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June 7, 2023 Beth Krehbiel, Authorized Agent Zumbro Valley Health Center Connections and Referral Unit 343 Wood Lake Dr SE Rochester, MN 55904 License Number 802787 CORRECTION ORDER Dear Beth: On March 29 through 31, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 343 Wood Lake Dr SE. As a result of this visit, DHS determined that you are in violation of sixteen of the detoxification program 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. 1. Violation: Standards governing the emergency use of seclusion did not meet requirements in the following ways: a. Seclusion rooms were not equipped in a manner that prevents clients from self-harm using hard objects; and b. Eight of eight client files reviewed for seclusion did not meet requirements in the following ways: 1) The client record did not include a description of the specific client behavior precipitating a decision to use seclusion including date, time and program staff present (client files numbered 7, 8, and 10); 2) Specific means used to limit the client’s behavior was not identified (client file numbered 10); 3) The client file did not contain documentation of reassessment of the client at least every 15 minutes to determine if seclusion could be terminated; rather, the assessments were completed hourly (client files numbered 1 and 7 through 13); 4) There was no description of the physical hold used to escort the client to seclusion (client file numbered 10); 5) Seclusion procedures did not end when the client was no longer dangerous (client files numbered 1 and 7 through 13); 6) Seclusion was used: i. For disciplinary purposes (client files numbered 1, 7 through 10, 12, and 13); ii. To enforce program rules (client files numbered 1, 7, 9 and 13); iii. For the convenience of staff (client files numbered 1, 7, and 9 through 13); and iv. As a part of the health monitoring plan (client files numbered 7, 9, 10, and 13); 7) The client’s health concerns were not considered in deciding whether to use seclusion (client files numbered 1, 7, 12 and 13); 8) Seclusion was used when less restrictive measures could have been effective and feasible (client files numbered 1 and 7 through 13); 9) Seclusion was employed for reasons other than the purpose of preventing a client from harming themselves or others (client files numbered 7, 8, 10, 11, and 13); 10) Clients were placed in seclusion for longer than 12 hours at any one time (client files numbered 1, 7, and 9 through 11); 11) Clients in seclusion were not always within hearing range of program staff (client files numbered 1 and 7 through 13); 12) Law enforcement was called to place the client in seclusion when there was no violation of the law (client files numbered 1, 8, 9, and 11 through 13); and 13) The client was not discharged when law enforcement used seclusion as required under Minnesota Rules, part 9530.6525 (client files numbered 1, 7, and 11 through 13). Rule Violated: Minnesota Rules, part 9530.6535, subparts 1, items A and B, 3, items A to D, G, and H, 4, items A, B, D, and E, and , 8, items A and B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that: a. All seclusion facilities are equipped in a manner that prevents clients from self-harm using hard objects; and b. The emergency use of seclusion meets all applicable requirements. Within 30 days of receipt of this order, submit documentation demonstrating that all staff have been trained on the appropriate use of seclusion and a statement of how seclusion rooms are equipped in a manner that prevents clients from self-harm. 2. Violation: Five of five client files reviewed for standards governing the use of physical holds did not meet requirements in the following ways: a. The time that the physical hold began and ended was not documented in the client record (client files numbered 1, 7, and 11 through 13); and b. The names of program staff directly involved in the physical hold were not documented in the client record (client files numbered 1, 7, 12, and 13). Rule Violated: Minnesota Rules, part 9530.6535, subpart 3, items C and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the use of all physical holds meet all applicable requirements. 3. Violation: The administrative review of protective procedures for 2021 to 2023 did not document any patterns or problems indicated by similarities in the time of day, day of the week, duration of the use of a procedure, individuals involved, or other factors associated with the use of protective procedures. Rule Violated: Minnesota Rules, part 9530.6535, subpart 9, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all administrative reviews of the use of protective procedures meet all applicable requirements. 4. Violation: The license holder failed to complete an internal review within the required timeline for a report that was made known to the program on July 16, 2021. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all written policies and procedures related to suspected or alleged maltreatment are established and enforced. 5. Violation: The license holder’s admission and discharge policies and practices did not meet requirements in the following ways: a. The admission policy contains inconsistent information about which staff are authorized to admit and discharge clients, as page numbered 1 states any CRU staff are authorized and page numbered 3 says only a nurse is authorized; b. The program did not follow their own admission policy that outlines program appointed health officers who may designate staff to involuntarily admit a client. Documentation showed that the program director, who does not meet the definition of a health officer and who is not listed as a program appointed health officer, was acting in the capacity of a health officer; c. Clients admitted under a peace and health officer hold were held for longer than 12 hours without being placed on an emergency hold pursuant to Minnesota Statutes, section 253B.051; and d. The discharge and transfer policy does not account for when the 12 hour peace and health officer hold expires and the client has not agreed to voluntarily admit and the program’s practice was to continue peace and health officer holds beyond 12 hours without initiating an emergency hold or obtaining a voluntary admit . Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a) and Minnesota Rules, part 9530.6525, subparts 1, 2, item E, and 4, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all admission and discharge requirements are met. Within thirty days of receipt of this order, submit revised policies that meet all applicable requirements and a statement about how the program is communicating with law enforcement and referring agents relating to the program’s admission policies and procedures for peace and health officer hold requirements. 6. Violation: The program failed to document an initial response to the client within 24 hours of the program’s receipt of the grievance as follows: a. May 4, 2021 grievance responded to on May 14, 2021; b. July 18, 2021 grievance responded to on August 16, 2021; c. March 18, 2022 grievance responded to on March 24, 2022; d. Three August 10, 2022 grievances responded to on August 12, 2022; e. August 14, 2022 grievance responded to on August 16, 2022; and f. October 28, 2022 grievance responded to on November 1, 2022. Rule Violated: Minnesota Rules, part 9530.6540, subpart 1, item B. Repeat Violation: In Correction Orders that DHS issued on December 14, 2017 and May 20, 2020, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. Within thirty days of receipt of this order, submit a statement of how the above violation has been corrected. 7. Violation: The license holder did not follow their own policy to inform a registered nurse of problems with medication administration including client refusal of a medication. Rule Violated: Minnesota Rules, part 9530.6555, subpart 1, item B. Repeat Violation: In a Correction Order that DHS issued on May 20, 2020, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration practices meet all applicable requirements. Within thirty days of receipt of this order, submit a documentation demonstrating that all staff have been trained on guidelines regarding when to inform a registered nurse of problems with medication administration. 8. Violation: The program failed to obtain and document the medical director’s annual approval of: a. The Critical Injury policy; and b. The infection control plan (only TB Infection Control policy was signed). Rule Violated: Minnesota Rules, part 9530.6560, subpart 5, items D and F. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all applicable medical supervision requirements are met. Within thirty days of receipt of this order, submit documentation demonstrating how this violation has been corrected. 9. Violation: Seven of seven client files reviewed for requirements governing service initiation did not meet requirements in the following ways: a. The program admitted clients who did not meet admission criteria (client files numbered 1, 5, and 8); b. There was no documentation demonstrating that the client received orientation to the HIV minimum standards within 72 hours of admission to the program (client files numbered 1 and 5); c. There was no documentation demonstrating that the client received orientation to policies and procedures governing maltreatment of vulnerable adults (client files numbered 1 and 5); d. Clients were not oriented to the program abuse prevention plan (client files numbered 1 through 6); e. Consent to the disclosure of suspected maltreatment was not sought as required under Minnesota Statutes, section 626.557, subdivision 3a (client file numbered 3); and f. An incident of suspected maltreatment was reported and consent was not sought again, after being refused upon admission, as required under Minnesota Statutes, section 626.557, subdivision 3a (client file numbered 1). Statute and Rule Violated: Minnesota Statutes, sections 245A.19, paragraphs (b) and (c), 245A.65, subdivisions 1, paragraph (c), 2, paragraph (a), and Minnesota Rules, part 9530.6525, subpart 2. Repeat Violation: In Correction Orders that DHS issued on December 14, 2017 and May 20, 2020, you were previously found in violation of these same statutes and rules. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all service initiation practices meet all applicable requirements. 10. Violation: Six of six client files reviewed for requirements governing individual abuse prevention plans (IAPPs) (client files numbered 1 through 6) did not meet requirements in the following ways: a. There was no individualized assessment of the client’s susceptibility to abuse by other individuals, including other vulnerable adults, and self-abuse; and b. There was no assessment of the client’s risk of abusing other vulnerable adults. The program failed to follow their own policy and the practice was to identify that clients were “unable to participate,” check a box on the template form for “other” and prompt a future review with the client. Statute and Rule Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), 626.557, subdivision 14, paragraph (b), and Minnesota Rules, part 9530.6585, subpart 3, item B. Repeat Violation: In a Correction Order that DHS issued on May 20, 2020, you were previously found in violation of this same statute and rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individualized assessments meet all applicable requirements. Within 30 days of receipt of this order, submit documentation demonstrating that all staff have been retrained on the requirements for IAPPs. 11. Violation: Two of five client files reviewed for health services did not meet requirements in the following ways: a. The follow-up screen was completed but did not contain information relating to behavioral risk factors (client file numbered 6); and b. Monitoring for client health did not occur: 1) At 3:00pm, rather was completed at 3:30pm on June 15, 2021 (client file numbered 1); and 2) At 6:45am on November 4, 2021 (client file numbered 6). Rule Violated: Minnesota Rules, part 9530.6550, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all health services meet all applicable requirements. 12. Violation: Two of four client files reviewed for client services did not: a. Contain a referral recognizing geographical, economic, educational, religious, cultural, and employment status information as factors affecting access to services, as indicated by the chemical use assessment (client file numbered 2); and b. Client education was not provided regarding: 1) Substance use disorder, including the effects of alcohol and other drugs and specific information about the effects of chemical use on unborn children (client file numbered 5); 2) Tuberculosis and reporting known cases of tuberculosis disease to health care authorities according to Minnesota Statutes, section 144.4804 (client file numbered 5); and 3) HIV as required in Minnesota Statutes, section 245A.19, paragraphs (b) and (c) (client files numbered 1 and 5). Rule Violated: Minnesota Rules, part 9530.6530, subparts 3, items A and B, and 4, items B and C. Repeat Violation: In a Correction Order that DHS issued on May 20, 2020, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all client services meet all applicable requirements. 13. Violation: Six of six client files reviewed for documentation of disbursement of the client’s property (client files numbered 1 through 6) did not identify what property was given back to the client upon discharge. 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 all client property management meets all applicable requirements. 14. Violation: Four of five personnel files reviewed for annual job performance evaluations (client files numbered 1 through 3 and 5) contained evaluations that were completed late. Rule Violated: Minnesota Rules, part 9530.6575, item E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personnel files contain annual job performance evaluations that meet all applicable requirements. 15. Violation: The personnel file reviewed for program director qualifications (personnel file numbered 7) demonstrated that the personnel lacked knowledge and understanding of the implications of parts 9530.6510 to 9530.6590 in the following ways: a. At the time of the licensing review, staff person numbered 7 (SP7) stated that “senior staff are present on each shift” when asked how the program designated the responsible staff person pursuant to Minnesota Rules, part 9530.6565, subpart 4; thus, demonstrating a lack of understanding for what a responsible staff person is responsible for; b. SP7 was signing off as a health officer, authorizing 72 hour emergency holds despite not meeting qualifications as a health officer as defined under Minnesota Statutes, section 253B.02, subdivision 9; and c. SP7 was operating under Minnesota Statutes, section 253B.05, which was repealed in 2018. Rule Violated: Minnesota Rules, part 9530.6565, subpart 3, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all staff persons meet all applicable requirements. 16. Violation: Five of five personnel files reviewed for documentation of orientation and annual training did not meet requirements in the following ways: a. The staff person was separated on July 9, 2021 and rehired on August 26, 2021; however, orientation was not provided upon rehire (personnel file numbered 6); b. The staff person was not provided specific training covering the facility’s policies for obtaining client releases of information required by Minnesota Statutes, section 626.557, subdivision 3a (personnel files numbered 1 through 5); and c. The staff person did not receive annual training as follows: 1) Infection control procedures annual training was not timely (personnel files numbered 1 and 2); and 2) HIV minimum standards annual training was not timely (personnel files numbered 1 and 2) Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.65, subdivision 3, Minnesota Rules, parts 9530.6570, subparts 1, item G, 2, items A to G, 3, and 9530.6575, item D. Repeat Violation: In Correction Orders that DHS issued on December 14, 2017 and May 20, 2020, you were previously found in violation of these same statutes and rules. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of staff development meets 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: Maura.McGarry@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Maura McGarry 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 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 Detoxification Program must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, parts 9530.6510 to 9530.6590 (Rule 32). · 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 licensor, Maura McGarry, at 651-431-6671. Sincerely, Kristi Strang, Substance Use Disorder Unit Supervisor Licensing Division Office of Inspector General
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