|
October 02, 2023 CERTIFIED MAIL Marlin Martin, Authorized Agent Valhalla Place Brainerd dba BHG Brainerd Treatment Center 5001 Spring Valley Rd Ste 600 Dallas, TX 75244-8217 License Number: 1108974 Licensing Report Number: 202210171 and 202301680 ORDER OF CONDITIONAL LICENSE Dear Marlin Martin: The Department of Human Services (DHS) is placing your license to provide substance use disorder treatment services at Valhalla Place Brainerd dba BHG Brainerd Treatment Center located at 2215 S 6th St, Brainerd, MN 56401, on conditional status for two years, beginning October 11, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with substance use disorder treatment licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On June 27, 28, 29, 30, July 05 and 07, 2023 DHS licensors conducted a licensing review and investigation at your facility located at 2215 S 6th St, Brainerd, MN 56401. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed substance use disorder treatment programs, citing 27 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature and Severity: The license holder failed to follow requirements which affected the health, safety, and rights of persons served: o The license holder failed to comply with background studies requirements (violation numbered 1). o The license holder failed to ensure client records were accurate and protected against loss, tampering, and unauthorized disclosure (violation numbered 2). o The program failed to ensure monthly supervision was provided by a registered nurse (violation numbered 3). o The license holder failed to ensure client documentation is accurate (violation numbered 4). o The program failed to comply with specific measures to reduce the possibility of diversion (violation numbered 5). o The program failed to comply with the unsupervised use of methadone hydrochloride (violation numbered 7). o The program failed to provide staff orientation and annual training as required (violation numbered 11 and 12). o The program failed to complete initial services plans as required (violation numbered 18). o The program failed to complete vulnerable adult determinations as required (violation numbered 19). Due to the serious nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide substance use disorder treatment is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: As a result of a licensing review, a DHS licensor determined that the license holder did not initiate background studies on three of twenty-three staff persons (SP) before they began working in a position allowing direct contact with persons served by the program. a. SP1 was hired and began working in a position allowing direct contact with persons served by the program on June 06, 2023. At the time of the licensing review on June 27, 2023, the license holder had not submitted a background study request to DHS for SP1; b. SP7 was hired and began working in a position allowing direct contact with persons served by the program on June 14, 2023. At the time of the licensing review on June 27, 2023, the license holder had not submitted a background study request to DHS for SP7; and c. SP8 was hired and began working in a position allowing direct contact with persons served by the program on June 26, 2023. At the time of the licensing review on June 27, 2023, the license holder had not submitted a background study request to DHS for SP8. The failure to initiate background study request on staff persons before they begin positions allowing direct contact with persons served by the program is a violation of background study requirements. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g). 2. Violation: The license holder failed to meet requirements governing client records. Client records were not protected against loss, tampering, or unauthorized disclosure as follows: a. During a demonstration by staff, it was found that signed notes in the electronic health record were able to be unlocked and edited by any staff member. The original entries were replaced by the edited version and were no longer contained within the client record; and b. During a tour of the facility, paper client records were observed to be stored in two rooms that were unlocked and were accessible by the public. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). 3. Violation: The license holder failed to maintain a registered nurse to provide monthly on-site supervision as defined by Minnesota Statutes, section 148.171, subdivision 23. Through interviews with staff, it was determined that monthly on-site supervision had not occurred since February 2023. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). 4. Violation: The license holder failed to meet requirements governing client record documentation as follows: a. Entries into the client record were not accurate: i. Templates auto populate incorrect information that is unable to be corrected as noted in the following: 1. Order Change Request notes auto populated the last 3 drug screens from date of note retrieval and not from date that note was completed (client files numbered 1 through 3); 2. Discharge Transfer Plan Form auto populated the date of discharge as the last date the client was dosed, not the actual date of discharge (client file numbered 4); and 3. Progress Note template auto populated incorrect urine drug screen results (client file numbered 3); b. Entries into the client record were not dated: i. The Progress Note template had a box for the service date; however, it did not allow it to be filled in by staff (client files numbered 2 and 3); and ii. The Order Change Request did not include the date it was signed by the staff person (client files numbered 1 through 3); and c. Treatment service documentation dated April 20, 2023 was not completed by the staff member who provided the service (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 2a and 2b, paragraph (c). 5. Violation: The license holder failed to follow their own process for performing diversion control measures as follows: a. The license holder contacted less than five percent of clients who had unsupervised use of medication to require clients to physically return to the program for the following months: i. July through December 2021; ii. March, September, October, and December 2022; and iii. January and April through June 2023; b. The central log did not document all related contacts for the following months: i. January, February, and June through November 2022; and ii. February 2023. Statute Violated: Minnesota Statutes, section 245A. 04, subdivision 14, paragraph ((b) and 245G.22, subdivision 17, paragraph (c). 6. Violation: One of three client files reviewed for requirements governing the prescription monitoring program (PMP) (client file numbered 1) did not meet requirements. The medical director or the medical director’s designee did not review the PMP data at least every 90 days for December 2022 and March 2023. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b). 7. Violation: Three of three client files reviewed for requirements governing the criteria for unsupervised use of methadone hydrochloride failed to meet requirements as follows: a. There was no documentation by a practitioner with authority to prescribe reviewing and determining whether dispensing medication for a client’s unsupervised use was appropriate to implement, increase, or extend the amount of time between visits to the program on April 10, 2023 (client file numbered 1); b. The criteria reviewed for determining whether dispensing medication for a client’s unsupervised use was appropriate to implement, increase, or extend the amount of time between visits to the program did not include or provided inconsistent information for the following: i. Absence of recent abuse of drugs: 1. A note dated March 06, 2022, indicated there was no recent abuse of drugs, however a urine drug screen dated February 11, 2022, indicated fentanyl use (client file numbered 1); and 2. A note dated May 04, 2023, indicated there was no recent abuse of drugs, however a urine drug screen dated April 25, 2023, indicated opiate use (client file numbered 3); ii. Regularity of program attendance. A note dated May 05, 2023, indicated there were no issues with the client’s regularity of program attendance, however the chart indicated that the client missed 8 dosing appointments in April 2023 (client file numbered 1); and iii. Reasonable assurance that unsupervised dose medication will be safely stored within the client’s home was not reviewed in notes dated: 1. January 09, February 01, and May 05, 2023 (client file numbered 1); 2. January 25, March 14, and April 22, 2023 (client file numbered 2); and 3. March 21 and May 03, 2023 (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.22, subdivision 6, paragraphs (a) and (b). 8. Violation: The license holder failed to monitor the implementation of policies and procedures in the following ways: a. The license holder has two policy manuals, one maintained through a share point website and one maintained as hard paper copies that contained the following conflicting procedures: i. MAT Service Termination and Discharge Planning; ii. Medication Assisted Therapy Programs Minnesota Prescription Monitoring Program Review Procedure and Prescription Drug Monitoring Program; and iii. MAT Diversion Control and Medication Callbacks; and b. Included policies that used the name of another license holder. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 14, paragraphs (a) and (b) and 245G.12. 9. Violation: The license holder failed to meet requirements governing programs serving persons with co-occurring disorders: a. During an interview with staff (staff person numbered 2), they were unable to describe the process for accessing a medical provider with appropriate expertise in prescribing psychotropic medications; b. No documentation of active interventions to stabilize mental health symptoms present in the individual treatment plans and treatment plan reviews (client file numbered 1); c. No documentation of collaboration with continuing care mental health providers and involvement of the providers in treatment planning meetings (client file numbered 1); Statute Violated: Minnesota Statutes, section 245G.20. 10. Violation: The license holder failed to document a response to a client’s grievance within three days of a staff member’s receipt of the grievance, as follows: a. An April 06, 2023, grievance response is not dated; b. A May 12, 2023, grievance was responded to on May 23, 2023; and c. A May 13, 2023, grievance was responded to on May 23, 2023. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. 11. Violation: Two of two personnel files reviewed for requirements governing staff orientation failed to meet requirements in the following ways: a. No orientation training was documented for the following: i. The staff member’s specific job responsibilities (personnel file numbered 1); ii. Policies and procedures (personnel files numbered 1 and 3); and iii. Drug and alcohol policy (personnel file numbered 1); b. There was no documentation to demonstrate the required orientation was completed within 24 working hours of starting for the following: i. Client confidentiality (personnel files numbered 1 and 3); ii. Client needs (personnel file numbered 3); and iii. HIV minimum standards (personnel file numbered 3); and c. There was no documentation to demonstrate the required orientation documentation was completed within 72 hours of first providing direct contact services to a vulnerable adult for the following (personnel file numbered 3): i. Maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; ii. The program abuse prevention plan; and iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivision 1. 12. Three of three personnel files reviewed for requirements governing annual staff training failed to meet requirements in the following ways: a. No annual training was documented for calendar year 2022 (personnel files numbered 2 and 4) for the following: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 260E, 626.557, and 626.5572; ii. The program abuse prevention plan; iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; iv. Specific training covering the facility’s policies for obtaining client releases of information required by Minnesota Statues, section 626.557, subdivision 3a, paragraph (a); and v. HIV Minimum Standards; and b. No annual training was documented by May 2023 (personnel file numbered 3) for the following: i. The program abuse prevention plan; and ii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraph (c). 13. Violation: One file reviewed for requirements governing staff development failed to meet requirements (personnel file numbered 3). There was no documentation of a minimum of 12 hours of training in co-occurring disorders completed within 6 months of employment. Statute Violated: Minnesota Statutes, section 245G.16, subdivision 3, paragraph (e). 14. Violation: Three of three files reviewed for requirements governing personnel file contents failed to meet requirements as follows: a. No written annual review was documented for the calendar year 2022 (personnel file numbered 4); and b. An annual review did not include the date it was completed; therefore, unable to determine if the written review was completed annually for the calendar year 2022 (personnel files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. 15. Violation: Three of three client files reviewed for requirements governing client orientation failed to meet requirements in the following ways: a. Clients were oriented to the incorrect client rights and not the Client Bill of Rights identified in Minnesota Statutes, section 148F.165 (client files numbered 1 through 3); and b. Clients did not receive orientation to the following: i. HIV minimum standards (client files numbered 1 through 3); ii. Personal electronic device policy (client files numbered 2 and 3); iii. Internal and external policies for reporting maltreatment of vulnerable adults (client files numbered 2 and 3); and iv. The program abuse prevention plan (client files numbered 2 and 3); and v. Information on tuberculosis education on a form approved by the commissioner (client files numbered 1 through 3). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a), and 245G.09, subdivision 3. 16. Violation: Two of three client files reviewed for requirements governing client confidentiality (client files numbered 2 and 3) failed to meet requirements. A release of information did not contain the signature date; therefore, unable to determine when the release would expire as it is based on one year from the signature date. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). 17. Violation: Two of two client files reviewed for requirements governing the contents of client records (client files numbered 1 and 2) failed to meet requirements. Clients identified as having opioid use disorder did not receive education concerning the following (client files numbered 1 and 2): a. Risk for opioid use disorder and dependence; b. Treatment options, including the use of a medication for opioid use disorder; c. The risk of and recognizing opioid overdose; and d. The use, availability, and administration of naloxone to respond to opioid overdose. Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1, paragraph (d) and 245G.09, subdivision 3. 18. Violation: Two of three client files reviewed for requirements governing initial services plans (client files numbered 2 and 3) failed to meet requirements. Client file did not contain an initial services plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1 and 245G.09, subdivision 3. 19. Violation: Two of three client files reviewed for requirements governing vulnerable adult determinations (client files numbered 2 and 3) failed to meet requirements. A determination of whether the client is a vulnerable adult was not completed. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (a) and 245G.04, subdivision 2, paragraph (a). 20. Violation: Three of three client files reviewed for requirements governing comprehensive assessments and comprehensive assessment summaries failed to meet requirements in the following ways: a. The comprehensive assessment and comprehensive assessment summary were not completed within 21 days from the day of service initiation (client files numbered 1 and 2); b. The comprehensive assessment did not contain the following information: i. The person-centered reason for the delay and planned completion date (client files numbered 1 and 2); ii. A description of the circumstances on the day of service initiation (client files numbered 1 and 2); iii. A list of previous attempts at treatment for mental illness (client file numbered 1); iv. Frequency and duration of use (client file numbered 2); v. Period of abstinence (client file numbered 1); vi. For each substance used within the previous 30 days, the date of most recent use and the absence or presence of previous withdrawal symptoms (client file numbered 1); vii. The client’s desire for family involvement in the treatment program (client file numbered 2); viii. No documentation of utilizing an approved co-occurring disorder screening tool to identify whether the client screens positive for co-occurring disorders (client file numbered 2); ix. A description of how use affected the client’s ability to function appropriately in a work and educational setting (client file numbered 1); x. The ability to understand written treatment materials, including rules and client rights (client file numbered 2); xi. A description of any risk-taking behavior, including behavior that puts the client at risk of exposure to blood-borne or sexually transmitted diseases (client file numbered 2); xii. Leisure time activities that have been associated with substance use (client file numbered 2); and xiii. Whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client file numbered 2); and c. The comprehensive assessment contained inconsistent information for the following: i. Frequency of use (client file numbered 1); ii. Duration of use (client file numbered 2); and iii. Mental health history, including symptoms and the effect on the client’s ability to function (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1, paragraph (a) and 2, paragraph (a) and 245G.22, subdivision 15, paragraph (b). 21. Violation: Three of four client files reviewed for requirements governing individual treatment plans (ITP) failed to meet requirements in the following ways: a. No ITP in client file (client file numbered 4); b. The ITP was not completed within 21 days from the day of service initiation (client files numbered 1 and 2); c. The ITP did not include the following: i. Methods to address each identified need in the comprehensive assessment summary (client file numbered 1); ii. Amount and frequency of treatment services (client file numbered 2); iii. Anticipated duration of treatment services (client file numbered 1); and iv. Resources to refer the client to when needs are the addressed concurrently by another provider (client files numbered 1 and 2); and d. The ITP was not updated based on new information gathered about the client’s condition (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2 and 245G.09, subdivision 3. 22. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following way: a. A weekly treatment plan review was not completed for the weeks starting: i. February 07 (client file numbered 1); and ii. January 23, January 30, February 13, February 20, and February 27, 2023 (client file numbered 2); b. A treatment plan review was not entered in the client’s file weekly or after each treatment service, whichever was less frequent for the week starting February 21, 2022 (client file numbered 1); c. The treatment plan review did not include the following: i. The span of time covered by the review for the notes dated: 1. February 04, 2022 (client file numbered 1); and 2. February 07, March 30, April 30, and May 30, 2023 (client files numbered 2); ii. Whether the methods to address the goals were effective (client file numbered 1); and iii. Monitoring of any physical and mental health problems (client file numbered 1); and d. Treatment plan review did not address each goal in the treatment plan for the note dated April 30, 2023 (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 3 and 245G.22, subdivision 15, paragraph (c). 23. Violation: One of three client files reviewed for requirements governing medication orders (client file numbered 2) failed to meet requirements. A client-specific order was not received prior to the program dispensing a medication used for the treatment of an opioid use disorder. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 3. 24. Violation: One file was reviewed for requirements governing discharge summaries (client file numbered 4) and failed to meet requirements as follows: a. The discharge summary was not recorded in the six dimensions listed in Minnesota Statutes, section 245G.05, subdivision 2, paragraph (c); and b. The discharge summary did not include the following: i. Risk descriptions according to Minnesota Statutes, section 245G.03; ii. The client’s living arrangements at service termination; and iii. Service termination diagnosis. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). 25. Violation: Three of three client files review for requirements governing the central registry did not meet requirements in the following ways: a. The original information of the data submitted to the state central registry at admission was not kept in the client’s record (client files numbered 2 and 3); and b. The information submitted to the state central registry did not include the client’s full name as the middle initial was missing (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a). 26. Violation: The license holder failed to meet requirements governing quality improvement plans. A quality improvement plan was not annually reviewed for calendar year 2022; therefore, the license holder did not evaluate the following: a. Determine whether the goals were met and, if, not whether additional action is required; b. To include new or continued goals based on an updated evaluation of services; and c. Identify two specific goal areas, in addition to others identified by the program, including: i. A goal concerning oversight and monitoring of the premises around and near the exterior of the program to reduce the possibility of medication use for the treatment of opioid use disorder being inappropriately used by a client; and ii. A goal concerning community outreach to increase coordination of services and identification of areas of concern to be addressed in the plan; and Statute Violated: Minnesota Statutes, section 245G.22, subdivision 18. 27. Violation: The license holder failed to meet requirements governing program abuse prevention plans. There was no documentation that the license holder’s governing body or the governing body’s delegated representative reviewed the plan for the calendar year 2022. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Immediate corrective action required You must immediately correct the violations cited above. You must immediately correct the violations cited above. Submit documentation to the DHS Licensor within 30 days of the effective date of this conditional license order explaining how you are correcting the violations. If you fail to demonstrate substantial compliance with Substance Use Disorder treatment requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Additionally, DHS will not approve a request to open a new licensed program from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the substance use disorder treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from the effective date of this conditional license order, you must notify current clients and all parties who refer clients to the program of the conditional status of the license. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. The notification must be approved by DHS Licensing prior to being sent to clients and all other parties. Therefore, the draft notice must be submitted to DHS Licensing for approval within 10 days of receipt of the order. While the license in on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving treatment services. The notification to new clients must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Documentation of notification of the conditional status must be maintained in each client’s file. 2. Within 15 days from the effective date of this conditional license order, you must identity a Compliance Officer who will be responsible for correcting the violations identified in this order, completing the terms identified in this order, and monitoring ongoing compliance with requirements for Substance Use Disorder treatment programs. The Compliance Officer cannot also hold the position of Treatment Director or Alcohol and Drug Counselor Supervisor and must know and understand the requirements of Minnesota Statutes, chapters 245A, 245G, and 260E, and sections 626.557 and 626.5572. The Compliance Officer must be approved by DHS Licensing. 3. Within 15 days from the effective date of this conditional license order, you must submit a description of how a registered nurse will provide supervision as defined in section 148.171, subdivision 23 to staff members who have been delegated the task of administration of medication or assisting with self-medication. The description must identify how supervision will be provided, including a minimum of monthly on-site supervision or more often if warranted by a client's health needs. The description must also address how supervision will be documented, including documenting review of medication administration records and documenting supervision provided to address missing documentation. The description must be approved the DHS Licensor and be included in the policies and procedure manual upon approval. 4. Within 30 days from the effective date of this conditional license order, you must develop and submit a plan for managing client record documentation. This plan must be approved by DHS Licensing and must include: a. A description of how you will ensure that client record is protected against loss, tampering, or unauthorized disclosure; b. A description of how you will ensure that entries into the client record are accurate; and c. A description of how you will ensure that corrections to entries are made in a way in which the original entry may still be read; and d. Name and title of those responsible to carry out the duties of the plan. 5. Within 30 days from the effective date of this conditional license order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by DHS Licensing and must include: a. A description of how you will ensure that background study requirements are met on an ongoing basis, including identifying who will be responsible for managing staff background studies, and documentation that the responsible person has received training on these duties; and b. A description of how you will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation that the person has received training on these duties. The plan must identify the material which will be used to complete each required orientation and training item and include forms which will be used to document staff orientation and training. 6. Within 30 days of receipt of this order, you must develop a self-monitoring plan for an ongoing approach for monitoring compliance with applicable rules and statutes requirements. The self-monitoring plan must include the following: a. Name and title of those responsible to carry out the duties of the plan; and b. A procedure that includes a sample review of patient records requirements, personnel files, a medication administration records, grievances, and monitoring of the implementation of policies and procedures monthly. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the monthly reviews and corrective actions taken must be submitted to your licensor quarterly, by the 15th of the month for January, April, July and October, or until otherwise determined by DHS Licensing during the duration of the conditional 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 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 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for 2 from that date. You continue to be required to comply with all substance use disorder treatment laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Substance use disorder treatment facilities are required to follow Minnesota Statutes, section 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. 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
|
