failed to include the current phone number   for the Board of Behavioral Health and Therapy (BBHT) in their grievance procedure.

Statute Violated: Minnesota Statutes, section 245F.10, subdivision 2.

21.  Violation: The license holder failed to follow the requirements for internal reporting for maltreatment of   vulnerable adults in the following ways:

a. Through an interview with staff (personnel file numbered 5), it was identified that s/he was unfamiliar with the license holder’s reporting policies and unaware of his/her responsibilities and requirements as the primary mandated reporter and did not:

i. Notify the reporter in writing within two working days whether the facility reported the incident to MAARC and in a manner that protects the confidentiality of the reporter; and

ii. Provide the reporter a written notice stating that if the reporter was not satisfied with the action taken by the license holder, the reporter could report externally.

Statute Violated: Minnesota Statutes, section 626.557, subdivision 4a.

22.  Violation: The license holder failed to include a current organizational chart indicating the lines of   authority and responsibilities in their personnel policy and procedures.

Statute Violated: Minnesota Statutes, section 245F.16, subdivision 1.

23.  Violation: The license holder failed to document the medical director’s annual approval in 2020 and   2021 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;

g. Protective procedures; and

h. A medication control plan.

Statute Violated: Minnesota Statutes, section 245F.14, subdivision 5.

Immediate corrective action required

You must immediately correct the violations cited above. Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations.

1. By secure email to: Charlene.hanson@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services
ATTN: Charlene Hanson
Licensing Division
PO Box 64242
St. Paul, MN 55164-0242

If you fail to demonstrate substantial compliance with Withdrawal Management 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 a new licensed program from the date of this order until the time your conditional license expires.

CONDITIONAL LICENSE TERMS

In addition to the Withdrawal Management licensing rules and statutes, you are required to comply with the following terms:

1.  Within 14 days of receipt of this order, you must notify current patients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request.

While the license is on conditional status, you must notify new patients and referral sources the license is on conditional status before they begin receiving services. The notification to new patients must specify the length of time of the conditional status of your license, the reasons the 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. A copy of the notice with patient and/or legal representative(s) signature must be maintained in the patient file.

Within 30 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice.

2.  Within 30 days of receipt of this order, you must develop a self-monitoring tool and plan that ensures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following:

a. Names and titles of those responsible to carry out duties within the plan; and

b. Procedure that includes a sample review of patient records requirements, personnel files, medication administration records, grievances, and monitoring of the implementation of policies and procedures on a monthly basis.

The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on April 15, 2023, July 15, 2023, October 15, 2023, and January 15, 2024, April 15, 2024, July 15, 2024, October, 15, 2024, January 15, 2025 or until otherwise determined by DHS Licensing.

3.   Within 30 days from when you received this 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; and

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.

4.  Within 60 days from when you received this order, you must submit revised policies and procedures to DHS Licensor for violations numbered 3 and 4 above, specifically outlining the programs procedure for determining a patient’s level of care. 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 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 Withdrawal Management laws and rules.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· Withdrawal Management programs are required to follow Minnesota Statutes, chapter 245F.

· 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

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/