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September 5, 2023 Michael McHugh, Authorized Agent Midwest Recovery Northfield 2626 82nd St. Ste. 305 Bloomington, MN 55425 License Number 1107137 CORRECTION ORDER Dear Michael: On May 31, June 1, and June 2, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 529 Woodley St. W., Northfield. As a result of this visit, DHS determined that you are in violation of seventeen 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. Practice and Procedure 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), (4). a. The program failed to offer family education to individuals with co-occurring mental health and substance use disorder problems; and b. Co-occurring counseling staff did not receive 8 hours of training on co-occurring disorders, annually (personnel file numbered 2, 3 and 5). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that co-occurring disorder and medical services meet all applicable requirements. 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. The public funding Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG . Within 30 days of receipt of this order, submit a plan for maintaining compliance on an ongoing basis. 2. Violation: The program did not allow clients to have visitors at the facility; therefore, the license holder did not set or post a notice of visiting rules and hours. Additionally, not allowing visitors is a rights violation under Minnesota Statutes, section 144.651, subdivision 26. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all visiting rights meet all applicable requirements. Within thirty days of receipt of this order, submit a notice of visiting rules and hours along with a statement that the notice has been posted at the facility. 3. Violation: The program’s grievance procedure did not meet requirements in the following ways: a. The grievance procedure contained an incorrect phone number for the Minnesota Board of Behavioral Health and Therapy; and b. The client handout stated the license holder is required to respond to the client’s grievance within 10 days instead of the required 3 days. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all grievance procedures and practices meet all applicable requirements. Within thirty days of receipt of this order, submit a revised grievance procedure and client handout relating to grievances. 4. Violation: Client education on tuberculosis was not provided on a form approved by the commissioner. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all client education meets all applicable requirements. Within 30 days of receipt of this order, submit the form that will be used moving forward. 5. Violation: The Program Abuse Prevention Plan (PAPP) did not meet the following requirements: a. Co-occurring and medical treatment services were not contained in the description of internal programming; and b. The PAPP was not reviewed annually, calendar year 2022. 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 that the PAPPs meets all applicable requirements. Within thirty days of receipt of this order, submit a revised PAPP. 6. Violation: The license holder did not complete an internal review relating to an internal report of suspected maltreatment received on February 19, 2022, and the reporter was not provided with a written notice stating whether the facility reported the incident to the common entry point (CEP) and that that if the mandated reporter was not satisfied with the action taken by the facility on whether to report the incident to the CEP, then the mandated reporter may report externally. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (b), and 626.557, subdivision 4a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all applicable internal review and written notice to mandated reporter requirements are met. 7. Violation: The treatment director did not designate a responsible staff member who, when present at the facility, is responsible for the delivery of treatment service during all hours of operation. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all responsible staff member meet all applicable requirements. Within thirty days of receipt of this order, submit a statement of how the above noncompliance has been corrected. 8. Violation: The plan for transfer of current or discharged clients and records was not reviewed and signed by a controlling individual for calendar year 2022. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all plan for transfer of current or discharged clients and records meet all applicable requirements. Client Files 9. Violation: Three of three client files reviewed for requirements governing service initiation and orientation did not contain required documentation as follows: a. That clients were given a written statement of client rights and responsibilities and that staff reviewed the statement with the client (client files numbered 1 and 3); b. That Minnesota Statutes, section 144.651 rights were reviewed with clients (client files numbered 1 through 3); c. That the grievance procedure was explained to clients (client files numbered 1 and 3); d. That the client received orientation to HIV minimum standards (client files numbered 1 and 3); e. That the client was informed of the program’s electronic device policy and the client’s right to refuse being photographed or recorded (client files numbered 1 and 3); f. That the client was oriented to internal and external reporting policies, including the telephone number for the Minnesota Adult Abuse Reporting Center and the program abuse prevention plan (client files numbered 1 and 3); g. That consent to disclosure of suspected maltreatment was sought (client files numbered 1 and 3); and h. That releases of information were signed by the client when there was an identified need to have information released, in that blank releases were pre-signed in advance (client files numbered 1 through 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivisions 1, paragraph (c), 2, paragraph (a), 245G.09, subdivisions 1 and 3, and 245G.15, subdivisions 1, 2 and 3, and 626.557, subdivision 3a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all service initiation and orientation meet all applicable requirements. 10. Violation: Three of three files reviewed for requirements governing individual abuse prevention plans (IAPPs) did not meet requirements in the following ways: a. The IAPP did not assess the client’s susceptibility to abuse other vulnerable adults (client files numbered 1 through 3); and b. The IAPP did not document the determination that the client does not need specific risk reduction measures in addition to those identified in the program abuse prevention plan (PAPP) and the assessment indicated none were needed (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), and 626.557, subdivision 14, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all IAPPs meet all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing comprehensive assessments and comprehensive assessment summaries did not meet requirements in the following ways: a. The comprehensive assessment and summary were not completed within 3 calendar days from the day of service initiation (client file numbered 3); b. No description of circumstances on the day of service initiation (section left blank on form) (client file numbered 1); c. The list of substance use history did not include the otherwise documented use of methamphetamine (client file numbered 2); d. Frequency and duration of use were not addressed (client file numbered 2); e. Information did not include the date of the most recent use and address the absence or presence of withdrawal symptoms (client files numbered 2 and 3); f. Psychotropic medications needed to maintain stability were not identified (client file numbered 3); g. The comprehensive assessment did not utilize screening tools approved by the commissioner (Global Appraisal of Individual Needs – Short Screener) to identify whether the client screened positive for co-occurring disorders (client files numbered 1 through 3); h. Social network in relation to expected support for recovery was not included (client files numbered 1 and 3); and i. Leisure time activities that have been associated with substance use were not listed (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1, paragraph (a), 2, (a), and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all applicable comprehensive assessment and comprehensive assessment summaries meet all applicable requirements. 12. Violation: Three of three client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. The treatment plan did not identify how family will be involved in the client’s treatment (client file numbered 1); b. Amount and frequency were not included (client files numbered 1 through 3); c. The section of the treatment plan that addressed resources to refer the client to when needs are to be addressed concurrently by another provider was left blank (client files numbered one through three); d. Entries in progress notes did not consistently include the job title or position of the staff person making the entry (client files numbered 1 through 3) and signature (client file numbered 1); e. Treatment plan reviews were missing for: 1) May 8 to May 14, 2023, and May 15 to May 21, 2023 (client file numbered 2) and 2) January 23 to January 29, 2023; February 20 to February 26, 2023; and March 13 to March 19, 2023 (client file numbered 3); and f. The treatment plan review did not: 1) Address whether goals were effective (client file numbered 1); 2) Include monitoring of any physical problems, as the section of the form was left blank (client files numbered 1 and 2); and 3) Document the participation of others (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1, 2, 2a, 2b, paragraph (c), and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all treatment services and treatment plan reviews meet all applicable requirements. 13. Violation: Two of two client files reviewed for assistance with self-medication contained blank entries on the medication administration record (client files numbered 1 and 3). Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all documentation of assistance with self-administration meets all applicable requirements. Personnel Files 14. Violation: The license holder did not document the program’s verification that a staff person who was hired as a student intern is enrolled in a program specializing in alcohol and drug counseling or mental health counseling at an accredited educational institution and is authorized by a licensing board to provide services under supervision of a licensed professional (personnel file numbered 1). Statute Violated: Minnesota Statutes, section 245g.11, subdivision 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that verification of employment qualifications meet all applicable requirements. 15. Violation: Four of five personnel files reviewed for orientation training within 24 working hours of starting did not meet requirements in the following ways: a. The staff person was hired on February 27, 2023 and did not receive orientation training until May 5, 2023 (personnel file numbered 1); b. An unsigned, undated Training Acknowledgement form was contained in the personnel file (personnel files numbered 2 and 3); and c. A staff person hired on June 23, 2022 did not receive orientation training until May 13, 2023 (personnel file numbered 4). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all orientation training meets all applicable requirements. Within thirty days of receipt of this order, submit documentation demonstrating that orientation training has been completed for staff persons numbered 2 and 3. 16. Violation: Three of three personnel files reviewed for annual training and development did not meet requirements in the following ways: a. No documentation of annual training in 2022 (personnel files numbered 2 and 3); and b. 12 hours of training in co-occurring disorders that includes competencies related to philosophy, trauma-informed care, screening, assessment, diagnosis and person-centered treatment planning, documentation, programming, medication, collaboration, mental health consultation, and discharge planning was not conducted (personnel files numbered 1 through 3). At the time of the licensing review, the program’s treatment director and human resources person stated that they were in the process of setting up an annual training curriculum for staff, as no annual training had been conducted for any applicable staff since the program had opened on June 4, 2021. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (c), (d), and (e), and 260E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all annual training and development meets all applicable requirements. Within thirty days of receipt of this order, submit documentation demonstrating that all staff have received the required annual training, as relevant to their positions and dates of hire. 17. Violation: Five of five personnel files did not contain: a. A completed job application signed by the staff member and containing the staff member’s qualifications for employment (personnel files numbered 1 through 4); b. For a staff member who provides 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 employer regarding substantiated sexual contact with a client (personnel files numbered 1 through 3 and 5); and c. Written annual review of the staff member’s job performance in 2022 (personnel files numbered 2 and 3). 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 all personnel files meet all applicable requirements. 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: Molly.Lang@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Molly Lang 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 Program must maintain compliance with the licensing statutes and rules, specifically 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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