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August 8, 2023 Al haqq Zayid, Authorized Agent Zulu Islamic Institute 1729 Lyndale Ave N Minneapolis, MN 55411 License Number: 1086165 CORRECTION ORDER Dear Al haqq: On May 15 and 16, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 1729 Lyndale Ave N, Minneapolis, MN 55411. As a result of this visit, DHS determined that you are in violation of 15 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, Procedures, and Practices 1. Violation: The license holder failed to post or give to interested persons the grievance procedure, program abuse prevention plan, vulnerable adult maltreatment reporting policies and procedures and service initiation criteria in a prominent and visible location in the program. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (a) and subdivision 2, paragraph (d), 245G.14, subdivision 1, and 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure physical plant postings meet all applicable requirements. 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 failed to meet requirements for specializing in the treatment of a person with co-occurring disorders. The license holder was unable to describe how the program has continued access to a medical provider with appropriate expertise in prescribing psychotropic medication. Statute Violated: Minnesota Statutes, section 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program has continued access to a medical provider with appropriate expertise in prescribing psychotropic medications. Within 30 days of receipt of this order, submit a policy for serving persons with co-occurring disorders that meets all applicable requirements. 4. Violation: The license holder’s treatment services policy did not include a description of: a. How the program will meet the requirements for guest speakers; and b. The location of service provision, including services provided via telehealth. Statute Violated: Minnesota Statutes, section 245G.07, subdivisions 3a, paragraphs (a), (b), and (d), subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the treatment services policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised treatment services policy that demonstrates compliance. 5. 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. 6. 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 7. Violation: Three of three client files reviewed for requirements governing client orientation (client files numbered 1, 2, and 3) did not meet requirements. No documentation of the following: a. HIV minimum standards within 72 hours of admission; b. The client received information on tuberculosis; c. Review of the personal electronic device policy and the client’s right to refuse being photographed or recorded; d. Maltreatment of vulnerable adults within 24 hours of admission; e. The program abuse prevention plan within 24 hours of admission; f. Consent to the disclosure of suspected maltreatment within 24 hours of admission; g. Client rights and responsibilities identified in Minnesota Statutes, section 148F.165; and h. Grievance procedure. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 1, paragraph (c), and subdivision 2, paragraph (a), 245G.09, subdivision 3, paragraph (1), and subdivision 1, and 245G.15, subdivisions 1, 2, and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 30 days after license becomes active, submit two client files that demonstrate compliance. 8. Violation: One of three client files reviewed for requirements governing client confidentiality (client file numbered 3) did not meet requirements. The client file 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. 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 assessment was not completed within three calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 1); b. The assessment was not completed (client file numbered 2); c. The assessment did not include information about the client’s needs that relate to substance use and personal strengths that support recovery, including mental health symptoms and the effect on the client’s ability to function (client files numbered 1 and 3); and d. The program did not provide educational information to the client identified as having opioid disorder, including: 1) The risk of and recognizing opioid overdose (client file numbered 3); and 2) The use, availability, and administration of naloxone to respond to opioid overdose (client file numbered 3); e. The assessment summary was not contained in the client file (client file numbered 2); and f. The assessment summary was not completed within three calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1, paragraph (a) and (b), subdivision 2 and 245G.09, subdivision 3, paragraph (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments and summaries meet all applicable requirements. 10. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITPs) did not meet requirements in the following ways: a. The ITP was not completed within 5 calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 1); b. The ITPs were not signed by the client (client files numbered 1 and 3); c. The ITP did not document the client’s involvement in the development of the plan (client file numbered 3); and d. The ITPs did not include specific goals and methods to address each need identified (client files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. 11. Violation: One file reviewed for requirements governing client record documentation (client file numbered 3) did not meet requirements. Each client entry did not include the job title of the staff person making the entry. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 12. Violation: Two of two files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. Treatment plan reviews were not entered in the client’s file weekly or after each treatment service as follows: 1) 12/26/22-1/1/23, 1/2/23-1/8/23, 1/23/23-1/29/23, 2/6/23-2/12/23, 2/20/23 through discharge date of 4/30/23 (client file numbered 1); and 2) 12/19/22-12/25/22, 12/26/22-1/1/23, 1/2/23-1/8/23, 1/23/22 through discharge date of 4/28/23 (client file numbered 2); b. The span of time covered by the review did not match the treatment week (client files numbered 1 and 2); and c. Treatment plan reviews did not document collaboration with continuing care mental health providers (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 3 and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 13. Violation: Three of three client files reviewed for requirements governing discharge summaries (client files numbered 1, 2, and 3) did not meet requirements. The discharge summaries did not include the client’s issues, strengths, and needs while participating in treatment. 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. Prior to changing license state from pending reopening to active, license holder must submit a mock client discharge summary that meet requirements. Personnel files 14. Violation: The license holder failed to maintain a personnel file for two of two employees (personnel files numbered 1 and 2) including the following required documentation: a. Orientation to: 1) The staff members specific job responsibilities; 2) Policies and procedures; 3) Client confidentiality; 4) Client needs; 5) HIV minimum standards; 6) Vulnerable adult maltreatment reporting; 7) Program abuse prevention plan; 8) Internal policies and procedures related to the prevention and reporting of maltreatment; and 9) Drug and alcohol policy; b. Personnel file documentation was not maintained: 1) A completed application for employment signed by the staff member; 2) Documentation related to the applicant’s background study data, according to chapter 245C; 3) Staff member provided psychotherapy services, 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; and 4) A written annual review of the employee’s job performance. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivisions 1, paragraph (7), and subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel file contents meets all applicable requirements. Prior to changing licensing state from pending reopening to active, license holder must submit a complete personnel file that demonstrates compliance. 15. Violation: The license holder failed to provide staff development for two of two employees (personnel files numbered 1 and 2) in the following ways: a. Annual training for calendar years 2021 and 2022 on the following topics: 1) Vulnerable adult maltreatment reporting; 2) Program abuse prevention plan; 3) Internal policies and procedures related to the prevention and reporting of maltreatment; 4) The facility’s policies for obtaining client releases of information required by 626.557, subdivision 3a, paragraph (a); 5) Maltreatment of minors reporting required by 260E; 6) Reporting of prenatal exposure to controlled substances; and 7) HIV minimum standards; b. Biennial and additional training was not completed: 1) Client confidentiality in 2021; 2) Client ethical boundaries in 2021; 3) Emergency procedures including behavioral in 2021; 4) Client rights as specified in Minnesota Statutes, section 148G.165 in 2021; and 5) Twelve hours of training in co-occurring disorders within 6 months of employment. 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 staff development meets all applicable requirements. Prior to changing licensing state from pending reopening to active, license holder must submit verification that personnel file numbered 1 received all required orientation and annual training. 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 651-431-66. Sincerely,
Licensing Division Office of Inspector General
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Paula Halverson, MH/SUD/CRF Unit Manager