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April 18, 2023
Emily Peach, Authorized Agent Oakridge Treatment Center, LLC 550 Main Street Suite 230 New Brighton, Minnesota 55112 License Number: 1082638 Report Numbers: 202206992 and 202207782 CORRECTION ORDER Dear Emily: On February 6, 7, 8, and 9, 2023, Department of Human Services (DHS) licensors conducted a licensing review and licensing investigations at your facility located at 4800 48th Street NE, Haverhill, Minnesota 55906. As a result of this visit, DHS determined that you are in violation of 16 of the Substance Use Disorder Treatment rules and statutes. As a result, DHS is issuing this order which requires you to take the correction action as described below. 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 did not meet requirements for receiving public funding reimbursement from the commissioner for services provided: a. The license holder failed to document that all 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 residential high-intensity treatment. 1) The files documented the clients received less than 30 hours of services: (i) 26 hours the week ending October 16, 2022 (client file numbered 1); (ii) 27.25 hours the week ending in 1/08/2023 (client file numbered 2); and 2) Documentation of services did not accurately identify the duration of services (client files numbered 1 and 2). The license holder identified that the amount of services provided did not reflect breaks, which occurred between each group and during groups that were two hours or longer; b. The license holder did not meet requirements for programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (5): 1) Co-occurring counseling staff completed the required 8 hours of co-occurring disorder training; however, the training was completed late for calendar year 2021 (personnel file numbered 2); and 2) The client files did not contain documentation that the clients received Diagnostic Assessments within ten days of admission (client files numbered 1 through 3). c. Documentation of services did not identify the nature of the service (client file numbered 2). The file contained documentation for New Year’s group on 1/02/2023, Sunday group on 1/08/2023, and Saturday group on 1/21/2023, which were not consistent with the program’s treatment services description or with the treatment services defined in Minnesota Statutes, section 245G.07, subdivisions 1 and 2. Statute 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. Additionally, 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. 2. Violation: The license holder’s policy and procedure manual contained two visitor policies with conflicting hours listed. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that visitor policies are consistent and meet all applicable requirements. 3. Violation: The license holder did not ensure that group counseling did not exceed 16 clients on January 30, 2023. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that group counseling does not exceed sixteen clients. 4. Violation: The license holder failed to protect client records against unauthorized disclosure in compliance with Code of Federal Regulations, title 42, chapter 1, part 2, sections 2.1-2.67: a. The license holder allowed individuals who were not staff members of the program to access client records without written client consent. During the licensing review, it was identified that the license holder’s practice was to allow communication with other treatment programs without clients’ consent, including allowing individuals from outside of the licensed program to access records in the electronic record system as needed; and b. A client file (client file numbered 2) contained a Release of Information form which did not include: 1) How much and what kind of information was to be disclosed; and 2) The purpose of the disclosure. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client records are protected from unauthorized disclosure, and that written consents to disclosure meet all applicable requirements of Code of Federal Regulations, title 42, chapter 1, part 2, section 2.31. License holder must ensure that client files cannot be accessed by other license holders. Within 30 days of receipt of this order, submit a description of how the process has been changed to meet applicable requirements. 5. Violation: The Program Description stated the program had two distinct levels of care: the MICD track, with a minimum of 30 hours of programming per week, and the MICD Extended Care track, with a minimum of 15 hours per week. The policy stated “The program components an individual will participate in will be dependent upon the specific track of treatment they are entering. The program schedule will reflect the specific components the individual will be recommended to participate in.” In addition, the Program Schedule policy stated the facility will maintain schedules for services provided in order to provide information relating to program services for each level of care. However, the facility had one treatment schedule only, which did not reflect the services provided for each level of care. Statute Violated: Minnesota Statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit a revised Program Description policy and schedule which meets requirements. Client Files 6. Violation: Two of two client files reviewed for requirements governing client orientation (client files numbered 1 and 2) did not meet requirements in the following ways: a. The clients received information on tuberculosis and tuberculosis screening; however, it was not the Commissioner approved information which the program’s policy identified was used for orientation; b. The clients did not receive orientation within 24 hours of admission to the program to the license holder’s internal and reporting policies; and c. The clients were not informed of the Personal Electronic Device policy according to the policies and procedure manual. Statutes Violated: Minnesota Statutes, sections 245G.09, subdivision 3, paragraph (1), 245G.15, subdivision 3, 245.09, subdivision 3, paragraph (1), and 245A.65, subdivision 1, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client orientation meets all applicable requirements. 7. 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. The absence or presence of previous withdrawal symptoms for each substance used in the previous 30 days (client files numbered 1 and 2); c. Whether or not physical concerns need to be referred to an appropriate health care professional (client file numbered 2); d. The effects of the client’s mental health on ability to function (client file numbered 2); and e. The client’s cultural background (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 the comprehensive assessments meet all applicable requirements. 8. Violation: Three of three client files reviewed for the requirements governing individual treatment plans (client files numbered 1 through 3) did not contain the amount and frequency of treatment services to be provided. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 9. Violation: One of two files reviewed for the requirements governing treatment plan reviews (client file numbered 2) did not address whether the methods to address the goals were effective. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment plan reviews meet all applicable requirements. 10. Violation: Two of two client files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. The Medication Administration Records did not document if medications were administered as prescribed on: 1) 9/30/2022, 10/01/2022, 10/02/2022, 10/03/2022, 10/04/2022, 10/10/2022, and 10/16/2022 (client file numbered 1); and 2) 12/30/2022, 1/17/2023, 1/18/2023, and 1/23/2023 (client file numbered 2); b. The Medication Administration Record did not document the reason for not administering a medication as prescribed on 12/29/2022 (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.01, subdivision 2, and 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration records meet all applicable requirements. 11. Violation: Three of three client files reviewed for the requirements governing discharge summaries (client files numbered 1, 2, and 4) did not include the services provided to the clients while participating in treatment. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on August 25, 2020, you were previously found in violation of this same statute. 12. Violation: Two of two client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Client response to treatment services for individual counseling sessions were not documented on 1/12/23 and 1/19/23 (client file numbered 2); and b. Client entries were not signed: 1) One group note and nineteen shift observations (client file numbered 2); and 2) Entries did not include job title or position (client file numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a and subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 13. Violation: Two of two client files reviewed for the requirements governing client property management did not document disbursement of client property (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of receipt and disbursement of the person's funds or other property is documented at the time of receipt or disbursement. Personnel Files 14. Violation: One of four personnel files reviewed for requirements governing annual staff training (personnel file numbered 3) documented the staff person received training late in 2022 on the following: a. Vulnerable Adults Maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; b. The license holder’s program abuse prevention plan; c. Mandatory reporting of Maltreatment of Minors, including reporting of prenatal exposure to controlled substances; and d. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245G.13, subdivision 2, paragraphs (c) and (d), 245A.65, subdivision 3, 260E.065, and 260E.31, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff training is completed and meets all applicable requirements. 15. Violation: Two of four personnel files reviewed for requirements governing written annual reviews of the employee’s job performance (personnel files numbered 1 and 3) contained reviews that were completed late in 2022. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, paragraph (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that written annual reviews are completed within the required timelines. 16. Violation: Two of two personnel files reviewed for the requirements governing staff supervision for individuals with a temporary permit did not document that supervision was provided for the following timeframes: a. April 29, 2019, through April 30, 2022 (personnel file numbered 2); and b. The weeks ending 8/07/2021, 1/1/2022, 1/8/2022, 2/26/2022, 3/5/2022, 4/16/22, 4/30/22, 5/21/2022, 6/18/2022, 7/16/2022, 10/8/2022, 10/29/2022, 11/05/22, 12/24/2022, 1/07/2023, and 2/04/2023 (personnel file numbered 3). Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that supervision is provided to individuals with a temporary permit and meets all applicable requirements. Corrective action required
You must correct the violations cited above. If you fail to correct the violations identified in the Correction Order within the specified time lines DHS 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 must be sent: 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 Treatment program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, chapter 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 your assigned licensor at Leah.Wachter@state.mn.us or 651-431-6614. Sincerely, Kristi Strang, Substance Use Disorder Unit Supervisor Licensing Division Office of Inspector General
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