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October 16, 2023 Christopher Briggs, Authorized Agent Pride Institute 14400 Martin Drive Eden Prairie, MN 55344 License Number 1030116 (245G) CORRECTION ORDER Dear Christopher: On October 2 and 3, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 2101 Hennepin Avenue Suite 202, Minneapolis, MN 55408. As a result of this visit, DHS determined that you are in violation of 19 of the Substance Use Disorder Treatment 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 have an identified treatment director at the time of the review. The organizational chart identified that the treatment director position was combined with the CEO position; however, the Compliance Officer (personnel file numbered 6) and the CEO (personnel file number 4) both stated the current CEO was not the treatment director, and the CEO did not receive orientation to the specific job responsibilities of the treatment director position. In addition, the Compliance Officer identified that the Director of Clinical Services position was equivalent to the treatment director; however, that person (personnel file numbered 5) was not on the staff list provided for the review or on the NetStudy 2.0 background study roster for the program, and the organizational chart and job description did not support that the position was the treatment director position as defined in section 245G.01, subdivision 27. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program has a treatment director who meets the qualifications of section 245G.11, subdivisions 1 and 3. Within 30 days of receipt of this order, submit a description of how this violation has been corrected, including documentation that the treatment director has been informed of the job responsibilities for the position. 2. Violation: The license holder did not ensure that at least one staff member on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate, and at least one staff member on the premises had a current American Red Cross community, American Heart Association, or equivalent CPR certificate: a. The license holder stated one staff person has been present during evening groups since 8/30/23 and there was no documentation of either a current first aid certificate or a current CPR certificate for the staff person; and b. The license holder did not provide documentation of compliance for times when clients were on the premises for day groups for the time period requested, which was the week ending 9/30/23. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medical emergency staff requirements are met. Within 30 days of receipt of this order, submit documentation which demonstrates compliance for the week prior to the submission. 3. 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 (b), clause (1) (client file numbered 2): a. 1 hour of individual counseling was billed, and 30 was minutes documented on: 1) 5/31/23; 2) 6/23/23; and 3) 7/11/23; b. 1 hour of individual counseling was billed, and the documentation did not identify the amount of service or who provided the service on: 1) 6/9/23; and 2) 6/29/23; c. 6 hours of group counseling were billed and 3 hours were documented on 6/6/23; and d. 2 hours of group counseling were billed and 1 hour was documented on 6/14/23. 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. 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. Repeat Violation: In a Correction Order that DHS issued on December 28, 2022, you were previously found in violation of this same statute. 4. Violation: The license holder did not meet requirements for use of guest speakers. A guest speaker provided treatment services on 9/11/23 and: a. The license holder did not provide the guest speaker with training before the guest speaker provided direct contact services on the following topics: 1) Mandatory reporting of maltreatment, as specified in sections 245A.65, 626.557, and 626.5572 and chapter 260E; 2) Applicable client confidentiality rules and regulations; 3) Ethical standards for client interactions; and 4) Emergency procedures; b. The treatment services description did not identify which groups and topics on which a guest speaker could provide services under the direct observation of an alcohol and drug counselor. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3a, paragraph (d), and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all applicable requirements for use of guest speakers are met. Within 30 days of receipt of this order, submit a procedure for use of guest speakers that meets all applicable requirements, including a revised treatment services description if applicable. 5. Violation: The license holder did not monitor implementation of policies and procedures by program staff, which resulted in not meeting requirements of Minnesota Statutes, section 245G.20 for license holders serving persons with co-occurring disorders: a. The license holder did not have a mental health professional available for staff member supervision. The Mental Health Services policy stated a licensed mental health practitioner provides supervision to the outpatient team and is available for consultation and attends staff meetings; however, the license holder stated that no mental health staff currently attend staff meetings. In addition, the program did not have a procedure for a mental health professional to be available for staff member supervision, as the policy stated a practitioner, not professional, would provide supervision; and b. The license holder did not have continuing documentation of collaboration with continuing care mental health providers for one of two client files reviewed (client file numbered 2). The client had an external psychiatrist and therapist and the license holder was unable to provide documentation of attempts to collaborate with them. The Mental Health Services policy stated collaboration with mental health providers is documented in the weekly review. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements for license holders serving persons with co-occurring disorders are met. Within 30 days of receipt of this order, submit a revised Mental Health Services policy which is current and meets all applicable requirements. If you are unable to meet the requirements in Minnesota Statutes, section 245G.20 for license holders serving persons with co-occurring disorders, contact DHS licensing to remove the specialty designation. 6. Violation: The program abuse prevention plan was not reviewed annually by the license holder's governing body or the governing body’s delegate using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. The license holder provided a copy of the plan which stated it was reviewed in May 2022 and October 2023. The review was not done annually, and there was not documentation of who completed the review, or that it was completed using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program abuse prevention plan is reviewed annually by the license holder's governing body or the governing body’s delegate. Within 30 days of receipt of this order, submit documentation of a recent review which demonstrates compliance. 7. Violation: The vulnerable adult maltreatment reporting policies did not meet requirements in the following ways: a. The license holder had two vulnerable adult maltreatment reporting policies, one in the policies and procedures manual and the client handbook, and one posted at the facility, which included conflicting information on the primary and secondary person or position to whom internal reports may be made and who is responsible for forwarding internal reports to the common entry point; and b. The vulnerable adult maltreatment reporting policy in the policies and procedures manual and client handbook identified a former position which was no longer a position in the program as the secondary position to whom internal reports may be made, who is responsible for forwarding internal reports to the common entry point, and who will ensure that, when required, internal reviews are completed. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraphs (a) and (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all vulnerable adult reporting policies are consistent, and meet all applicable requirements. Within 30 days of receipt of this order, submit a revised policy which meets all requirements. Repeat Violation: You were previously found in violation of this same statute in: · A Correction Order that DHS issued on December 28, 2022 · A Correction Order that DHS issued on August 13, 2021 8. Violation: The license holder had two policies regarding the use of any personal electronic device that can record, transmit, or make images of another client, the Cellular Phones Other Mobile Electronic Devices Usage policy and the “Personal Electronic Device” section of the Client Handbook, which were not consistent. One policy stated clients are not permitted to have devices in group and the other stated clients are not permitted to use devices in group, but did not prohibit clients from having them. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personal electronic device policies are consistent, and that clients are informed of the personal electronic device policy and the right to refuse being photographed or recorded. Within 30 days of receipt of this order, submit a revised policy which will be in both the policies and procedures manual and the Client Handbook which meets all applicable requirements. 9. Violation: The personnel policies did not meet requirements in the following ways: a. A job description was not included for the treatment director position; b. The Alcohol and Drug Counselor Supervisor job description did not include qualifications consistent with the requirements in section 245G.11, subdivision 4; and c. The organizational chart was not accurate: 1) The Alcohol and Drug Counselor Supervisor was not included in the chart; and 2) The chart included a Lead Counselor position, which the license holder stated was no longer a position in the program. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the personnel policies meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment director job description, a revised Alcohol and Drug Counselor Supervisor job description, and a revised organizational chart which meet all applicable requirements. Personnel Files 10. Violation: The license holder failed to follow the personnel training plan term from their Order of Conditional License dated March 30, 2022, and two of two personnel files reviewed for requirements governing orientation did not contain documentation that orientation was provided as required: a. Orientation was not documented as provided within 24 working hours on: 1) The staff members’ specific job responsibilities (personnel files numbered 1 and 2); 2) Policies and procedures (personnel files numbered 1 and 2); 3) Client needs (personnel files numbered 1 and 2); 4) Client confidentiality (personnel file numbered 1); and 5) HIV minimum standards (personnel file numbered 1); b. The file did not include documentation of vulnerable adult maltreatment orientation as required (personnel file numbered 1). The license holder did not document the date the staff member first provided direct contact services to a vulnerable adult; therefore, it could not be determined if orientation was provided within 72 hours of first provided direct contact services to a vulnerable adult as required by section 245G.65, subdivision 3. However, the license holder’s policies required orientation to “the requirements of Minnesota Statute 626.557, all internal policies and procedures related to vulnerable adults, and the vulnerable adult prevention plan” to be provided within the first 72 hours of employment or within 24 working hours of starting. The staff person did not receive training in accordance with the license holder’s policies; and c. Training about the program's drug and alcohol policy was not completed: 1) The file did not contain documentation of training (personnel file numbered 1); and 2) The policy and procedure for training was not completed (personnel file numbered 2). The Drug and Alcohol Policy stated “All new employees will receive training and educational materials concerning the Facility's commitment to a drug free work place including but not limited to the contents of this policy. This training will be conducted during the initial implementation of this policy and during orientation. Employees are required to acknowledge they have received a copy of this Policy.” The file included documentation that the policy was sent to the staff person; however, the license holder stated the staff person did not return the acknowledgement as required. Statute Violated: Minnesota Statutes, sections 245A.04, subdivisions 1, paragraph (c), and 14, paragraph (b), 245A.06, subdivisions 1 and 3, 245A.65, subdivision 3, and 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff orientation is provided. Within 30 days of receipt of this order, submit documentation that orientation has been provided for the staff persons and topics identified above. Repeat Violation: In a Correction Order that DHS issued on December 28, 2022, you were previously found in violation of this same statute. 11. Violation: One personnel file was reviewed for requirements governing individuals with a temporary permit from the Board of Behavioral Health and Therapy to provide substance use disorder treatment service (personnel file numbered 1) and did not contain documentation that supervision was provided at least on a weekly basis. The file was reviewed for supervision from 6/12/23 to 9/30/23, and supervision was not documented the weeks ending 9/2/23, 9/9/23, 9/16/23, 9/23/23, and 9/30/23. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that individuals with a temporary permit receive supervision at least weekly. Within 30 days of receipt of this order, submit documentation that supervision was provided to the staff person identified above for the two weeks immediately following receipt of the order. 12. Violation: Two of three personnel files reviewed for requirements governing opiate antagonists training (personnel files numbered 1 and 2) did not contain documentation of training. Statute Violated: Minnesota Statutes, sections 245A.242 and 245G.08, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff undergo training in the specific mode of opiate antagonists administration used at the program. Within 30 days of receipt of this order, submit documentation of training for the staff persons identified above. 13. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not contain: a. Documentation of inquiries required by sections 604.20 to 604.205 for staff members who provided psychotherapy services made to the staff members’ former employers regarding substantiated sexual contact with a client (personnel files numbered 1 and 2); b. A completed application for employment signed by the staff member and containing the staff member's qualifications for employment (personnel file numbered 1); and c. A written annual review of the employee's job performance (personnel file numbered 3). Following the review, the license holder provided a performance review completed on 1/23/23 and stated it had not yet been entered in the personnel file. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the requirement in item (a) above has been met for the staff person’s identified. Repeat Violation: In a Correction Order that DHS issued on December 28, 2022, you were previously found in violation of this same statute. Client Files 14. Violation: Three of three client files reviewed for requirements governing client record protection contained written consents to disclose information which did not meet requirements of Code of Federal Regulations title 42, chapter 1, part 2, subpart B, section 2.31 to include: a. The purpose of the disclosure (client files number 1, 2, and 3); and b. The date, event, or condition upon which the consents would expire if not revoked before (client files numbered 1 and 2). 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 records are protected according to Code of Federal Regulations title 42. Repeat Violation: In a Correction Order that DHS issued on December 28, 2022, you were previously found in violation of this same statute. 15. Violation: One of three client files reviewed for requirements governing initial services plans (client file numbered 3) did not address immediate health concerns which were identified in the initial services plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. 16. Violation: Two of two clients files reviewed for requirements governing comprehensive assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: a. Sexual orientation (client file numbered 2); b. Frequency of use (client file numbered 2); c. Mental health history, including: 1) Symptoms (client file numbered 1); and 2) The effect on the clients’ ability to function (client files numbered 1 and 2); d. A description of how use affected the client’s ability to function appropriately in a work setting (client file numbered 1); and e. Leisure time activities that have been associated with substance use (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Repeat Violation: You were previously found in violation of this same statute in: · A Correction Order that DHS issued on December 28, 2022 · A Correction Order that DHS issued on August 13, 2021 17. Violation: One of two client files reviewed for requirements governing individual treatment plans (client file numbered 2) did not meet requirements in the following ways: a. The plan was not updated based on new information gathered about the client's condition and whether methods identified had the intended effect; and b. The plan did not include resources to refer the client to when the client's needs were to be addressed concurrently by another provider. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Repeat Violation: You were previously found in violation of this same statute in: · A Correction Order that DHS issued on December 28, 2022 · A Correction Order that DHS issued on August 13, 2021 18. Violation: One of two client files reviewed for requirements governing client record documentation (client file numbered 2) did not document in the client record significant events that occurred at the program on the day the event occurred. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b. Corrective Action Required: Immediately and on an ongoing basis, the license holder must document in the client record any significant event that occurs at the program on the day the event occurs. 19. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. A treatment plan review was not entered in the client file the week ending 9/23/23 (client file numbered 1); and b. A treatment plan review did not document staff recommendations for changes in the methods identified in the treatment plan (client file numbered 2). 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 are entered in client files weekly and meet all applicable requirements. Recommendations The following recommendations are not requirements of Minnesota Statutes or laws governing your services or facility. These recommendations are being made to assist the license holder with achieving and maintaining compliance with applicable requirements on an ongoing basis. Failure to follow these recommendations will not result in a fine or 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. Based on the number and nature of violations identified in this order, including repeat violations, it is recommended that you: 1. Contact your DHS licensor to discuss revisions to your self-monitoring procedures, required in the Order of Conditional License dated March 30, 2022. 2. Revise and resubmit the personnel training plan which was provided in response to term 7 of the Order of Conditional License dated March 30, 2022. You may contact your DHS licensor to discuss revisions; however, it is recommended that at a minimum the plan include: a. A policy which identifies all orientation and new-hire training items, the required completion timeline of each, and how training for each item is completed (for example, an electronic training module, an acknowledgment form, New Employee Orientation session, etc.); b. A policy which identifies all annual and two year training items; c. A procedure which identifies who is responsible for ensuring that orientation and training is completed and documented in the personnel file; d. A revised New Hire Checklist which includes the date of the completion of each item and the name of the staff who verified completion, and initials or signature of the staff person. 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 at: 1. By secure email to: Leah.Wachter@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Leah Wachter 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 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 Leah.Wachter@state.mn.us or at 651-431-6614. Sincerely, Leah Wachter, Senior Licensor Licensing Division Office of Inspector General
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