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August 09, 2023 Muna Ahmed Mohamed, Authorized Agent OSOY Healing Health LLC 1841 E Lake St Minneapolis, MN 55407-1809 License Number 1108448 CORRECTION ORDER Dear Muna Ahmed Mohamed: On June 12 and 13, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 1841 E Lake St, Minneapolis, MN, 55407-1809. As a result of this visit, DHS determined that you are in violation of 12 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. Policies, Practices, and Procedures 1. Violation: The license holder’s grievance procedure did not include the current telephone number and address of the Minnesota Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statute, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a revised grievance procedure that meets all applicable requirements. Personnel Files 2. Violation: One of two personnel files reviewed for requirements governing staff orientation did not include training on the staff member’s specific job responsibilities (personnel file numbered 2). Through staff interviews (staff person numbered 3) it was determined that the treatment director is also the alcohol and drug counselor supervisor. The job description for the treatment director did not include the job duties or qualifications for an alcohol and drug counselor supervisor. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit a job description for the combined treatment director and alcohol and drug counselor position that meets all applicable requirements. 3. Violation: Two of two personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of annual training for calendar year 2022 on the following topics: a. Program abuse prevention plan (personnel file numbered 2); b. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 2); c. Specific training covering the facility’s policies for obtaining client releases of information required by Minnesota Statutes, section 626.557, subdivision 31, paragraph (a) (personnel files numbered 1 and 2); and d. HIV minimum standards (personnel file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff annual training meets all applicable requirements. Within 30 days of receipt of this order, submit verification that the staff identified above have completed the trainings identified above. 4. Violation: One of two personnel files reviewed for additional staff training requirements did not have documentation of a minimum of 12 hours of training in co-occurring disorders within 6 months of employment (personnel file numbered 1). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff development is complete and meets all applicable requirements. 5. Violation: Two of two personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. There was no documentation of inquires made to former employers regarding substantiated sexual contact with a client as required by Minnesota Statutes, chapter 604 (personnel files numbered 1 and 2); and b. There was no documentation that the written review of the employee’s job performance for April 2022 through April 2023 was completed (personnel file numbered 1). 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 that the contents of personnel files meet all applicable requirements. Client Files 6. Violation: The program did not follow their own procedure for communicating staff-approved service termination criteria to clients (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245G.14, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service termination policy meets all applicable requirements and matches with program practice. 7. Violation: One of two client files reviewed for requirements governing confidentiality demonstrated that the program disclosed client information without a release of information (client file numbered 1). 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 that client records are protected against unauthorized disclosure. 8. Violation: Two of two client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed within 3 calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 1); b. The comprehensive assessment contents did not include the following: i. A person-centered reason for the delay in completing the comprehensive assessment (client file numbered 1); ii. A description of the circumstances on the day of service initiation (client file numbered 2); iii. A list of substance use history including amounts and types of substances used (client file numbered 2); and iv. Leisure time activities that have been associated with substance use (client file numbered 2); and c. The comprehensive assessment contents contained inconsistent information regarding frequency and duration of use (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 9. Violation: One of two client files reviewed for requirements governing comprehensive assessment summaries contained a comprehensive assessment summary that was not completed within 3 calendar days on which a treatment session has been provided from the day of service initiation (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessment summaries meet all applicable requirements. 10. Violation: Two of two client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways (client files numbered 1 and 2): a. The ITP did not include the amount and frequency of treatment services; and b. The ITP did not indicate which goals the client must reach to complete treatment and termination services. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 11. Violation: Two of two client files reviewed for requirements governing client record documentation did not meet requirements in the following ways (client files numbered 1 and 2): a. Group notes consisted of a full day of programming and did not document the type and amount of each type of treatment service provided to the client; b. Entries into client’s records did not include the job title or position of the staff person making the entry; and c. Progress notes were not signed. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. Within 30 days of receipt of this order, submit progress notes from two client files that meet all applicable requirements. 12. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. A treatment plan review was not entered into the client’s file for the week starting January 16, 2023 (client file numbered 1); b. A treatment plan review did not indicate the span of time covered by the review (client file numbered 2); and c. Treatment plan reviews indicated the methods to address the goal were ineffective, however did not document staff recommendations for changes to the treatment plan client files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Needed: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. You must correct the violations cited above. Submit requested documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. 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 RECOMMENDATIONS The following recommendations are provided to call your attention to an area where your facility is in minimum compliance with the requirements of statutes or laws, but it would be advisable to strengthen your efforts in these areas: 1. Minnesota Statutes, section 245G.14, subdivision 1 requires a license holder to have personnel policies that include a chart or description of the organizational structure. Job titles for several positions have been changed and this is not reflected on the organizational chart. It is recommended that the organizational chart be updated to reflect current job titles. 2. Minnesota Statutes, section 626.557 prohibits the program from disclosing patient identifying information in connection with a report of suspected maltreatment unless the vulnerable adult or their guardian, conservator, or legal representative has consented to this disclosure. The program’s maltreatment of vulnerable adult reporting policy states that all known or suspected maltreatment of a vulnerable adult must be reported immediately and does not include the program’s policy on seeking consent prior to disclosing. It is recommended that the policy be updated to reflect the program’s practice of seeking consent and to include the prohibitions outlined in Minnesota Statutes, section 626.557. Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow these recommendations result in a violation of statutes or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license. 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, section 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 Paula Halverson, Manager, at 651-431-5653.
Sincerely, Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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