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October 10, 2023 Idman Mohamed, Authorized Agent Abria Recovery 14750 Lac Lavon Dr Burnsville, MN 55306 License Number: 1103458 AMENDED CORRECTION ORDER NOTICE: This Amended Correction Order supersedes a Correction Order issued May 9, 2023, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on May 30, 2023. This Amended Order reflects the final decision on the request for reconsideration issued on September 27, 2023. Dear Idman: On March 6, 7, and 8, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 13401 County Road 5, Burnsville, MN, 55337. As a result of this visit, DHS determined that you are in violation of 12 of the Substance Use Disorder rules and statutes. 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. Practices, Policies, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided: a. Treatment services were not conducted by a qualified staff member as defined by the commissioners list of professionals qualified to provide treatment services, Minnesota Statutes, section 245G.07, subdivision 3: 1) Two hours on July 25, 2022 (client file numbered 2); 2) Two hours on August 1, 2022 (client file numbered 2); 3) Two hours on August 2, 2022 (client file numbered 2); 4) Two hours on August 8, 2022 (client file numbered 2); 5) Two hours on August 9, 2022 (client file numbered 2); 6) Two hours on August 15, 2022 (client file numbered 2); 7) Two hours on August 16, 2022 (client file numbered 2); 8) Two hours on August 18, 2022 (client file numbered 2); 9) Two hours on August 22, 2022 (client file numbered 2); 10) Two hours on August 23, 2022 (client file numbered 2); 11) Two hours on August 30, 2022 (client file numbered 2); 12) Two hours on September 6, 2022 (client file numbered 3); 13) Two hours on September 12, 2022 (client file numbered 3); 14) Two hours on September 13, 2022 (client file numbered 3); 15) Two hours on September 19, 2022 (client file numbered 3); 16) Two hours on September 20, 2022 (client file numbered 3); 17) Two hours on September 26, 2022 (client file numbered 3); 18) Two hours on September 27, 2022 (client file numbered 3); 19) Two hours on October 2, 2022 (client file numbered 3); 20) Two hours on October 10, 2022 (client file numbered 3); 21) Two hours on October 11, 2022 (client file numbered 3); 22) Two hours on October 17, 2022 (client file numbered 3); 23) Two hours on October 18, 2022 (client file numbered 3); 24) Three hours on October 20, 2022 (client file numbered 3); 25) Two hours on October 24, 2022 (client file numbered 3); 26) Two hours on October 25, 2022 (client file numbered 3); 27) Two hours on October 31, 2022 (client file numbered 3); 28) One hour on January 23, 2023 (client file numbered 1); 29) Four hours on January 30, 2023 (client file numbered 1); 30) Two hours on February 6, 2023 (client file numbered 1); and 31) Two hours on February 13, 2023 (client file numbered 1); b. Peer recovery support services were not provided one-to-one according to Minnesota Statutes, section 245G.11, subdivision 8: 1) One hour on August 26, 2022 (client file numbered 2); 2) One hour on September 1, 2022 (client file numbered 2); 3) Three hours on September 2, 2022 (client file numbered 2); 4) One hour on September 2, 2022 (client file numbered 3); 5) One hour on September 7, 2022 (client file numbered 3); 6) One hour on September 9, 2022 (client file numbered 3); 7) One hour on September 12, 2022 (client file numbered 3); 8) One hour and 27 minutes on September 13, 2022 (client file numbered 3); and 9) One hour on September 16, 2022 (client file numbered 3); c. Service notes did not include information consistent with treatment services: 1) On July 29, 2022, note indicated 2 hours billed for outing (client file numbered 2); 2) On July 28, 2022, August 3, 2022, August 26, 2022, and August 31, 2022, notes say the group was sober recreation but describes an outing not connected to the treatment plan (client file numbered 2); 3) On August 4, 2022, August 18, 2022, August 19, 2022, August 24, 2022, September 1, 2022, September 2, 2022, and September 19, 2022, notes do not say what type of service was provided (client files numbered 2 and 3); and 4) On August 5, 2022 and August 19, 2022, notes described free time to use library resources which is not a treatment service facilitated by staff and education cannot be off-site; d. One personnel file reviewed for qualifications of a licensed professional (personnel file numbered 5) did not meet requirements to provide treatment services; e. The license holder did not meet requirements for programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), clause (5): 1) Documentation did not include a mental health diagnostic assessment within 10 days of admission when scoring positive on a mental health screen (client files numbered 1 and 2). 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 services are provided in the amount and type for which they are billed. Additionally, 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. 2. Violation: The license holder’s treatment services description failed to include a description detailing which services were provided off-site. Statute Violated: Minnesota Statutes, section 245G.07, 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. Client Files 3. Violation: Two of two client files reviewed for requirements governing client rights protection (client file numbered 3) did not meet requirements. Client rights and grievance policy were not reviewed at service initiation. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, paragraph (1), and 245G.15, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client rights protection meets all applicable requirements. 4. Violation: One of three client files reviewed for requirements governing client orientation (client file numbered 1) did not meet requirements. Maltreatment of vulnerable adults was not reviewed within 24 hours of admission and the program abuse prevention plan was not reviewed at orientation. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, paragraph (1), and 245A.65, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 5. Violation: Three of three client files reviewed for requirements governing confidentiality contained releases of information which did not meet CFR 42 requirements: a. A signed release for 245G facilities did not identify the program or entity to whom information would be disclosed (client files numbered 1 through 3); and b. A blank release was signed by the client and did not include the program or entity to whom information would be disclosed, purpose, or type of information to be disclosed (client file numbered 3). 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 client confidentiality meets all applicable requirements. 6. Violation: Three of four client files reviewed for governing initial services plans (ISP) did not meet the requirements in the following ways: a. The ISP was not completed within 24 hours of the day of service initiation (client files numbered 2, 3, and 4); and b. The ISP was not client specific (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3, paragraph (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans meet all applicable requirements. 7. Violation: Two of three client files reviewed for requirements governing vulnerable adult assessments (client files numbered 2 and 3) did not contain assessments that were completed within the required timeframe. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure vulnerable adult assessments meet all applicable requirements. 8. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet the requirements in the following ways: a. The assessment was not completed within 3 calendar days and there was no documentation to show a person-centered reason for the delay and the planned completion date of the assessment. Assessment did not include a full substance use history including amounts and types of substances used. Client reported that s/he had used cocaine and other drugs but only alcohol was listed in use history (client file numbered 2); b. The assessment did not include mental health history, including symptoms, and the effect on the client’s ability to function (client files numbered 1 and 2); c. The assessment did not describe how substance use affected the client’s ability to function appropriately in work settings (client file numbered 3); d. The assessment did not document social network in relation to expected support for recovery (client file numbered 2); e. The assessment did not document leisure time activities that have been associated with substance use (client file numbered 3); and f. The summary was not completed within 3 calendar days from service initiation. Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1 and 2, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments and summaries meet all applicable requirements. 9. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet the requirements in the following ways: a. ITPs were not completed within 5 calendar days on which a treatment session has been provided (client files numbered 1, 2, and 3); b. ITP was not signed by the client (client filed numbered 3); c. ITP did not document the client’s involvement in the development of the plan (client file numbered 3); d. ITP did not document how the family or others will be involved in the client’s treatment (client file numbered 1); e. ITPs did not document the specific services for which a client has an assessed need and the plan to provide the services (client files numbered 1 through 4); f. ITPs did not identify the goals the client must reach to complete treatment and terminate services (client files numbered 1, 3, and 4); and g. ITP did not contain active interventions to stabilize mental health symptoms (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 1, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. 10. Violation: Three of three client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. The license holder did not ensure that the staff member who provided the treatment service documented in the clients record the date, type, and amount of treatment service provided and the client’s response to each treatment service within seven days (client files numbered 2 and 3); 1) Note for service provided on 9/1/2022 by the Certified Peer Specialist was entered by the Licensed Drug and Alcohol Counselor (LADC) (client file numbered 2); 2) Group note on 1/18/2023 did not indicate the type of serviced provided (client file numbered 1); 3) Group note for 9/6/2022 was not signed within 7 days (client file numbered 3); 4) Note for 9/15/2022 individual counseling had conflicting time periods and a group note for the same date indicated the client was in group at the same time (client file numbered 3); 5) Group note on 9/13/2022 did not include the type of service provided (client file numbered 3); and b. Documentation did not include staff signature and job title; 1) GAIN-SS form was not signed (client files numbered 1, 2, and 3); 2) Group notes dated 8/10/22, 8/17/22, and 8/24/22 did not contain staff job title (client file numbered 2); and 3) Group note dated 9/7/22 did not contain staff job title (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 11. Violation: Two of four client files reviewed for requirements governing treatment plan reviews did not meet the requirements in the following ways: a. Reviews were not documented weekly or after each treatment service: 1) The weeks of 7/9-7/15/22, 7/30-8/5/22, 8/6-8/12/22, 8/13-8/19/22, 8/20-8/26/22, and 8/27-9/2/22 (client file numbered 2); and 2) The weeks of 9/24-9/30/22, 10/1-10/7/22, 10/8-10/14/22, 10/15-10/21/22, 10/29-11/4/22, 11/5-11/11/22, 11/12-11/18/22, 12/3-12/9/22, 12/10-12/16/22, and 12/17-12/23/22 (client file numbered 3); b. Reviews did not state whether the methods to address the goals were effective (client file numbered 3); and c. Reviews did not document the participation of others (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 12. Violation: Two of two client files reviewed for requirements governing discharge summaries did not meet the requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination (client files numbered 2 and 3); b. The discharge summary did not include the client’s progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 2); and c. The discharge summary did not include continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Corrective action required 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: 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 Recommendations The following recommendations are being made to assist you with achieving and maintaining compliance with applicable requirements on an ongoing basis. Failure to follow these recommendations will not result in an action against your license at this time. However, should failure to follow 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. You may contact your licensor for more information if you choose to implement these recommendations. 1. It is recommended that you update your policies and procedures to clearly distinguish that you are licensed as a non-residential provider, and offer supported housing separate of the 245G program. 2. It is recommended that this information also be included in the intake packet used to provide client orientation to ensure the information is consistent with you being a non-residential program with sober/supportive housing. 3. It is recommended that staff clearly understand their roles between the licensed 245G program and the housing services and be trained on what information may be shared between the two. 4. It is recommended that you contact DHS Licensing if you wish to follow the recommendation to assist with further guidance. Final Agency Decision As stated, above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated May 30, 2023. As such, the decision is not subject to appeal. 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 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 651-431-6617. Sincerely,
Char Hanson, Senior Licensor Licensing Division Office of Inspector General
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