Minnesota

March 23, 2023

Carmen Wilson, Authorized Agent

Tomorrow LLC dba Anchorage

P.O. Box 128

Pillager, MN 56473

License Number: 1044799

Dear Carmen Wilson:

This matter arises from an Order of Conditional License, dated December 14, 2022, issued after a licensing review conducted on October 10 through 13, 2022 (See attached Exhibit A). On January 3, 2023, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration on behalf of Tomorrow LLC dba Anchorage (“Anchorage”) of the Order of Conditional License.

You requested reconsideration of the following citations: 1, 3, 4, 6, 15, 19, 20, 22, 25, 26, 27, 30, 33, 35, 36, and 37. You did not request reconsideration of the remaining citations, and those citations are therefore final and not included in the scope of this review.

A. CONDITIONAL LICENSE DISPUTED, YOUR RECONSIDERATION REQUEST REGARDING STATUTORY CITATIONS AND LICENSING VIOLATIONS, AND DHS’ RESPONSE

1. Citation 1: Minnesota Statutes, sections 245C.03, subdivision 1, paragraph (a), 245C.04, subdivision 1, paragraph (g), 245C.07, paragraph (b), and 245C.13, subdivision 2

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.

Request for reconsideration: You specifically request reconsideration of violation a, clause 1. You indicate in the reconsideration request that the individual identified in the violation did not have any direct contact and was therefore outside of the background studies requirements. The individual served as an off-site clinical supervisor, has not entered Anchorage’s building since 2020 and has no direct contact with clients.

You also request reconsideration of violation d. You indicate in the request for reconsideration that the employee identified in the violation had previously completed a background study as part of their employment in Anchorage’s outpatient program, and the employee was transferred to the residential program in 2021 when the outpatient program closed. Because both programs were operated by Anchorage and were “affiliated” in NetStudy, Anchorage did not know additional actions were required.

DHS’ response: As to violation a, clause 1, at the time of the licensing review, the individual that was the subject of the violation had no current background study, and it appeared the individual had a previous background study under the license approximately a year before they were hired. Although you indicated the individual did not have client contact, records showed the individual completed diagnostic assessments with clients August 13, 2020 through August 2021. As a result, there is sufficient evidence to support the violation.

As to violation d, although the individual that was the subject of the violation had a background study initiated for the outpatient program, you did not affiliate the individual to the residential program prior to the closing of the outpatient program. At the time of the licensing review, the individual did not have a background study for the residential program, and a background study was later initiated on October 11, 2022, after an immediate removal notification was sent to Anchorage. As a result, there is sufficient evidence to support the violation.

Because the record supports the citation, it is affirmed.

2. Citation 3: Minnesota Statutes, sections 245G.07, subdivisions 2 and 3, 245G.11, subdivisions 4 and 7, paragraph (a), and 245G.13, subdivision 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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

Request for reconsideration: You specifically request reconsideration of violation b. You indicate in the reconsideration request that you relied on the Minnesota Board of Behavioral Health and Therapy, which showed the individual that is the subject of the violation had the clinical supervision delegation. Anchorage was aware of the requirements and sought to comply with them.

You also requested reconsideration of violation c. Although you included this citation in the reconsideration request and indicated corrective measures that have been taken, you do not dispute the accuracy of the citation.

DHS’ response: As to violation b, although a resume for the individual identified in the violation was not provided, you indicated the individual had experience in three positions totaling 2.5 years of experience. When asked at the time of the review how the individual met the requirement to have three years of experience providing individual and group counseling to individuals with substance use disorder, you acknowledged the requirement was not met. As to violation c, the accuracy of the violation was not disputed. As a result, because the record supports the citation, it is affirmed.

3. Citation 4: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191.

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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

Request for reconsideration: You specifically provide information requesting reconsideration of violation b, clause 1. You indicate the individual that is the subject of the violation had all required trainings and submits supporting documentation. As to the remaining violations in the citation, although you included this citation in the reconsideration request and indicated corrective measures that have been taken, you do not dispute the accuracy of the citation.

DHS’ response: As to violation b, although the documentation submitted does indicate the individual completed 8 hours of co-occurring training in calendar year 2022, there was no documentation provided for calendar year 2021. You did not submit that documentation during the licensing review or after the review was completed. As to the remaining violations in the citation, the accuracy of the violation was not disputed. As a result, because the record supports the citation, it is affirmed.

4. Citation 6: Minnesota Statutes, sections 245A.04, subdivision 14, and 245G.08, subdivision 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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

Request for reconsideration: Although you included this citation in the reconsideration request and indicating corrective measures that have been taken, you do not dispute the accuracy of the citation.

DHS’ response: Because the record supports the citation, it is affirmed.

5. Citation 15: Minnesota Statutes, section 245G.06, subdivisions 1 and 2, 245G.07, subdivision 1, paragraph (b), and 245G.09, subdivision 3.

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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

DHS’ response: Because the record supports the citation, it is affirmed.

6. Citation 19: Minnesota Statutes, section Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3.

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.

DHS’ response: Because the record supports the citation, it is affirmed.

7. Citation 20: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (b), and 245G.09, subdivision 3.

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).

DHS’ response: Because the record supports the citation, it is affirmed.

8. Citation 22: Minnesota Statutes, section 245G.05, subdivision 2, and 245G.09, subdivision 3.

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

The summary was completed four days after service initiation (client file numbered 2).

DHS’ response: Because the record supports the citation, it is affirmed.

9. Citation 25: Minnesota Statutes, section 245G.06, subdivision 4, and 245G.09, subdivision 3.

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).

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

DHS’ response: Because the record supports the citation, it is affirmed.

10. Citation 26: Minnesota Statutes, section 245G.06, subdivisions 2a and b.

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).

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

DHS’ response: Because the record supports the citation, it is affirmed.

11. Citation 27: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c), 245A.04, subdivision 14, paragraph (b), and 245G.21, subdivision 3.

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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

DHS’ response: Because the record supports the citation, it is affirmed.

12. Citation 30: Minnesota Statutes, section 245G.08, subdivisions 5, paragraph (c), and 6.

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.

DHS’ response: Because the record supports the citation, it is affirmed.

13. Citation 33: Minnesota Statutes, section 245G.21, subdivision 2.

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.

DHS’ response: Because the record supports the citation, it is affirmed.

14. Citation 35: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b).

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.

Request for reconsideration: You indicate in the reconsideration request that the treatment activities have sign-in sheets that indicate the date, duration and nature of each treatment services, and you provide supporting documentation.

DHS’ response: However, the documentation provided did not include the duration of the treatment service. Also, although program policy indicated the program tracks and records client attendance to treatment services by activities and group sign-in sheets and group or individual note documentation, the program was inconsistent with that practice. As a result, because the record supports the citation, it is affirmed.

15. Citation 36: Minnesota Statutes, section 245G.10, subdivision 15a, paragraph (a).

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.

DHS’ response: Because the record supports the citation, it is affirmed.

16. Citation 37: Minnesota Statutes, sections 245A.04, subdivision 16, and 245G.09, subdivision 2.

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.

Repeat Violation: In a Correction Order issued on December 20, 2019, you were found in violation of the same statute.

DHS’ response: Because the record supports the citation, it is affirmed.

B. DISPOSITION

Based on the foregoing, the Commissioner finds that the citations in the December 14, 2022, Order of Conditional License are supported by the record, and they are affirmed.

Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program.

In the request for reconsideration, you indicate the belief that the program should not be on a conditional license. You indicate that improvement protocols detailed in the reconsideration request demonstrate the program’s commitment to providing services to vulnerable persons. You also state the belief that additional agency oversight with a corrective action plan would be sufficient to improve and enhance internal practices, and you indicate the program has already began implementing the terms of the conditional license.

The Commissioner appreciates that the program has taken steps to ensure compliance. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and determined that a conditional license is warranted. The Conditional Order cites thirty-eight citations reflecting that Anchorage has failed to comply with multiple requirements. The license holder challenged only sixteen of the thirty-eight citations on reconsideration, which resulted in all the citations being affirmed. The remaining citations along with the twenty-two citations that were unchallenged support the need for a conditional license because they demonstrate a history of serious and chronic licensing violations that indicate a failure to follow procedure and practice requirements which affect the health, safety, and rights of clients.

With regard to chronicity, the license holder failed to correct prior violations cited on multiple occasions. Twenty-five of the violations cited in the Conditional Order under review were previously cited in a Correction Order dated December 20, 2019. The failure to correct a large number of citations strongly supports the need for a conditional license, the terms of which are focused on ensuring that the license holder is taking meaningful steps toward achieving compliance and thereby protecting clients’ health, safety, and rights.

The nature of the cited violations is also a basis for the conditional license. The citations involved a failure to follow requirements which affected the health and safety of the persons served, including a failure to ensure staff were qualified, a failure to ensure that staff requirements for first aid certification were met, a failure to account for all scheduled drugs each shift, a failure to provide required staff supervision, a failure to complete a treatment plan for 115 days after service initiation, and a failure to comply with background studies requirements. Background study requirements are in place to ensure the safety of the residents served by the program. Also, the license holder failed to meet requirements which resulted in violations that were severe in number and duration, including multiple instances involving staff training and reporting. These violations included a failure to complete internal reviews of suspected vulnerable adult maltreatment regarding multiple reports, a failure to provide training related to duties in implementing policies and procedures for two personnel files, a failure to provide required staff orientation in four of four personnel files reviewed, and a failure to provide staff training for six of six personnel files reviewed. Requirements regarding staff training and orientation are in place to ensure staff are familiar with policies and procedures related to resident safety and well-being and that staff are able to provide qualified care to those residents.

Due to the need to monitor Anchorage for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on December 14, 2022.

The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter.

C. TERMS OF THE CONDITIONAL LICENSE

In addition to the 245G licensing rules and statutes, you are required to comply with the following terms:

1. Within 15 days from the date of receipt of this reconsideration decision, 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 date of receipt of this reconsideration decision, 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 date of receipt of this reconsideration decision, 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 date of receipt of this reconsideration decision, 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 date of receipt of this reconsideration decision, 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 date of receipt of this reconsideration decision, 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 licensor will monitor your compliance with all applicable laws and rules. Verification of compliance may include unannounced visits. Failure to comply with the requirements in Minnesota Statutes, chapter 245A (Human Services Licensing Act), Minnesota Statutes, chapter 245C (Human Services Background Study Act), Minnesota Statutes, chapter 245G (Chemical Dependency Based Treatment), Minnesota Statutes, section 626.557, and with the terms of your conditional license may result in further negative action, including revocation of your license.

This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115.

If you have any questions regarding the Order of Conditional License, please contact Kristi Strang, Unit Supervisor, at (651) 431-6611.

Sincerely,

Frances Simon Standing, Attorney

Legal Counsel’s Office

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/