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May 22, 2023 Emily Peach, Authorized Agent New Beginnings Waverly LLC 550 Main Street Suite 230 New Brighton, MN 55112 License Number 1089815 (245G) License Number 1089816 (245G) Report Number 202203220 Report Number 202207229 Report Number 202301117 CORRECTION ORDER On March 27 through March 31, and April 3, 2023, Department of Human Services (DHS) licensors conducted licensing reviews and investigations at your facilities: · New Beginnings Waverly LLC Estes, license number 1089815, located at 7300 Estes Avenue, Waverly, MN 55390 · New Beginnings Waverly LLC North Shore Drive, license number 1089816, located at 109 North Shore Drive, Waverly, MN 55390 As a result of this visit, DHS determined that you are in violation of 21 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 under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Practices, Postings, 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. The files documented the clients received less than 30 hours of services the weeks ending: 1) 1/15/23, 1/22/23, and 1/29/23 (client file numbered 1); 2) 10/23/22 and 11/6/22 (client file numbered 7); and 3) 11/27/22 (client file numbered 6); b. Client files did not contain documentation that the clients received Diagnostic Assessments within ten days of admission, as required for programs that offer services to individuals with co-occurring mental health and substance use disorder problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (5) (client files numbered 1, 4, and 6 through 8); c. Documentation of group services for residential and non-residential clients did not accurately identify the duration of services (client files numbered 1, 4, 5, 6, 7, and 9). The amount of services documented on group notes did not reflect breaks, which were identified during the review as occurring between each group, and during groups as needed; and d. The license holder allowed unqualified individuals to co-facilitate treatment services: 1) The license holder’s practice was to allow Licensed Practical Nurses to co-facilitate education groups (1089815 and 1089816); and 2) Group service notes identified that clients co-facilitated group on 12/21/22, 12/28/22, and 12/29/22 (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Repeat Violation: In a Correction Order that DHS issued on December 13, 2021, you were previously found in violation of this same statute. 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 failed to meet requirements of vulnerable adult maltreatment procedures: a. The license holder did not complete an internal review within 30 calendar days when the facility knew of an external report of alleged or suspected maltreatment (1089816). The facility was informed of a report of suspected maltreatment on 10/4/22, and completed an internal review 11/8/22; b. The internal review for a report of suspected maltreatment on 2/3/23 incorrectly stated the event was not similar to past events (1089816). The reported event was the same as the event in a report of suspected maltreatment on 10/4/22; c. The facility received an internal report of suspected maltreatment on 2/3/23, and the reporter was not given a written notice stating whether the facility reported the incident to the common entry point (1089816); and d. The license holder’s annual review of the program abuse prevention plans did not use the assessment factors in the plan and substantiated maltreatment findings that occurred since the last review (1089815 and 1089816). A combined review for both licenses was completed 5/27/22, and the review documentation stated the “facility has had substantiated maltreatment findings within the past year”; however, the review did not say which of the two licenses had the substantiated maltreatment or how it related to the assessment factors in the plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivisions 1, paragraph (b), and 2, paragraph (a), and 626.557, subdivision 4a, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure vulnerable adult maltreatment procedures meet all applicable requirements. 3. Violation: The license holder failed to protect client rights as identified in Minnesota Statutes, section 144.651, subdivision 23 (1089815 and 1089816). The license holder’s practice was to require residents to perform services for the facility, specifically cleaning common areas daily, and the services were not included for therapeutic purposes and appropriately goal-related in the clients’ individual medical records. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client rights are protected. Within 30 days of receipt of this order, submit a description of how this violation has been corrected. 4. Violation: The license holder failed to respond within three days to client grievances received by staff members on 4/28/22 (1089815 and 1089816). Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on December 13, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure grievances are responded to within three days as required. 5. Violation: The license holder had multiple visitors policies with conflicting visiting hours: a. The visiting hours in the policy manual were Saturdays from 10:15am to 11:30am and Wednesdays from 5:30pm to 7:30pm, the visiting hours in the client orientation folders were Saturdays from 9:00am to 11:00am and Wednesdays from 6:30pm to 8:00pm, and the visiting hours posted at the facility were Saturdays from 9:00am to 11:00am and Wednesdays from 6:00pm to 7:00pm (1089815); and b. The visiting hours in the policy manual and posted at the facility were Saturdays from 1:30pm to 3:30pm and Tuesdays from 6:30pm to 7:30pm, and the visiting hours in the client orientation folders were Sundays from 1:30pm to 3:30pm and Tuesdays from 6:30pm to 8:00pm (1089816). Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all visitors policies are consistent and meet all applicable requirements. 6. Violation: The license holder failed to ensure that counseling groups did not exceed 16 clients: a. Group counseling sessions had 18 clients on 3/2/23 and 3/3/23 (1089815); and b. A group counseling session had 24 clients on 3/16/23 (1089816). Statute Violated: Minnesota Statutes, section 245G.10, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all visitors policies are consistent and meet all applicable requirements. 7. Violation: The description of treatment services did not meet requirements at the time of review in the following ways: a. The policies did not include descriptions of required treatment services: 1) A treatment service to help the client integrate gains made during treatment into daily living and to reduce the client's reliance on a staff member for support (1089815 and 1089816); and 2) Treatment coordination (1089815); b. The policies did not include descriptions of services which were provided: 1) Communication Group, which was on the treatment services schedule (1089815); 2) Self-Discovery group, which was documented in client files as a treatment service provided (1089815); and 3) Therapeutic recreation, which was documented in client files as a treatment service provided (1089816); c. The license holder identified that guest speakers were utilized, and the policies did not identify which groups and topics on which a guest speaker could provide under the direct observation of an alcohol and drug counselor (1089815 and 1089816). Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 1, paragraph (a), and 2, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit revised treatment services descriptions and schedules which meet requirements. 8. Violation: The written procedures for assessing and monitoring a client's health did not include use of a standardized data collection tool for collecting health-related information about each client. The Residential Health Monitoring Plan and the Admission Health History policies stated health histories were done within 24 hours of admission; however, the policies did not identify the standardized data collection tool for collecting health histories, which the license holder stated was the Comprehensive Assessment. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health services procedures meet all applicable requirements. Within 30 days of receipt of this order, submit revised written procedures for assessing and monitoring a client's health which meet all applicable requirements. The policies and procedures must be approved and signed by a registered nurse. Client Files Client files reviewed are identified in the following manner: · 1089815: client files numbered 1 through 5 · 1089816: client files numbered 6 through 9 9. Violation: One of eight client files reviewed for requirements governing consent to report suspected maltreatment (client file numbered 9) did not contain documentation that the license holder sought consent to the disclosure of suspected maltreatment upon admission. Statute Violated: Minnesota Statutes, section 626.557, subdivision 3a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that consent to the disclosure of suspected maltreatment is sought upon admission. 10. Violation: One of eight client files reviewed for requirements governing initial services plans (client file numbered 2) did not address immediate health concerns which were identified in the initial services plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements. 11. Violation: One of eight client files reviewed for requirements governing individual abuse prevention plans (client file numbered 1) did not a detail the measures to be taken to minimize the risk that the client might reasonably be expected to pose to visitors to the facility and persons outside the facility, when the facility knew that the client had committed a violent crime or an act of physical aggression towards others. Statute Violated: Minnesota Statutes, sections 626.557, subdivision 14, paragraph (c), and 245G.04, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. 12. Violation: Seven of eight client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: 1) A list of previous attempts at treatment for substance misuse or substance use disorder (client file numbered 4); 2) Family history of substance use and misuse (client files numbered 1, 2, 4, 6, 7, and 8). The assessment was limited to substance use by siblings; and 3) Whether or not physical and medical concerns needed to be referred to an appropriate health care professional (client files numbered 4, 7, and 9); b. The substance use histories were not complete: 1) The assessment included a date of last use of a substance and did not including amount, frequency and duration of that substance use (client file numbered 9); and 2) The amounts of frequencies of substances used were limited to the heaviest use and the last use (client files numbered 7, 8, and 9). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Repeat Violation: You were previously found in violation of this same statute in Correction Order that DHS issued on: · December 13, 2021 · August 20, 2019 Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that comprehensive assessments meet all applicable requirements. 13. Violation: Eight of eight client files reviewed for requirements governing individual treatment plan reviews did not include: a. The goals and methods did not include amount, frequency, and anticipated duration of treatment service (client files numbered 1 through 4 and 6 through 9); and b. Resources to refer the clients to when needs were to be addressed concurrently by another provide. The license holder referred clients to outside providers, and did not include the resources, for treatment plan needs to: 1) Complete diagnostic assessments (client files numbered 1, 2, 3, 6, and 7); and 2) Complete health and physicals (client files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on December 13, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit one individual treatment plan from one recently admitted client from each license which meets all applicable requirements. 14. Violation: Six of eight client files reviewed for requirements governing client record documentation did not meet the requirements in the following ways: a. A note was not entered on the day a significant event occurred at the program (client file numbered 2); b. Entries in the records did not include the job title or position of the staff person making the entry (client files numbered 1 through 4, 6, and 7); c. Documentation of treatment services did not include the type of service provided (client files numbered 1 through 4, 6, 7, and 9); d. Documentation of treatment services did not include the clients’ responses to the services (client files numbered 1 and 6); and e. Client absences from the treatment service, including the reason for the absences, were not documented on the day they occurred (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that client record documentation meets all applicable requirements. 15. Violation: Two of eight client files reviewed for requirements governing treatment plan reviews did not meet the requirements in the following ways: a. Reviews did not include monitoring of physical health problems (client file numbered 9); and b. A treatment plan review did not address whether the methods to address the goals were effective (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: You were previously found in violation of this same statute in Correction Order that DHS issued on: · December 13, 2021 · August 20, 2019 Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that treatment plan reviews meet all applicable requirements. 16. Violation: One of seven client files reviewed for requirements governing documentation of medication administration (client file numbered 4) did not include: a. The date and time of the client’s use of PRN medications in December 2022 (client file numbered 4); and b. Whether or not a medication was administered as prescribed 1) When a medication was identified as lost in July 20222 (client file numbered 2); and 2) On three instances in December 2022 (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245G.01, subdivision 2, and 245G.08, subdivision 5, paragraph (c).
Repeat Violation: In a Correction Order that DHS issued on December 13, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that documentation of medication administration meets all applicable requirements. 17. Violation: Two of eight client files reviewed for requirements governing discharge summaries did not include: a. The clients’ living arrangements at service termination (client files numbered 2 and 3); b. The client's progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 3); and c. Referrals made for continuing care recommendations (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: You were previously found in violation of this same statute in Correction Order that DHS issued on: · December 13, 2021 · August 20, 2019 Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that discharge summaries meet all applicable requirements. 18. Violation: Four of six client files reviewed for requirements governing client property management did not meet requirements in the following ways: a. Documentation of receipt of the clients’ property did not include the clients’ signature, or the signature of the conservator or payee, at the time of receipt (client files numbered 1 and 4); and b. Documentation of disbursement of the clients’ property did not include the clients’ signature, or the signature of the conservator or payee, at the time of disbursement (client files numbered 6 and 8). 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 that client property management documentation meets all applicable requirements. Personnel Files Personnel files reviewed are identified in the following manner: · 1089815: client files numbered 1 through 5 · 1089816: client files numbered 6 through 10\ 19. Violation: One personnel file was reviewed for requirements governing supervision of individuals with a temporary permit to provide chemical dependency treatment services (personnel file numbered 5) and supervision was not documented as provided the weeks ending 1/6/23, 1/20/23, 2/2/23, 2/9/23, 2/16/23, and 2/23/23. Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 11, and 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the supervision of individuals with a temporary permit to provide chemical dependency treatment services is completed and meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of supervision for personnel file numbered 5 for the two weeks preceding the submission. 20. Violation: Two of four personnel files reviewed for requirements governing staff development did not document that training was received as required: a. Training required annually was received late in 2023 (personnel file numbered 3) on: 1) Vulnerable adult reporting requirements and definitions in sections 245A.65, 626.557, and 626.5572; 2) All internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults; 3) Specific training covering the facility's policies for obtaining a client release of information, required by section 626.557, subdivision 3a, paragraph (a); 4) The license holder's program abuse prevention plan; and 5) Mandatory reporting of maltreatment of minors as specified in chapter 260E, including reporting of prenatal exposure to controlled substances; b. Training required every two years was received late in 2022 (personnel file numbered 1) on client confidentiality rules and regulations. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivisions 2, paragraph (c), and 3. Repeat Violation: You were previously found in violation of this same statute in Correction Order that DHS issued on: · December 13, 2021 · August 20, 2019 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff development training is completed and meets all applicable requirements. 21. Violation: One personnel file was reviewed for requirements governing medication administration training (personnel file numbered 4) and did not contain documentation that training was completed as required. The file contained documentation of training and observation of the staff person by a Licensed Practical Nurse, not a Registered Nurse. Statute Violated: Minnesota Statutes, sections 245G.08, subdivision 5, and 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff delegated the task of administration of medication or assistance with self-medication receive training that meets all applicable requirements. Corrective action required You must correct the violations cited above. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 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 RECOMMENDATIONS The following recommendations are being made to assist you with achieving and maintaining compliance with applicable requirements on an ongoing basis. Failure to follow these recommendations will not result in an action against your license at this time. However, should failure to follow recommendations result in a violation of statutes or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license. You may contact your licensor for more information if you choose to implement these recommendations. 1. It is recommended that you develop procedures to maintain accurate staff lists for each licensed location. During the licensing review, multiple different versions of staff lists were provided to DHS licensors, due to the license holder’s practice of utilizing company staff at various different programs. License holders must be able to be provide accurate staff information for each license during licensing reviews, including identifying all staff of the license and each staff person’s date of hire at that license. A staff person must meet all applicable personnel requirements for a license before providing services at that license. 2. It is recommended that you develop a policy and procedure to ensure and document that a registered nurse provides supervision as required by Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Supervision for purposes of this requirement is defined in section 148.171, subdivision 23, and must minimally include monthly on-site supervision or more often if warranted by a client's health needs. 3. It is recommended that you identify procedures to refer to outside agencies for treatment needs in the corresponding policies, so that all staff are aware of the procedures: · The procedure at the time of the review was to have client health and physicals completed by a contracted agency, and the Residential Health Monitoring Plan did not reflect that procedure. The plan stated “Each patient will receive a physical exam unless they have had a previous routine physical exam within the last 30 days… Routine physical exams will be done on-site unless health concerns warrant further examination”; and · The procedure at the time of the review was to refer clients to a contracted agency for psychiatric services, and the license holder did not have policies regarding this procedure, including policies to ensure that clients scoring positive on a standardized mental health screen receive a mental health diagnostic assessment within ten days of admission. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Substance Use Disorder 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 me at Leah.Wachter@state.mn.us or at 651-431-6614. Sincerely, Leah Wachter, Senior Licensor Licensing Division Office of Inspector General
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