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May 31, 2023 Mark Casagrande, Authorized Agent Park Avenue Center 2318 Park Avenue S Minneapolis, MN 55404 License Number 1077904 License Number 1057578 AMENDED CORRECTION ORDER Dear Mark: On January 23 through 27, and 30, 2023, Department of Human Services (DHS) licensors conducted licensing reviews of the following facilities: · Park Avenue Center on Nicollet, license number 1077904, located at 2430 Nicollet Avenue, Minneapolis, MN 55404 · Park Avenue Center on 24th, license number 1057578, located at 2318 Park Avenue S, Minneapolis, MN 55404 As a result of this review, a Correction Order was issued on April 13, 2023. The DHS Division of Licensing received an email response from you on April, 19, 2023 stating your concerns over violation numbered 2. After careful consideration, violation numbered 2 is rescinded from the Correction Order issued on April 13, 2023. This Amended Correction Order supersedes the Correction Order issued on April 13, 2023, which must be destroyed. DHS determined that you are in violation of twenty-three of the Substance Use Disorder rules and statutes. As a result, DHS is issuing this order which requires you to take the corrective 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 programs failed to follow licensing rules and statutes, as described below. Policy, Procedure and Practice 1. Violation: The license holder (1077904 and 1057578) did not meet requirements for receiving public funding reimbursement from the commissioner for services provided as required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b), clause (1). a. The license holder’s practice with individual sessions that did not go beyond 31 minutes was to bill for treatment coordination for the following: 1) A note entered on September 23, 2022, documented a 17 minute individual session, but was billed as treatment coordination (client file numbered 5); 2) An October 20, 2022,20 minute individual session was billed as treatment coordination (client file numbered 6); and b. As required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (4): 1) Diagnostic assessment due May 21, 2022 and not received until June 2, 2022 (client file numbered 1); 2) Diagnostic assessment due September 23, 2022 and not received until December 8, 2022 (client file numbered 2); 3) Diagnostic assessment due May 21, 2022 and not received until June 2, 2022 (client file numbered 3); 4) Diagnostic assessment due August 19, 2022 and not received until August 31, 2022 (client file numbered 5); and 5) Diagnostic assessment due October 22, 2022 and not received until October 25, 2022 (client file numbered 6). 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. 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. The public funding Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG . Within 30 days of receipt of this order, submit a plan for maintaining compliance on an ongoing basis. 2. Violation: The license holder failed to protect client records from unauthorized disclosure (1077904 and 1057578) in the following ways: a. The program’s practice was to allow communication between 245G staff and housing staff without client consent to disclosure. This was confirmed by program staff at the time of the licensing review and documented in client files; b. The program did not follow their own Client Records policy that stated all files will document consent to the disclosure of suspected maltreatment according to Minnesota Statutes, section 626.5572, subdivision 3 would be sought at admission; and c. The consent to disclose suspected maltreatment did not meet the requirements for written consents to a disclosure identified in Code of Federal Regulations, title 42, chapter 1, part 2, section 2.31. 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 and document that disclosure consents meet all applicable requirements. 3. Violation: The service initiation and termination policies (1077904 and 1057578) did not meet requirements in the following ways: a. The written protocol for assisting clients in need of care not provided by the license holder and a client who poses a substantial likelihood of harm to the client or others, if the behavior is beyond the behavior management capabilities of the staff members, was specific to denial of service initiation and did not include clients terminated from services; b. The written protocol for service termination and denial of service initiation that poses an immediate threat to the health of any individual or requires immediate medical intervention must be referred to a medical facility capable of admitting the client was specific to denial of service initiation and did not include clients terminated from services; and c. The Admissions and Discharge Policy did not include the following: 1) Procedures for clients whose services were terminated under subdivision 2; 2) A description of client behavior that constitutes reason for a staff-member requested service termination; and 3) A requirement for staff members to assist the client with assessing needs of care or other resources. Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 2, paragraphs (a) and (b), and 3. Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure that service initiation and termination policies meet all applicable requirements. Within 30 days of receipt of this order, submit revised service initiation and termination policies that meet all applicable requirements. 4. Violation: The grievance procedure (1077904 and 1057578) used for client orientation did not contain the current address and telephone number for the Minnesota Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policy and procedure manual and orientation material are current and meet all applicable requirements. Within 30 days of receipt of this order, submit a revised grievance procedure that meets all applicable requirements. 5. Violation: The Photographs, Videos, and Cell Phones policy and practice (1077904 and 1057578) did not meet requirements in the following ways: a. Policy did not include information that: 1) A photograph, video, or motion picture of a client taken in the provision of treatment service is considered client records; 2) A photograph for identification and a recording by video or audio technology to enhance either therapy or staff member supervision may be required of a client, but may only be available for use as communications within a program; and 3) A client must be informed when the client's actions are being recorded by camera or other technology; and b. Clients were not being oriented to the right to refuse being photographed. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights are protected and that policies for photographing clients meet all applicable requirements. Within 30 days of receipt of this order, submit revised policy and procedures that meet all applicable requirements. 6. Violation: The license holder (1077904 and 1057578) did not follow their own policy to provide tuberculosis (TB) education. TB education provided to clients did not include the commissioner approved form, the form was not part of client intake material, and staff stated at the time of the licensing review that the approved TB handout is not provided during education treatment sessions. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245G.07, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that TB education policies are followed and meet all applicable requirements. Within 30 days of receipt of this order, submit a statement of how this violation has been corrected. 7. Violation: Treatment services policies (1077904 and 1057578) did not meet requirements in the following ways: a. The policy and procedure manual referenced repealed Minnesota Rules, part 9530.6450 in the Treatment Services policy; b. The policy included aftercare and the license holder’s practice was to provide group counseling services to former clients who have been discharged; and c. The description of treatment services did not: 1) Include client education on symptoms of mental illness, the possibility of comorbidity, or the need for continued medication compliance while recovering from substance use disorder; 2) Clearly describe treatment coordination provided one-to-one; 3) Include a comprehensive list of the amount and type of each service provided; 4) Define the program’s treatment week; 5) Include employment and educational services; and 6) Clearly identify what services may be provided off-site. Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 1, 2 , and 4, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that policy is reflective of program practices and that policy, procedure and practices meet all applicable requirements. Within 30 days of receipt of this order, submit revised treatment services policies and procedures that meet all applicable requirements. 8. Violation: Monthly on-site supervision of assistance with self-administration of medication by a registered nurse (1077904 and 1057578) was not provided in October and November, 2022. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services meet all applicable requirements. Within 30 days of receipt of this order, submit revised policies and procedures that meet all applicable requirements. 9. Violation: The program abuse prevention plan (1077904 and 1057578) did not include a description of staffing patterns. 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 that program abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit revised program abuse prevention plans that meet all applicable requirements. 10. Violation: The policy and procedure manual (1077904 and 1057578) referenced repealed Maltreatment of Minors Act Statutes, sections 626.556 and 626.5561. Statute Violated: Minnesota Statutes, sections 245G.12 and 260E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that reporting policies are current and meet all applicable requirements. Within 30 days of receipt of this order, submit a revised policy that meets all applicable requirements. Client Files Client files reviewed are identified in the following manner: · 1057578: client files numbered 1 through 4 · 1077904: client files numbered 5 through 8 11. Violation: Six of eight client files reviewed for requirements governing initial service plans did not meet requirements in the following ways: a. The plans were not person-centered and client specific (client files numbered 2 through 4 and 6 through 8); and b. The plans did not address immediate health and safety concerns (client files numbered 3 and 6). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all initial service plans meet all applicable requirements. 12. Violation: Eight of eight client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessments did not include a description of circumstances on the day of service initiation (client files numbered 1 through 8); b. The list of previous attempts at treatment for substance misuse or substance use disorder was not a complete list (client files numbered 7 and 8); c. The list of substance use history was not a complete list including: 1) Amounts used (client file numbered 5); 2) Type of substances used (client file numbered 1); 3) Frequency (client files numbered 1 and 5); and 4) Duration (client files numbered 1 and 5 through 8); d. Information did not address the absence or presence of withdrawal symptoms (client file numbered 3); e. Desire for family involvement in the treatment program (client files numbered 1 through 8); f. Level of family support (client file numbered 8); g. Mental health symptoms and effect on the clients’ ability to function (client file numbered 1); h. A description of how use affected the client’s ability to function appropriately in work settings (client files numbered 1 through 8); and i. Leisure time activities that have been associated with substance use (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 13. Violation: One of eight client files reviewed did not contain a comprehensive assessment summary (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessment summaries meet all applicable requirements. 14. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. The plans did not include the client’s involvement in the development of the plan (client files numbered 1 through 8); b. The plan did not include how family or others will be involved in the client’s treatment (client file numbered 2); c. The plans did not include specific goals and methods to address each identified need in the comprehensive assessment summary, including amount, frequency, and anticipated duration of treatment service (client files numbered 1 through 8); d. The plans did not include goals the client must reach to complete treatment and terminate services (client files numbered 1 through 8); and e. A change to the plan was not signed by the client (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit treatment plans from the files of one client recently admitted to 1077904 and one client recently admitted to 1057578 that demonstrate compliance. 15. Violation: Eight of eight client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. Four of seven client files reviewed for documentation of treatment services did not contain: 1) Client’s response to each treatment service (client files numbered 3 through 5 and 7); 2) Type of service (client file numbered 3); and 3) Documentation within seven days of providing the service (client file numbered 3); b. Treatment plan review was not signed (client file numbered 1); c. Group note not signed, January 15, 2023 (client file numbered 3); d. Discharge of medication not signed (client file numbered 4); e. Missing job title or position (client files numbered 2 through 8); f. Reviews were not entered in the client’s files for weeks ending: 1) September 25, 2022 (client file numbered 2); 2) December 18, 2022 (client file numbered 3); 3) September 11 and 18, 2022 (client file numbered 4); 4) October 9, 2022 (client file numbered 5); and 5) December 11, 2022 (client file numbered 8); and g. Reviews did not: 1) Indicate the span of time covered by the reviews (client files numbered 1 and 3 through 8); and 2) Address each goal in the treatment plans and whether the methods to address the goals were effective (client files numbered 1, 6, and 8). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment services and treatment plan reviews meet all applicable requirements. 16. Violation: Two of eight client files reviewed for requirements governing medication administration procedures did not meet requirements in the following ways: a. Use of medication did not include a staff signature (client files numbered 7 and 8); and b. Guidelines were not followed for informing a registered nurse of problems with self-administration, including failure to administer (client file numbered 8). 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 procedures meet all applicable requirements. 17. Violation: Six of six client files reviewed for requirements governing service discharge summaries (client files numbered 1, 2, 4 through 6, and 8) did not meet requirements in the following ways: a. The summaries did not include all services provided; and b. The summaries did not include continuing care recommendations for transitions to more or less intense services and referrals made with specific attention to continuity of care for mental health. Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. 18. Violation: Six of six client files reviewed for requirements governing client property management (client files numbered 1 through 4, 7, and 8) did not contain documentation of program receipt of medication, whereas disbursement of medication was documented with signature. 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 procedures meet all applicable requirements. Personnel Files Personnel files reviewed are identified in the following manner: · 1057578: personnel files numbered 1 through 4, 8 and 10 · 1077904: personnel files numbered 4 through 14 19. Violation: The license holder did not affiliate staff persons to the active background study rosters for licenses with which the staff were affiliated (personnel files numbered 5 and 7 through 14). Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 7, and 245C.07, paragraph (a). Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure that background studies meet all applicable requirements. 20. Violation: Six of six personnel files reviewed for requirements governing staff qualifications did not meet requirements in the following ways: a. The files did not contain documentation that the individual providing treatment coordination was skilled in the process of identifying and assessing a wide range of needs, and knowledgeable about local community resources and how to use those resources for the benefit of the client (personnel files numbered 5 and 8); b. The files did not contain documentation that a treatment coordinator received at least one hour of supervision regarding individual service delivery from an alcohol and drug counselor or a mental health professional who has substance use treatment and assessments within the scope of their practice monthly (personnel files numbered 1, 5, and 8); c. The file (personnel file numbered 3) did not contain documentation that a recovery peer had: 1) A minimum of one year in recovery from substance use disorder; and 2) Received ongoing supervision in areas specific to the domains of the recovery peer's role by an alcohol and drug counselor; and d. The file (personnel file numbered 7) did not contain documentation of: 1) Weekly supervision by the supervising licensed alcohol and drug counselor from May 28, 2020 through December 31, 2021; and 2) The amount of supervision for weeks ending October 8, 2022 through January 7, 2023. Statute Violated: Minnesota Statutes, section 245G.11, subdivisions 7, paragraphs (a) and (b), 8, and 10, paragraph (a). Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure and document that staff qualifications meet all applicable requirements. Within 30 days of receipt of this order, submit documentation which demonstrates the violation identified above has been corrected. 21. Violation: Two of seven personnel files reviewed for requirements governing staff orientation (personnel files numbered 2 and 6) did not contain documentation of training related to the staff member’s specific job responsibilities. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure and document that staff orientation is completed and meets all applicable requirements. 22. Violation: Five of five personnel files reviewed for staff development did not meet requirements in the following ways: a. The files did not contain documentation that the staff member was trained every two years in client rights as specified in Minnesota Statutes, section 253B.03 (personnel files numbered 4, 7, 11, and 12); and b. The file did not contain documentation that of a minimum of 12 hours of training in co-occurring disorders (personnel file numbered 13). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraphs (b) and (e). Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure and document that staff development is complete and meets all applicable requirements 23. Violation: Five of eleven personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. The file contained an application for employment that was not signed by the staff member (personnel file numbered 10); and b. Written annual reviews were not completed in the required timelines: 1) Completed November 17, 2022 and due end of October, 2022 (personnel file numbered 1); 2) Completed November 3, 2021 and due end of October, 2021 (personnel file numbered 7); 3) Completed November 8, 2021 and due end of October, 2021 (personnel file numbered 11); and 4) Completed November 4, 2021 and due end of October 2021 (personnel file numbered 12). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. 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: Molly.Lang@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Molly Lang Licensing Division PO Box 64242 St. Paul, MN 55164-0242 RECOMMENDATION The following recommendation is provided to call your attention to an area where your facility is in minimum compliance with the requirements of statutes or laws, but it would be advisable to strengthen your efforts in these areas: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b) requires a license holder to have a policy and procedure that identifies how the program will track and record client attendance at treatment activities, including the date, duration, and nature of each treatment service provided to the client. During the licensing review, group sign-in sheets that were used to track client attendance identified that clients routinely went in and out of groups, including groups identified as counseling groups. This practice resulted in not ensuring that counseling groups did not exceed 16 clients. It is recommended that the license holder consider how having clients continuously enter and exit counseling groups allows for therapeutic programming and that the attendance policy and procedure be revised to address instances wherein clients are not able to attend groups for the full duration. Failure to follow this recommendation will not result in a fine or action against your license at this time. However, should failure to follow this recommendation 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. 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 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 651-431-6611. Sincerely, Kristi Strang, Substance Use Disorder Unit Supervisor Licensing Division Office of Inspector General
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