|
May 22, 2023 Andrew Horowitz, Authorized Agent Gateway Recovery Center 6775 Cahill Ave Inver Grove Heights, MN 55076 License Number: 1103791 CORRECTION ORDER Dear Andrew: On March 21, 22, and 23, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 6775 Cahill Ave, Inver Grove Heights, MN 55076. 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. Policies, Practices, and Procedures 1. Violation: The license holder did not document the date and time of the admission request when processing denials of admission. Statute Violated: Minnesota Statutes, section 245F.08, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admissions meet all applicable requirements. 2. Violation: The license holder did not ensure that the central log documenting each incident involving the use of law enforcement included the time law enforcement left the program and whether any injuries occurred. Statute Violated: Minnesota Statutes, section 245F.09, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the use of law enforcement documentation meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing grievance procedures in the following ways: a. The license holder’s initial response to the patient who filed the grievance was greater than 24 hours of the programs receipt of the grievance; and b. The grievance procedure did not have the current phone number for the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, sections 245F.10, subdivision 2, and 245A.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure grievance procedures meet all applicable requirements. 4. Violation: The license holder did not have documentation that the program abuse prevention plan was reviewed in 2021. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program abuse prevention plans meet all applicable requirements. 5. Violation: The license holder did not meet requirements governing internal reporting practices for maltreatment of vulnerable adults in the following ways: a. When an internal report was made, the license holder did not: 1) Provide written notice to the reporter in a manner that protects the confidentiality of the reporter within two working days stating whether the facility reported the incident to MAARC; and 2) Inform the reporter in writing that if the mandated reporter was not satisfied with the action taken by the facility, the reporter may report externally; b. Internal reviews did not include: 1) Whether there is a need for additional staffing; 2) If the reported event is similar to past events with the vulnerable adults or the services involved; and 3) Whether there is a need for any corrective action to be taken by the license holder to protect the health and safety of vulnerable adults. Statute Violated: Minnesota Statutes, sections 626.557, subdivision 4a, and 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure internal reporting practices meet all applicable requirements. 6. Violation: The license holder did not obtain and document the medical director’s annual approval in 2021 of the following procedures: a. Admission, discharge, and transfer criteria and procedures; b. Health services plan; c. Physical indicators for 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. Infection control program; g. Protective procedures; and h. Medication control plan. Statute Violated: Minnesota Statutes, section 245F, 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. Patient Files 7. Violation: Three of three patient files reviewed for requirements governing individual abuse prevention plans (IAPPs) (patient files numbered 1, 2, and 3) did not meet requirements in the following ways: a. The IAPPs 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). The form limited the assessment to the categories of sexual abuse, physical abuse, self-abuse, and financial exploitation, and did not include all times of abuse defined in Minnesota Statutes, section 626.5572; and b. The IAPPs did not document if it was determined that the vulnerable adult did not need specific risk reduction measures in addition to those identified in the program abuse prevention plan. Statute Violated: Minnesota Statutes, sections 626.557, subdivision 14, paragraph (b), and 245A.65, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual abuse prevention plans meet all applicable requirements. 8. Violation: Three of three patient files reviewed for requirements governing medical services (patient files numbered 1, 2, and 3) did not meet requirements. The follow up screenings conducted between 4 and 12 hours after service initiation did not contain information related to other health complaints, and behavioral risk factors that the patients may not have communicated at service initiation. Statute Violated: Minnesota Statutes, section 245F.12, subdivision 1, paragraph (2). 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. 9. Violation: Three of three patient files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessments did not include a description of the circumstances on the day of service initiation (patient files numbered 1 and 2); b. The assessments did not include previous attempts at treatment for mental illness (patient files numbered 1, 2, and 3); c. The assessments did not include the effects of mental health on the client’s ability to function (patient files numbered 1, 2, and 3); d. The assessments did not include a mental health screening approved by the commissioner (patient files numbered 1, 2, and 3); and e. The assessment did not include a description of how use affected the patient’s ability to function appropriately in an educational setting (patient files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 10. Violation: One of three patient files reviewed for requirements governing progress notes did not include documentation of referrals made to other services or agencies (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2, paragraphs (3). 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. 11. Violation: One of three patient files reviewed contained a discharge plan that did not document referrals made to other services of agencies at the time of transition (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3, paragraphs (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. 12. Violation: Three of three patient files reviewed for requirements governing patient record entries (patient files numbered 1, 2, and 3) contained entries that did not include a signature and date by the staff member making the entry. 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 13. Violation: One of four personnel files reviewed for requirements governing staff qualifications (personnel file numbered 2) did not contain documentation of a recovery peer’s staff qualifications. Statute Violated: Minnesota Statutes, section 245F.15, subdivision 7, paragraph (3). 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: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. Specific license holder and staff responsibilities for patient confidentiality (personnel file numbered 2); b. Patient ethical boundaries and patient rights, including the rights of patient admitted under Minnesota Statutes, chapter 253B (personnel file numbered 2); c. Infection control procedures (personnel files numbered 2 and 5); d. Mandatory reporting under Minnesota Statutes, chapter 260E, and sections 245A and 626.557 including specific training covering the facility’s policies concerning obtaining patient releases (personnel file numbered 2); e. Vulnerable adult requirements within 72 hours of first providing direct contact services to a vulnerable adult including reporting requirements and definitions in sections 626.557 and 626.5572 (personnel file numbered 2); f. The license holder’s program abuse prevention plan and all internal policies and procedure related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2 and 5); g. HIV minimum standards as required in section 245A.19 (personnel file numbered 2); h. Motivational counseling techniques and identifying stages of change (personnel files numbered 2, 4, and 5); i. The specific job functions for which the staff member was hired (personnel files numbered 2, 4, and 5); j. Program policies and procedures (personnel files numbered 2, 4, and 5); and k. Patient needs (personnel files numbered 2, 4, and 5). 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: Five of five personnel files reviewed for requirements governing annual and biennial training did not meet requirements in the following ways: a. Training on Infection control procedures was: 1) Not completed in 2022 (personnel files numbered 2, 3, 4, and 5); and 2) Not completed in 2023 (personnel file numbered 2); b. Vulnerable adult maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 was: 1) Not completed in 2022 (personnel file numbered 6); 2) Not completed in 2023 (personnel file numbered 2); and 3) Completed late in 2022 (personnel files numbered 4 and 5); c. The license holders program abuse prevention and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was: 1) Not completed in 2021 (personnel files numbered 3, 4, and 6); 2) Not completed in 2022 (personnel files numbered 3, 4, 5, and 6); and 3) Not completed late in 2023 (personnel file numbered 2); d. Specific training covering the facility’s polices for obtaining patient releases of information required by 626.557, subdivision 3a, paragraph (a) was: 1) Not completed in 2022 (personnel files numbered 3, 4, 5, and 6); and 2) Not completed in 2023 (personnel file numbered 2); e. Mandatory reporting under Minnesota Statutes, chapter 260E was: 1) Not completed in 2021 (personnel file numbered 6); 2) Not completed in 2022 (personnel file numbered 3); 3) Not completed in 2023 (personnel file numbered 2); and 4) Completed late in 2022 (personnel files numbered 4 and 5); f. HIV minimum standards: 1) Not completed in 2022 (personnel files numbered 3, 4, 5, and 6); and 2) Not completed in 2023 (personnel file numbered 2); g. Motivational counseling techniques and identifying stages of change: 1) Not completed in 2021 and 2022 (personnel files numbered 3, 4, 5, and 6); and 2) Not completed in 2023 (personnel file numbered 2); h. Specific license holder and staff responsibilities for patient confidentiality was not completed in 2022 (personnel file numbered 3); and i. The rights of patient admitted under Minnesota Statutes, chapter 253B was not completed in 2022 (personnel file numbered 6). Statute Violated: Minnesota Statutes, sections 245F.16, subdivision 2, paragraphs (c) and (d), and 245A, subdivision 3. 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 and 2023 have now been completed for the corresponding staff persons. 16. Violation: Five of six 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 4); b. Documentation of orientation and subsequent training (personnel files numbered 2, 3, and 6); and c. Annual job performance evaluation was: 1) Completed late in 2022 (personnel files numbered 4, 5, and 6); and 2) Not completed in 2023 (personnel file numbered 2). 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. You must 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. 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 You are required to place this Correction Order in a place that is clearly noticeable to the people receiving services and all visitors to the facility for two years, even if you appeal. 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, section 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 651-431-6611. Sincerely, Kristi Strang, Substance Use Disorder Unit Supervisor Licensing Division Office of Inspector General
|
