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August 09, 2023 Crystal Hill, Authorized Agent Twin Cities Wellness Center & Recovery Gym 2912 N 2nd St Minneapolis, MN 55411-1601 License Number 1110582 Report Number 202303007 CORRECTION ORDER Dear Crystal: On May 31, June 01 and 05, 2023 a Department of Human Services (DHS) licensor conducted a licensing review and investigation at your facility located at 2912 N 2nd St, Minneapolis, MN 55411-1601. 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, Practices, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided as required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (5) as follows: a. The license holder failed to offer family education that addressed mental health and substance use disorder and the interaction between the two (client file numbered 4); and b. A client did not receive a standardized mental health screen and therefore it was unable to be determined if the client was appropriate for co-occurring services, however the program billed services provided to that client with the co-occurring rate enhancement (client file numbered 5). Statute Violated: Minnesota Statutes, section 245A. 191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that all required services are provided and are billed for in the correct type and amount. 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 proved by law. 2. Violation: The license holder failed to develop program policies and procedures necessary to maintain compliance with licensing requirements under Minnesota Statutes 245G and monitor implementation of by program staff as follows: a. The license holder’s Service Initiation Policy was not reflective of actual program practices. Through chart reviews and conversation with staff (staff persons numbered 2 and 5) it was determined that upon service initiation, clients are admitted to a specific phase of programming based on presenting needs, however the specific service initiation criteria for each phase is not outlined in the program’s policy; b. The license holder did not follow their own policy Handling of Client Funds and Property. Through conversations with staff (staff persons numbered 2 and 5) and an inspection of the physical plant, it was determined that the program does not follow their own policy on cell phone restrictions; c. The license holder’s treatment services description did not contain the required information: i. A comprehensive list of the amount and type of services provided; ii. Which services met the definition of group counseling under Minnesota Statutes, section 245G.01, subdivision 13a; iii. Groups and topics on which a guest speaker could provide services; iv. Which services could be provided via telehealth; v. Define the program’s treatment week; and vi. An accurate description of the treatment services offered; d. The license holder’s program abuse prevention plan did not contain a population assessment that included age and gender; e. The license holder had two conflicting procedures for reporting the maltreatment of vulnerable adults according to Minnesota Statutes, sections 245A.65 and 626.557; and f. The license holder’s Client Orientation Packet referenced incorrect statutes regarding client rights. Statute Violated: Minnesota Statute, sections 245A.04, subdivision14, paragraphs (a) and (b), 245A.65, subdivisions 1, paragraph (a) and (b) and 2, paragraph (a), 245G.07, 245G.12, and 245G.14, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all program policies and procedures meet all applicable licensing requirements, that program staff are trained related to their duties in implementing the program’s policies and procedures, and that implementation of policies and procedures is monitored. Within 30 days of receipt of this order, submit a service initiation policy, a client funds and property policy, a treatment service description, a program abuse prevention plan, a reporting of maltreatment of vulnerable adults policy and a client orientation packet that meets all applicable requirements and a plan to train staff on the revised program policies. 3. Violation: The license holder did not meet requirements governing grievance procedures in the following ways: a. The license holder’s Client Grievance Procedure did not contain the current telephone number and address of the Board of Behavioral Health and Therapy; and b. The license holder failed to respond to a client’s grievance received on May 25, 2022 within three days of a staff member’s receipt of the grievance. Statute Violated: Minnesota Statutes, 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 4. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. No orientation training was documented for the following (personnel file numbered 3); i. Policies and procedures; ii. Client confidentiality; iii. HIV minimum standards iv. Client needs; v. Reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; vi. Program abuse prevention plan; and vii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; b. No date of completion identified; therefore, unable to determine if required staff orientation was completed within 24 working hours of starting (personnel file numbered 2); and c. No documentation of orientation to HIV minimum standards within 24 hours of starting (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 5. Violation: One personnel file was reviewed for requirements governing annual trainings (personnel file numbered 1) and did not include specific training covering the license holder’s policies for obtaining a release of client information as required by Minnesota Statutes, section 626.557, subdivision 3a, paragraph (a). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff annual training meets all applicable requirements. 6. Violation: Three of three personnel files reviewed for requirements governing the contents of personnel files 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 2 and 3); and b. No date of completion identified; therefore, unable to determine if the written review of the employee’s job performance for February 2022 through February 2023 was done annually (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 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 7. Violation: One of five client files reviewed for requirements governing confidentiality did not meet requirements (client file numbered 2). The client’s file contained a release of information that did not specify who information may be disclosed to. 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 all client records are protected against unauthorized disclosure in accordance with Minnesota Statutes, section 254A.09, chapter 13, and Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 6.27, and title 45, parts 160 to 164. 8. Violation: One of five client files reviewed for requirements governing client orientation did not meet requirements (client file numbered 3). The client file did not contain documentation that the client was oriented to the grievance procedure on the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, and 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 9. Violation: Five of five client files reviewed for requirements governing the contents of client records did not meet requirements (client files 1 through 5). Clients did not receive information on tuberculosis education on a formed approved by the commissioner. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1, paragraph (a) and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the content of client records meets all applicable requirements. Within 30 days of receipt of this order, the license holder must submit documentation from two recently admitted client files that demonstrate the clients received tuberculosis education on a form approved by the commissioner. 10. Violation: Two of five client files reviewed for requirements governing initial service plans (ISP) did not meet requirements in the following ways: a. The ISP was not person-centered and client specific (client file numbered 1); b. The ISP did not address immediate health and safety concerns (client file numbered 1); and c. The ISP did not identify treatment needs to be addressed during the time between the day of service initiation and the development of the individual treatment plan (client files numbered 1 and 5). Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. 11. Violation: Five of five client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment did not contain the following information: i. A description of the circumstances on the day of service initiation (client files numbered 1, 2 and 5); ii. A list of previous attempts at treatment for substance misuse or substance use disorder (client file numbered 1); iii. Frequency of use (client file numbered 2); iv. Duration of use (client files numbered 4 and 5); v. Period of abstinence (client file numbered 1); vi. Effects of mental health on the client’s ability to function (client file numbered 5); vii. Psychotropic medications needed to maintain stability (client file numbered 5); viii. A GAIN-SS (client file numbered 5); and ix. Leisure time activities that have been associated with substance use (client files numbered 1 through 4); and b. The comprehensive assessment contained inconsistent information on whether medical concerns need to be referred to an appropriate health care professional (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a) and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 12. Violation: Five of five client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed within five calendar days on which a treatment session had been provided from the day of service initiation (client files numbered 1 and 5); b. The ITP did not include the amount and frequency of treatment services (client files numbered 1 through 5); c. The ITP did not include resources to refer the client to when needs were to be addressed concurrently by another provider (client files numbered 1 and 2); d. The ITP did not include goals the client must reach to complete treatment and terminate services (client file numbered 2); e. The ITP was not updated based on new information gathered about the client’s condition (client files numbered 2 and 3); and f. The ITP did not contain active interventions to stabilize mental health symptoms (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2, and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 13. Violation: Five of five client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Entries in the client records were not signed by the staff person making the entry: i. Treatment plan dated October 16, 2022 (client file numbered 1); and ii. Peer Recovery Service Note dated December 14, 2022 (client file numbered 2); and b. Entries into client records did not include the job title or position of the staff person making the entry (client files numbered 1 through 5). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 2b, paragraph (c) and 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 14. Violation: Five of five client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. Treatment plan reviews were not completed for the following weeks starting on: i. October 24, October 31, November 07, and December 12, 2022 (client file numbered 1); and ii. December 26, 2022 (client file numbered 2); b. Treatment plan reviews did not include the correct span of time covered by the reviews. Treatment plan reviews for the weeks starting on November 28, December 19, and December 26, 2022 were signed prior to the end date of the review period identified in the notes (client file numbered 1); c. Treatment plan review did not address each goal in the treatment plan for the week starting December 19, 2022 (client file numbered 1); d. Treatment plan reviews did not indicate whether the methods to address the goals were effective (client files numbered 2 through 5); e. Treatment plan reviews did not include monitoring of any physical and mental health problems for the following weeks starting on: i. December 05, 2022 (client files numbered 1 and 2); and ii. December 26, 2022 (client file numbered 2); f. Treatment plan reviews did not document if client agreed with changes to the treatment plan (client file numbered 2); and g. Treatment plan reviews did not contain documentation of 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 that treatment plan reviews meet all applicable requirements. 15. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 1); and b. The discharge summary did not include the client’s progress toward achieving each of the goals identified in the individual treatment plan (client files numbered 2 and 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that discharge summaries meet all applicable requirements. Within 30 days of receipt of this order, the license holder must submit discharge summaries from two discharged clients that 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.06, subdivision 4, paragraph (a) requires a license holder to provide a copy of the client’s service discharge summary upon the client’s request. Through conversations with staff (staff persons numbered 2 and 5), it was determined that clients are offered a copy of their discharge summary at service termination. For client’s that are not present during the development of the discharge summary, there was no process in place for informing that a copy of the discharge summary could be provided. It is recommended that this information is communicated with clients at service initiation, along with service termination criteria. 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, Unit Manager, at 651-431-5653 Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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