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June 6, 2023 Cathleen Harvieau, Authorized Agent Care Crossings 5901 Omaha Ave N, Suite 110 Oak Park Heights, MN 55082 License Number: 1102300 CORRECTION ORDER Dear Cathleen: On April 11, 12, and 13, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 5901 Omaha Ave N, Suite 110, Oak Park Heights, MN 55082. As a result of this visit, DHS determined that you are in violation of 15 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. Policies, Practices, and Procedures 1. Violation: The license holder did not have the updated telephone number for the Board of Behavioral Health and Therapy in their grievance procedure. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, paragraph (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedures meets all applicable requirements. 2. Violation: The license holder did not have documentation of a plan for transfer of client records on file and subsequently, did not sign the plan annually as required. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure plans for transfer of client’s records meet all applicable requirements. Within 30 days of receipt of this order, submit a signed agreement with another provider that has agreed to accept and maintain the programs closed case records and provide follow up services as necessary. Client Files 3. Violation: Four of four client files reviewed for requirements governing client’s rights protection (client files numbered 1, 2, 4, and 5) did not document that the staff reviewed the client’s rights and responsibilities on the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clients’ receive orientation to their rights and meet all applicable requirements. 4. Violation: Four of four client files reviewed for requirements governing reporting of maltreatment of vulnerable adults (client files numbered 1, 2, 4, and 5) did not seek consent to the disclosure of suspected maltreatment from the client upon admission. Statute Violated: Minnesota Statutes, section 626.557, subdivision 3a, paragraph (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that reporting of maltreatment of vulnerable adults meet all applicable requirements. 5. Violation: Four of four client files reviewed for requirements governing initial services plan (ISP) (client files numbered 1, 2, 4, and 5) did not meet requirements in the following ways: a. The ISP was not person-centered and client specific; and b. The ISP did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3, paragraph (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. 6. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The assessment was not completed within three calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 5); b. The assessment was not signed and dated by a qualified staff member (client files numbered 4 and 5); c. The assessment that authorized the treatment service was not reviewed and updated as necessary by an alcohol and drug counselor to ensure compliance of the assessment (client file numbered 1); d. The assessment did not include information about the client’s sex, cultural background, sexual orientation, living situation, economic status, and level of education (client file numbered 1); e. The assessment did not describe the circumstances on the day of service initiation (client files numbered 1, 4, and 5); f. The assessment did not list previous attempts at treatment for compulsive gambling (client file numbered 1); g. The assessment did not list previous attempts at treatment for mental illness (client file numbered 1); h. The assessment did not list amounts used for the substance’s marijuana, cocaine, and hallucinogens listed in use history (client file numbered 4); i. The assessment did not list frequency and duration of use for hallucinogens (client file numbered 4); j. The assessment did not document any periods of abstinence (client file numbered 1); k. The assessment did not include circumstances of relapse, if any (client file numbered 1); l. The assessment did not address the absence or presence of previous withdrawal symptoms (client files numbered 1, 4, and 5); m. The assessment did not document the client’s desire for family involvement in the treatment program and the level of family support (client file numbered 1); n. The mental health history did not include symptoms and the effect on the client’s ability to function (client files numbered 4 and 5); o. The assessment did not include information about a mental health screening tool approved by the commissioner (client files numbered 1, 4, and 5); p. The assessment did not include a description of how use affected the client’s ability to function appropriately in an educational setting (client files numbered 1, 4, and 5); q. The assessment did not include a description of any risk-taking behavior, including behavior that puts the client at risk of exposure to blood-borne or sexually transmitted diseases (client file numbered 1); r. The assessment did not include a social network in relation to expected support for recovery (client files numbered 1 and 5); s. The assessment did not include leisure time activities that have been associated with substance use (client files numbered 1 and 4); and t. The assessment did not document whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client files numbered 1 and 4). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1, paragraph (a), and 245G.09, subdivision 3, paragraph (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 7. Violation: Three of three client files reviewed for requirements governing comprehensive assessments summaries did not meet requirements in the following ways: a. The summaries were not completed within three calendar days on which a treatment session had been provided from the day of service initiation (client files numbered 1, 4, and 5); b. The summaries did not have a risk description for each dimension (client files numbered 4 and 5); c. The summaries did not include a narrative summary supporting the risk descriptions (client files numbered 1, 4, and 5); d. The summary did not include a determination of whether the client has a substance use disorder (client file numbered 5); and e. The assessment summaries did not contain information relevant to treatment service planning in the dimensions (client files numbered 1, 4, and 5). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 2, paragraphs (a), (b), and (c), and 245G.09, subdivision 3, paragraph (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessment summaries meet all applicable requirements. 8. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITPs were not signed by the client (client files numbered 2, 4, and 5); b. The ITPs did not document the client’s involvement in the development of the plan (client files numbered 1, 2, 4, and 5); c. The ITP did not prioritize the client’s needs and focus according to each issue addressed in the assessment summary (client file numbered 5); d. The ITPs did not include the amount, frequency, and anticipated duration of the treatment service (client files numbered 2, 4, and 5); and e. The ITP did not include resources to refer the client to when needs are to be addressed concurrently by another provider; client stated he was interested in seeing a mental health therapist (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2, and 245G.09, subdivision 3, paragraph (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all application requirements. 9. Violation: Four of five client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Documentation did not include the client’s response to each treatment service (client files numbered 1, 4, and 5); b. Documentation was not completed within seven days of providing the treatment service (client files numbered1, 2, 4, and 5); and c. Each entry did not include the staff members job title or position of the staff making the entry (client files 2 and 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 10. Violation: Four of four client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. Treatment plan reviews were not documented for weeks: 1) 3/6/23-3/12/23, 3/13/23-3/19/23, 3/20/23-3/26/23, 3/27/23-4/2/23 (client file numbered 1); 2) 2/6/23-2/12/23, 3/20/23-3/26/23, 3/27/23-4/2/23 (client file numbered 2); 3) 2/27/23-3/5/23 (client file numbered 4); and 4) 1/1/23-2/5/23, 2/6/23-2/12/23, 2/13/23-2/19/23, 2/20/23-2/26/23, 2/27/23-3/5/23, 3/6/23-3/12/23, 3/13/23-3/19/23, 3/20/23-3/26/23, 3/27/23-4/2/23 (client file numbered 5); and b. Treatment plan reviews did not specify the span of time covered by the reviews (client files numbered 1, 2, and 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 11. Violation: One client file reviewed for requirements governing discharge summaries (client file numbered 3) did not contain a completed discharge summary within 5 days of the client’s service termination. The discharge summary listed the admission date for date of completion. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. Personnel Files 12. Violation: One personnel file reviewed for requirements governing qualifications for persons providing treatment services did not meet requirements. The supervising licensed alcohol and drug counselor did not document the amount and type of supervision provided on a weekly basis for an individual with a temporary permit (personnel file numbered 4). Statute Violated: Minnesota Statutes, section 245G.11, subdivisions 6 and 11. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure qualifications for persons providing treatment services meet all applicable requirements. 13. Violation: Three of three personnel files reviewed for requirements governing orientation (personnel files numbered 2, 3, and 4) did not include documentation that internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was reviewed. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. 14. Violation: Two of two personnel file reviewed for requirements governing annual and additional training did not meet requirements in the following ways: a. Annual training was not completed in 2023 (personnel file numbered 1): 1) Mandatory reporting requirements in 245A.65, 626.557, and 626.5572; 2) Program abuse prevention plan; 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; 4) Facilities polices for obtaining client releases of information; 5) Reporting of maltreatment of minors; 6) Reporting of prenatal exposure to controlled substances; and 7) HIV minimum standards; and b. Twelve hours of training in co-occurring disorders was not completed within six months of employment (personnel file numbered 4). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure annual training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the trainings identified above as not completed in 2023 and the 12 hours of training in co-occurring disorders have now been completed for the corresponding staff persons. 15. Violation: Four of four personnel files reviewed for requirements governing personnel file contents did not meet requirements. Documentation did not include: a. The applicant’s background study data, according to chapter 245C (personnel files numbered 2, 3, and 4); b. Employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel files numbered 1 and 4); and c. A written annual review of the employee’s job performance in 2023 (personnel file numbered 1). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel file contents meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of an inquiry to the staff member’s former employers regarding substantiated sexual contact with a client and a completed 2023 annual review of the employee’s job performance for the corresponding staff persons. 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Substance Use Disorder treatment 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 651-431-6611. Sincerely, Kristi Strang, SUD Unit Supervisor Licensing Division Office of Inspector General
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