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06/13/2023 Molly Corene Pena, Authorized Agent Refractions LLC 22575 43rd Ave N Saint Augusta, MN 56301 License Number: 1097727 (IRTS/RCS) Program Location: 22575 43rd Ave N, Saint Augusta, MN 56301 CORRECTION ORDER Dear Molly Corene Pena: On 04/26/2023, 04/27/2023 and 04/28/2023, the Department of Human Services (DHS) conducted a licensing review at Refractions LLC. DHS requires you to take the corrective action described below. Details of our findings, next steps, and your options are explained below. Standards reviewed The licensing review determined compliance with the provisions governing intensive residential treatment services and residential crisis stabilization services under Minnesota Statutes, chapter 245I. Licensing violations DHS determined that your program failed to follow the standard(s) described below. Physical Plant 1. Violation: The license holder's postings did not meet the following requirements: a. The grievance procedure was not posted in a place visible to clients Citation: Minnesota Statutes, section 245I.12, subdivision 5, paragraph (c) Corrective Action Required: This violation was corrected during the on-site licensing review. No additional action is required. Policies and Procedures 2. Violation: The license holder's grievance policy did not meet requirements in the following ways: a. Current contact information for the following entities was not included: 1. The Office of Health Facilities Complaints; and 2. All applicable health-related licensing boards. Citation: Minnesota Statutes, section 245I.12, subdivision 5, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. Submit a revised policy within 30 days of receipt of this order. 3. Violation: The license holder's personnel policies did not include the following requirements: a. Policies prohibiting staff from sexual contact with a client; and b. Policies prohibiting staff from neglecting, abusing, or maltreating a client. Citation: Minnesota Statutes, section 245I.03, subdivision 8, clauses (4) and (3) Corrective Action Required: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy that demonstrates compliance. 4. Violation: The license holder's training plan did not include a description of how the license holder will: a. Verifying and documenting previous training. Citation: Minnesota Statutes, section 245I.05, subdivision 1, clause (3) Corrective Action Required: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised plan that demonstrates compliance. 5. Violation: The license holder's data privacy procedures did not include the following required components: a. Procedures for staff to promptly document a client's revocation of consent to disclose the client's health record; and b. Procedure to verify that the license holder has permission to disclose a client's health record before releasing any client data. Citation: Minnesota Statutes, section 245I.03, subdivision 10, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a procedure that demonstrates compliance. Program Practices 6. Violation: The license holder did not have documentation of treatment team members participating in a team meeting or ancillary meeting for the following week(s) sampled: · January 30, 2023, 2 of 11 staff did not attend; and · March 27, 2023, 3 of 15 staff did not attend. Citation: Minnesota Statutes, section 245I.23, subdivision 14, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. Client Records 7. Violation: 1 of 3 client files reviewed for the immediate needs assessment did not meet requirements in the following ways: a. The assessment was not completed within 12 hours of the client's admission (C5). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 8. Violation: 1 of 3 client files reviewed for the initial treatment plan did not meet requirements in the following ways: a. The plan was not completed within 24 hours of admission (C5). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. 9. Violation: 2 of 2 client files reviewed did not meet substance use assessment requirements: a. The substance use assessment did not include the following: 1. Assessment of the effects of substance use on the client's relationship with family members (C3 and C6); and 2. Assessment of the effects of substance use on the client's relationship with others (C3 and C6). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (h) Corrective Action Required: Correct immediately and maintain compliance. 10. Violation: 1 of 3 client files reviewed did not meet requirements for required treatment services in the following ways: a. For a client receiving Intensive Residential Treatment Services (IRTS), the license holder failed to provide: 1. Crisis prevention planning to assist clients including: i. Identifying and addressing patterns in the client's history and experience of mental health (C5); and ii. De-escalation strategies that have been effective in the past (C5). Citation: Minnesota Statutes, section 245I.23, subdivision 4, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. 11. Violation: 1 of 2 client files reviewed did not meet discharge requirements in the following ways: a. The client was not provided a copy of the discharge summary (C6). Citation: Minnesota Statutes, section 245I.23, subdivision 18, paragraph (c) Corrective Action Required: Correct immediately and maintain compliance. 12. Violation: 3 of 3 client files reviewed did not meet the following individual treatment plan (ITP) requirements: a. The ITP did not include the following: 1. A schedule for accomplishing goals and objectives (C3, C5 and C6). b. The ITP did not document the reason that the license holder did not involve the client's family or other natural supports (C5). Citation: Minnesota Statutes, section 245I.10, subdivision 8, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 13. Violation: 1 of 1 client files reviewed did not meet requirements for the license holder assisting with the safekeeping of funds or other property: a. The receipt and disbursement of the funds or other property was not immediately documented at the time of receipt or disbursement (C5). Citation: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c) Corrective Action Required: Correct immediately and maintain compliance. Staff Records 14. Violation: 4 of 4 personnel files reviewed for requirements governing documentation of training did not include the following: a. Name and credentials of the trainer (SP1, SP2, SP3 and SP4); and b. Method of evaluating the trainee's competency upon completion of training (SP1, SP2, SP3 and SP4). Citation: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 15. Violation: 2 of 2 personnel files reviewed for requirements governing initial training did not meet requirements in the following ways: a. The following trainings were not completed prior to providing direct contact services to clients: 1. Professional boundaries (SP1). b. For staff identified as needing additional trainings before providing direct contact services, training did not include the following: 1. Staff did not receive at least 30 hours of training in specific areas (SP1). c. The following trainings were not completed within 90 days of first providing direct contact services to an adult client: 1. Person-centered individual treatment plans (SP1 and SP4); and 2. Culturally responsive treatment practice (SP1 and SP4). Citation: Minnesota Statutes, section 245I.05, subdivision 3, paragraphs (c), (d) and (b) Corrective Action Required: Correct immediately and maintain compliance. Written response required If you fail to correct the violation(s) within the time limits identified above, DHS may impose a fine or take an action on your license. If requested above, send your written response and any supporting documentation to your licensor electronically or at the address below: Commissioner, Department of Human Services ATTN: Susan Schill-Grotte 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 • Identify what is inaccurate or incomplete about the information in this 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: Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit P.O. Box 64953 Saint 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. 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 bring it to: Commissioner, Department of Human Services Office of Inspector General, Legal Counsel’s Office - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. 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 651-431-6604 or at Susan.Schill-Grotte@state.mn.us. Sincerely, Susan Schill-Grotte, Licensor Licensing Division Office of Inspector General
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