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July 18, 2023 Emily Peach, Authorized Agent Oakridge Treatment Center, LLC 550 Main Street, Suite 230 New Brighton, MN 55112 License Number: 1082638 Report Numbers: 202206992 and 202207782
Dear Emily Peach: On May 10, 2023, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on April 18, 2023. You requested reconsideration of: citation 1, paragraph b, clause 2; citation 1, paragraph c; citation 4, paragraph a; citation 5; and citation 7, paragraph a. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 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. 1) The files documented the clients received less than 30 hours of services: (i) 26 hours the week ending October 16, 2022 (client file numbered 1); (ii) 27.25 hours the week ending in 1/08/2023 (client file numbered 2); and 2) Documentation of services did not accurately identify the duration of services (client files numbered 1 and 2). The license holder identified that the amount of services provided did not reflect breaks, which occurred between each group and during groups that were two hours or longer; b. The license holder did not meet requirements for programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (5): 1) Co-occurring counseling staff completed the required 8 hours of co-occurring disorder training; however, the training was completed late for calendar year 2021 (personnel file numbered 2); and 2) The client files did not contain documentation that the clients received Diagnostic Assessments within ten days of admission (client files numbered 1 through 3). c. Documentation of services did not identify the nature of the service (client file numbered 2). The file contained documentation for New Year’s group on 1/02/2023, Sunday group on 1/08/2023, and Saturday group on 1/21/2023, which were not consistent with the program’s treatment services description or with the treatment services defined in Minnesota Statutes, section 245G.07, subdivisions 1 and 2. Request for Reconsideration. You challenged only paragraph b, clause 2, and paragraph c of the citation. You submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), At the time of application for licensure or renewal of a license under this chapter, the applicant or license holder must acknowledge on the form provided by the commissioner if the applicant or license holder elects to receive any public funding reimbursement from the commissioner for services provided under the license that: (1) the applicant's or license holder's compliance with the provider enrollment agreement or registration requirements for receipt of public funding may be monitored by the commissioner as part of a licensing investigation or licensing inspection; and (2) noncompliance with the provider enrollment agreement or registration requirements for receipt of public funding that is identified through a licensing investigation or licensing inspection, or noncompliance with a licensing requirement that is a basis of enrollment for reimbursement for a service, may result in the actions listed in the statute, including a correction order. Pursuant to Minnesota Statutes, section 245A.191, when a substance use disorder treatment provider licensed under this chapter, and governed by the standards of chapter 245G or Minnesota Rules, parts 2960.0430 to 2960.0490, agrees to meet the applicable requirements under section 254B.05, subdivision 5, to be eligible for enhanced funding from the behavioral health fund, the applicable requirements under section 254B.05 are also licensing requirements that may be monitored for compliance through licensing investigations and licensing inspections. Noncompliance with the identified requirements may result in the actions listed in the statute, including a correction order. With regard to paragraph b, clause 2, you indicate that all clients received Diagnostic Assessments during their stay. You acknowledge that the client in file #2 received the Assessment three days late, but you indicate the clients in files #1 and #3 received their Assessments within 10 days of their admission. You indicate you submitted Diagnostic Assessments for the three clients. However, you acknowledge the Diagnostic Assessment for client file #2 was late. Also, during the licensing review, licensors were unable to locate Diagnostic Assessments in the client files. Although you submitted documents titled “Therapist Initial Visit Note” during the licensing visit and with the reconsideration request, the forms do not meet requirements of Diagnostic Assessments. There is therefore sufficient evidence to support the citation, and it is affirmed. With regard to paragraph c, the information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation as to paragraph c. Citation 4: Violation: The license holder failed to protect client records against unauthorized disclosure in compliance with Code of Federal Regulations, title 42, chapter 1, part 2, sections 2.1-2.67: a. The license holder allowed individuals who were not staff members of the program to access client records without written client consent. During the licensing review, it was identified that the license holder’s practice was to allow communication with other treatment programs without clients’ consent, including allowing individuals from outside of the licensed program to access records in the electronic record system as needed; and b. A client file (client file numbered 2) contained a Release of Information form which did not include: 1) How much and what kind of information was to be disclosed; and 2) The purpose of the disclosure. Request for Reconsideration. You challenged only paragraph a of the citation. You indicated the citation was issued in error because the program follows all requirements related to protected health information. You indicate that although information from a previous treatment stay at another treatment center location was visible to clinical staff at Oakridge, the information could be exchanged without patient consent with administrative personnel who needed to know the information in connection with their duties.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a), a license holder must maintain a file of current and accurate client records on the premises where the treatment service is provided or coordinated. For services provided off site, client records must be available at the program and adhere to the same clinical and administrative policies and procedures as services provided on site. The content and format of client records must be uniform and entries in each record must be signed and dated by the staff member making the entry. Client records must be protected against loss, tampering, or unauthorized disclosure according to section 254A.09, chapter 13, and Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67, and title 45, parts 160 to 164.. Client file #2 contained a document with multiple progress note entries by different individuals, including two notes entered after the client was discharged from your program, and the last two entries were entered by individuals who were not staff at your program. Those entries were notes related to another substance use disorder treatment program to which the client had been transferred on the day of discharge, and the individuals who made the entries had access to all information on the document. The document was disclosed without the client’s consent. Also, during the licensing review, staff at your program demonstrated the ability to access electronic health records of another substance use disorder treatment program, and the license holder indicated it was the program’s process to allow staff employed by one substance use disorder treatment program to access electronic health records of clients in any of the other substance use disorder treatment programs overseen by the same company. The Code of Federal Regulations, title 42, subpart A, section 2.2, imposes restrictions upon the disclosure and use of any substance use disorder patient records which are maintained in connection with the performance of any part 2 program. Both your program and the other substance use disorder treatment program meet the definition for a part 2 program under the Code of Federal Regulations, title 42, subpart B, section 2.11. Although the Code of Federal Regulations, subpart B, section 2.12 (c), lists exceptions to the restrictions on disclosure, the exceptions you referenced do not apply. The exception for communication within a part 2 program does apply because each program is a separate part 2 program, and communication is between two part 2 programs rather than within one part 2 program. The exception for communication between a part 2 program and an entity that has direct administrative control over the program does not apply because one part 2 program does not have administrative control over another. Finally, there is no exception for exchanging information between programs when a substance use disorder program is a component of a larger behavioral health program or a general health program. There is therefore sufficient evidence to support the violation stated in paragraph a, and it is affirmed. Citation 5: Violation: The Program Description stated the program had two distinct levels of care: the MICD track, with a minimum of 30 hours of programming per week, and the MICD Extended Care track, with a minimum of 15 hours per week. The policy stated “The program components an individual will participate in will be dependent upon the specific track of treatment they are entering. The program schedule will reflect the specific components the individual will be recommended to participate in.” In addition, the Program Schedule policy stated the facility will maintain schedules for services provided in order to provide information relating to program services for each level of care. However, the facility had one treatment schedule only, which did not reflect the services provided for each level of care. Request for Reconsideration. You submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.12, a license holder must develop a written policies and procedures manual, indexed according to section 245A.04, subdivision 14, paragraph (c), that provides staff members immediate access to all policies and procedures and provides a client and other authorized parties access to all policies and procedures. The manual must contain the thirteen materials specified in the statute. Information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation. It is recommended that the program’s policy reflect that the program is individualizing the schedule per client. Citation 7: Violation: Two of two client files reviewed for requirements governing comprehensive assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: a. A description of the circumstances on the day of service initiation (client file numbered 2); b. The absence or presence of previous withdrawal symptoms for each substance used in the previous 30 days (client files numbered 1 and 2); c. Whether or not physical concerns need to be referred to an appropriate health care professional (client file numbered 2); d. The effects of the client’s mental health on ability to function (client file numbered 2); and e. The client’s cultural background (client file numbered 2). Request for Reconsideration. You challenged only paragraph a of the citation. You submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a), a comprehensive assessment of the client's substance use disorder must be administered face-to-face by an alcohol and drug counselor within three calendar days from the day of service initiation for a residential program or within three calendar days on which a treatment session has been provided of the day of service initiation for a client in a nonresidential program. If the comprehensive assessment is not completed within the required time frame, the person-centered reason for the delay and the planned completion date must be documented in the client's file. The comprehensive assessment is complete upon a qualified staff member's dated signature. If the client received a comprehensive assessment that authorized the treatment service, an alcohol and drug counselor may use the comprehensive assessment for requirements of this subdivision but must document a review of the comprehensive assessment and update the comprehensive assessment as clinically necessary to ensure compliance with this subdivision within applicable timelines. The comprehensive assessment must include sufficient information to complete the assessment summary according to subdivision 2 and the individual treatment plan according to section 245G.06. The comprehensive assessment must include information about the client's needs that relate to substance use and personal strengths that support recovery, including seventeen listed items. Information submitted with the reconsideration request shows the license holder was in compliance with the requirements with regard to paragraph a. As a result, it is appropriate to rescind the citation with regard to paragraph a.
Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support citation 1 as to paragraph b, clause 2, and citation 4 as to paragraph a, and they are affirmed. The Commissioner finds it is appropriate to rescind the following: citation 1 as to paragraph c; , citation 5; and citation 7, paragraph a. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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