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07/27/2023 Laura Kahler Loftness, Authorized Agent Transitions on Broadway 6120 EARLE BROWN DR STE 100 Brooklyn Center, MN 55430-4100 License Number: 1078061 (IRTS/RCS) Program Location: 3776 W BROADWAY AVE, Robbinsdale, MN 55422-2336 CORRECTION ORDER Dear Laura Kahler Loftness: On 05/22/2023, 05/23/2023 and 05/24/2023, the Department of Human Services (DHS) conducted a licensing review at Transitions on Broadway. 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. Policies and Procedures 1. Violation: The license holder's discharge policy did not identify the required criteria for the following types of discharge: a. Non-program initiated discharge: 1. A source of payment for services is no longer available. Citation: Minnesota Statutes, section 245I.23, subdivision 18, paragraph (d) Corrective Action Required: Correct immediately and maintain compliance. Submit a revised policy within 30 days of receipt of this order. 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. 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. Program Practices 3. Violation: The license holder did not have documentation of treatment team members participating in a team meeting or ancillary meeting for: • For the following weeks(s) sampled December 14, 2022 1 of 18 staff did not attend; February 15, 2023 1 of 15 staff did not attend; April 26, 2023 2 of 18 staff did not attend Citation: Minnesota Statutes, section 245I.23, subdivision 14, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 4. Violation: The license holder did not meet critical incident reporting requirements: a. The critical incident was not reported to the Commissioner within 10 days • For incident(s) dated February 28, 2023; March 9, 2023; March 14, 2023; April 10, 2023; Citation: Minnesota Statutes, section 245I.13 Corrective Action Required: Correct immediately and maintain compliance. 5. Violation: The license holder's response to grievances reviewed did not meet requirements in the following ways: a. The response to the grievance did not include the date of the response. A total of 2 grievances were reviewed. Citation: Minnesota Statutes, section 245I.12, subdivision 5, paragraph (c) Corrective Action Required: Correct immediately and maintain compliance. Client Records 6. 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 (C1). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 7. Violation: 2 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 (C1); b. The plan was not based on the client's referral information (C1); and c. The plan was not based on the client's immediate needs assessment (C3). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. 8. Violation: 3 of 3 client files reviewed did not meet level of care assessment requirements in the following ways: a. The assessment was not completed within five days of admission (C3); b. The assessment was not updated within 60 days of admission (C1); and c. The assessment was not signed and dated by the person completing the assessment, including the staff person's credentials (C2). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (d); and section 245I.08, subdivision 2, paragraph (3) Corrective Action Required: Correct immediately and maintain compliance. 9. Violation: 4 of 4 client files reviewed did not meet substance use assessment requirements: a. The client file did not include a substance use assessment (C1, C2 and C3); and b. The substance use assessment was not completed within 30 days of admission (C4). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (h) Corrective Action Required: Correct immediately and maintain compliance. 10. Violation: 2 of 3 client files reviewed did not meet requirements for weekly reviews in the following ways: • December 28, 2022 and February 1, 2023 (C1) a. A qualified staff did not review the client's treatment plan (C1); b. A qualified staff did not review the client's individual abuse prevention plan (C1); and c. The treatment plan review was not documented in the client file (C1 and C2) • For week(s) March 1, 2023; March 8, 2023; and March 15, 2023 (C2) • For week(s) December 28, 2022 and February 1, 2023 (C1) Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (i) Corrective Action Required: Correct immediately and maintain compliance. 11. 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 (C1); and ii. De-escalation strategies that have been effective in the past (C1). Citation: Minnesota Statutes, section 245I.23, subdivision 4, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. 12. Violation: 4 of 4 client files reviewed did not meet discharge requirements in the following ways: a. The discharge summary was not completed prior to a program-initiated discharge (C5); b. For a program-initiated discharge, the license holder's discharge review process exceeded five working days (C1 and C5); c. The client was not provided a copy of the discharge summary (C2); d. For a successful discharge, the summary did not contain: 1. The client's response to their treatment plan (C2); and 2. The client's crisis plan (C2). e. For a program-initiated discharge, the license holder failed to: 1. Consult with the client's family and other natural supports prior to a program-initiated discharge (C5); 2. Consult with the client's case manager prior to a program-initiated discharge (C1 and C5); 3. Review the issues involved in the program's decision to discharge the client from the program (C1 and C5); 4. Determine whether the license holder, treatment team and any interested party can develop additional strategies to resolve the issues leading to the client's discharge (C1 and C5); and 5. Allow the client to have the opportunity to continue receiving services from the license holder (C1). f. For a program-initiated discharge, the summary did not contain: 1. Alternatives to discharge that the license holder considered or attempted (C1, C4 and C5); 2. The names of the individuals involved in the decision to discharge the client (C1 and C4); 3. A description of each individual's involvement in the decision to discharge the client (C1, C4 and C5); and 4. The recommended actions, supports and services that will assist the client with a successful transition to another setting (C1 and C5). Citation: Minnesota Statutes, section 245I.23, subdivision 18, paragraphs (h), (g) and (c) Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit one successful, one non-program initiated, and one program initiated discharge summary that demonstrates compliance. 13. Violation: 1 of 3 client files reviewed did not meet requirements for daily documentation in the following ways: a. The daily summary did not include: 1. Observations about the client's behaviors (C1); and 2. Observations about the client's symptoms (C1). Citation: Minnesota Statutes, section 245I.23, subdivision 12, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 14. Violation: 1 of 3 client files reviewed did not meet orientation requirements. The record did not contain documentation indicating the client was given information on: a. Client right (C1); and b. Grievance policy (C1). Citation: Minnesota Statutes, section 245I.12, subdivision 3 and subdivision 5, paragraph (b) Corrective Action Required: Correct immediately and maintain compliance. 15. Violation: 1 of 2 client files reviewed did not meet requirements for a standard diagnostic assessment (DA): a. The diagnostic assessment was not completed within 10 days of admission (C1) Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (e) Corrective Action Required: Correct immediately and maintain compliance. 16. Violation: 3 of 3 client files reviewed did not meet the following functional assessment requirements: a. The client file did not contain a functional assessment (C1); and b. The functional assessment was not completed within 30 days of admission (C2 and C3) Citation: Minnesota Statutes, section 245I.10, subdivision 9, clause (4); and section 245I.23, subdivision 7, paragraph (g) Corrective Action Required: Correct immediately and maintain compliance. 17. Violation: 3 of 3 client files reviewed did not meet the following individual treatment plan (ITP) requirements: a. The individual treatment plan was not completed within 10 days of admission (C1 and C3) b. The ITP was not based on the client's diagnostic assessment and baseline measurements (C1); c. The individual treatment plan was not updated within 40 days of admission (C1 and C2) d. The individual treatment plan was not updated when significant changes occurred (C1) e. The ITP did not include the following: 1. Measureable treatment objectives (C1, C2 and C3); 2. A schedule for accomplishing goals and objectives (C2); 3. Treatment strategies (C1, C2 and C3); 4. Strategies to engage the client if they have a history of not engaging in treatment (C1); 5. Referrals and resources for the client's health and safety (C1) 6. The staff persons responsible for following up with referrals and resources (C1) 7. The reason the license holder did not make a referral when one was identified (C1) f. The ITP did not document the reason that the license holder did not involve the client's family or other natural supports (C1 and C3). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (f); and section 245I.10, subdivision 8, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit individual treatment plans, for two recipients that demonstrates compliance. 18. Violation: 1 of 3 client files reviewed for medication administration did not meet requirements. The license holder did not: a. Document the following: 1. Concerns about the client’s medications (C1); 2. Medication errors (C1); and 3. Medication omissions (C1). Citation: Minnesota Statutes, section 245I.11, subdivision 5, clauses (2), (5) and (4) Corrective Action Required: Correct immediately and maintain compliance. 19. Violation: 1 of 3 client files reviewed did not meet progress note requirements. The progress note did not include: a. Documentation of the scope of service, incuding the following required components: 1. The targeted goal (C1); 2. The intervention the staff provided (C1); and 3. The staff person's plans for making changes to treatment if the intervention was ineffective (C1). b. Documentation of significant observations by staff, including the the following required components: 1. Emergency interventions by staff (C1); 2. Consultations with other professionals (C1); and 3. Referrals to other professionals (C1). Citation: Minnesota Statutes, section 245I.08, subdivision 4 Corrective Action Required: Correct immediately and maintain compliance. 20. 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 (C2). Citation: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c) Corrective Action Required: Correct immediately and maintain compliance. 21. Violation: 1 of 3 client files reviewed did not meet client orientation requirements: a. The client was not oriented to the program abuse prevention plan (PAPP) (C1); b. The client's orientation to the PAPP was not completed within the required time frame (C1); and c. The client was not oriented to Vulnerable Adult reporting with 72 hours of providing direct contact services (C1). Citation: Minnesota Statutes, section 245A.65, subdivision 3 Corrective Action Required: Correct immediately and maintain compliance. 22. Violation: 2 of 3 client files reviewed did not meet individual abuse prevention plan (IAPP) requirements: a. The client file of a vulnerable adult did not contain an IAPP (C2); b. The IAPP was not completed as part of the initial treatment plan (C1); c. The IAPP was not reviewed by the treatment team weekly (C1); and d. The IAPP was not revised as needed (C1). Citation: Minnesota Statutes, section 245A.65, subdivision 2; and section 245I.23, subdivision 7, paragraph (c) Corrective Action Required: Correct immediately and maintain compliance. Staff Records 23. Violation: 3 of 4 personnel files reviewed for requirements governing file content did not meet requirements. The file did not contain the following: a. Verification of the staff person's qualifications (SP2 and SP3); and b. Date staff person began having direct contact with clients (SP2, SP3 and SP4). Citation: Minnesota Statutes, section 245I.07, subdivision (a) Corrective Action Required: Correct immediately and maintain compliance. 24. Violation: 3 of 4 personnel files reviewed for requirements governing documentation of training did not include the following: a. Name and credentials of the trainer (SP2, SP3 and SP4); and b. Length of training in hours and minutes (SP2, SP3 and SP4). Citation: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 25. Violation: 1 of 4 personnel files reviewed for requirements governing treatment supervision plans did not meet requirements in the following ways: a. The treatment supervision plan was not developed within 30 days of the staff person's first day of employment (SP3). Citation: Minnesota Statutes, section 245I.06, subdivision 2, paragraph (a) Corrective Action Required: Correct immediately and maintain compliance. 26. Violation: 1 of 3 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. Emergency procedures including fire and inclement weather (SP3); 2. Emergency procedures including reporting missing persons (SP3); 3. Emergency procedures including behavioral emergencies (SP3); 4. Emergency procedures including medical emergencies (SP3); and 5. License holder's policy and procedures (SP3). 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 (SP3); and 2. Mental health de-escalation techniques (SP3). Citation: Minnesota Statutes, section 245I.05, subdivision 3, paragraphs (b) and (c) Corrective Action Required: Correct immediately and maintain compliance. 27. Violation: For 1 of 2 personnel files reviewed, the individual's background study was not affiliated under the correct roster (SP3). The background study was initiated under license number 1090406, however, staff began direct contact on 11/24/2022 and the staff person was not affiliated to the roster for 1078061 (SP3) Citation: Minnesota Statutes, section 245C.07, paragraph (a) 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 at: Commissioner, Department of Human Services ATTN: Tina Christensen 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 651-431-6610 or at Tina.Christensen@state.mn.us. Sincerely, Tina Christensen, Licensor Licensing Division Office of Inspector General
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