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August 10, 2023 Sukimo Knight, Authorized Agent Breakthrough 5 County Road B E Little Canada, MN 55117 License Number: 1104734 CORRECTION ORDER Dear Sukimo: On June 12 and 13, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 2147 University Ave W, Suite 106, St. Paul, MN 55114. As a result of this visit, DHS determined that you are in violation of 19 of the provisions governing Substance Use Disorder treatment services under Minnesota Statutes, chapter 245G. 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: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided: a. Adolescent treatment services were not completed by a qualified staff member (client file numbered 2): 1) Four hours on April 12, 2023; 2) One hour on April 13, 2023; 3) Two hours on April 27, 2023; 4) Four hours on May 3, 2023; 5) Four hours on May 10, 2023; 6) Four hours on May 11, 2023; 7) Four hours on May 18, 2023; 8) Three hours on May 26, 2023; 9) Three hours on May 31, 2023; and 10) Four hours on June 1, 2023. Statute Violated: Minnesota Statutes, section 245A.167. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they are billed. Additionally, the noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. Policies, Practices, and Procedures 2. Violation: The license holder’s grievance procedure did not contain the current telephone number for the Board of Behavioral Health and Therapy. 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 procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that demonstrates compliance. 3. Violation: The license holder did not have documentation the program abuse prevention plan was reviewed in calendar year 2021 and 2022 by the governing body or delegate. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program abuse prevention plan reviews meet all applicable requirements. 4. Violation: The license holder did not have documentation the plan for transfer of clients and records upon closure was reviewed in calendar year 2021 and 2022 by a controlling individual. 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 a review of the plans for transfer of clients and records upon closure meets all applicable requirements. Client Files 5. Violation: Three of three client files reviewed for requirements governing client rights protection and client orientation did not meet requirements. No documentation of the following: a. HIV minimum standards (client file numbered 2); b. TB information (client file numbered 2); c. Personal electronic device policy (client files 1, 2, and 3); d. The internal and external reporting policies for maltreatment of vulnerable adults (client files 1 and 3); e. Program abuse prevention plan (client file numbered 2); f. A written statement of the clients’ rights and responsibilities identified in Minnesota Statutes, section 148F.165 (client files numbered 1 and 2); g. Staff reviewing the client’s rights with the client (client files numbered 1 and 3); and h. Grievance procedure (client file numbered 2) Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivisions 1, paragraph (c), subdivision 2, paragraph (a), 245G.15, subdivisions 1, 2, and 3, and 245G.09, subdivision 3, paragraph (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client rights protection and client orientation meets all applicable requirements. 6. Violation: One of three client files reviewed for requirements governing client confidentiality (client file numbered 3) contained a pre-signed ROI that did not have an entity listed. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure client confidentiality meets all applicable requirements. 7. Violation: Two of three client files reviewed for requirements governing initial services plan (ISP) did not meet requirements in the following ways: a. ISP was not completed within 24 hours of the day of service initiation (client file numbered 2); b. ISP was not client specific (client file numbered 3); c. ISP did not address immediate health and safety concerns (client file numbered 3); and d. ISP did not identify needs to be addressed during the time between the day of service initiation and development of the individual treatment plan (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. 8. Violation: One of two client files reviewed for requirements governing VA assessment and determination (client file numbered 3) did not meet requirements in the following ways: a. The assessment was not completed within 24 hours of admission; and b. The license holder had no documentation of determination utilizing the vulnerable adult definition under MN statute, section 626.5572, subdivision 21, paragraph (a), clause (4). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that VA assessments and determination meet all applicable requirements. 9. Violation: Three of three client files reviewed for requirements governing comprehensive assessments and summaries did not meet requirements in the following ways: a. The comprehensive assessment was not completed within 3 calendar days on which a treatment service had been provided from the day of service initiation (client files numbered 2 and 3); b. The assessment did not include information about the client’s needs that relate to substance use and personal strengths that support recovery, including: 1) Previous attempts at treatment for mental illness was not documented (client file numbered 2); 2) The mental health history did not include symptoms and the effect on the client’s ability to function (client files numbered 1, 2, and 3); 3) A description of how use affected the client’s ability to function appropriately in a work setting was not included (client file numbered 1); and 4) Leisure time activities that have been associated with substance use was not documented (client file numbered 2); c. The comprehensive summaries were not competed within 3 calendar days on which a treatment session had been provided from the day of service initiation (client files numbered 1 and 2); and d. The comprehensive assessment did not utilize a screening tool approved by the commissioner (client files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1, paragraph (a), and subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit two client comprehensive assessments that meet all applicable requirements. 10. Violation: Two of three client files reviewed for requirements governing individual treatment plans (ITP) (client files numbered 2 and 3) did not meet requirements. ITPs were not completed within 5 calendar days on which a treatment session had been provided from the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.06 subdivision 1 and 245G.18, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans, including adolescents, meets all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing client record documentation (client files numbered 1, 2, and 3) did not meet requirements in the following ways: a. Treatment service documentation was not completed within seven days of providing the treatment service; b. Each entry in the client’s record was not dated and did not include staff job title; and c. Alcohol and drug counselor-temp is signing documents as a licensed alcohol and drug counselor. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client documentation meets all applicable requirements. Within 30 days of receipt of this order, submit verification that credentials in electronic health records reflects all staff positions. 12. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. TPRs were not entered in the client’s file weekly or after each treatment service: 1) 4/10/23-4/16/23, 5/1/23-5/7/23, 5/8/23-5/14/23, 5/15/23-5/21/23 (client file numbered 1); 2) 4/10/23-4/16/23, 4/17/23-4/23/23, 4/24/23-4/30/23, 5/1/23-5/7/23, 5/8/23-5/14/23, 5/15/23-5/21/23, 5/22/23-5/28/23 (client file numbered 2); and 3) 12/5/22-12/11/22,2/20/23-2/26/23, 3/6/23-3/23/23; 3/27/23-4/2/23, 4/3/23-4/9/23 (client file numbered 3); b. The span of time covered by the review did not match the treatment week for week 5/29/23-6/4/23 (client file numbered 2); and c. TPRs did not include monitoring of any physical and/or mental health problems (client file numbered 3) for weeks 12/26/22-1/1/23, 2/6/23-2/12/23, 2/13/23-2/29/23, 2/20/23-2/26/23, 2/27/23-3/5/23. 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. Within 30 days of receipt of this order, submit two client treatment plan reviews that demonstrate compliance. 13. Violation: Two of three client files reviewed for requirements governing record keeping did not ensure that each entry was signed and dated by the staff member making the entry: a. June 1, 2023 (client file numbered 2); and b. January 18, 2023 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure record keeping meets all applicable requirements. 14. Violation: One client file reviewed for requirements governing discharge summaries (client file numbered 3) did not include continuing care recommendations and referrals made for continuity of care. 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 15. Violation: Two of three personnel files reviewed for adolescent requirements (personnel files numbered 2 and 3) did not have documentation of: a. Additional 30 hours of classroom instruction or one three-credit semester college course in adolescent development; and b. At least 150 supervised experience as an adolescent counselor, either as a student or as a staff member. Statute Violated: Minnesota Statutes, section 245G.18, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure qualifications for persons providing treatment services to adolescents meet all applicable requirements. Within 30 days of receipt of this order, the license holder must submit documentation of staff qualifications for those who provide adolescent treatment services. 16. Violation: One personnel file reviewed for requirements governing qualifications for persons providing treatment services (personnel file numbered 3) did not meet requirements. From date of hire, 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. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 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. 17. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. Orientation to client needs was not provided within 24 hours (personnel files numbered 2, 3, and 4); and b. Orientation to maltreatment reporting was not provided within 72 hours for the following: 1) Vulnerable adults’ maltreatment, including reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 3 and 4); 2) Program abuse prevention plan (personnel files numbered 2, 3, and 4); and 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2, and 3). Statute Violated: Minnesota Statutes, sections 245G.13, subdivision 1, paragraph (7), and 245A.65, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. 18. Violation: Two of two personnel files reviewed for requirements governing annual, biennial, and additional training did not meet requirements in the following ways: a. No documentation of annual training in calendar year 2022 (personnel files numbered 3 and 4): 1) Vulnerable adults’ maltreatment reporting was completed late; 2) Program abuse prevention plan; 3) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was completed late; 4) Facility’s policies for obtaining client releases of information was completed late; 5) Reporting of maltreatment of minors, according to 260E; 6) Reporting of prenatal exposure to controlled substances; and 7) HIV minimum standards was completed late; b. Emergency procedures including behavioral was not completed in 2023 (personnel file numbered 4); and c. Twelve hours of training in co-occurring disorders within 6 months of employment was not completed (personnel files numbered 3 and 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure training components meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above staff received training that demonstrates compliance. 19. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. 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 2, 3, and 4); and b. A written annual review was not completed in February of calendar year 2022 and 2023 (personnel file numbered 4). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. 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 that the above personnel file contents demonstrate compliance. 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: Charlene.M.Hanson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Char Hanson 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 Substance Use Disorder treatment program 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 651-431-5653. Sincerely, 
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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