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October 26, 2023 CERTIFIED MAIL Gerald Powers, Authorized Agent Pathway House 613 2nd St. SW Rochester, MN 55902 License Number: 802845 (245G) ORDER OF CONDITIONAL LICENSE Dear Gerald Powers: The Department of Human Services (DHS) is placing your license to provide substance use disorder services at Pathway House, 613 2nd St. SW, Rochester, MN 55902 on conditional status for two years, beginning November 8, 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 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 July 24, 25 and 26, 2023, DHS licensors conducted a licensing review and investigation at your facility located at 613 2nd St. SW, Rochester, MN 55902. As a result of this licensing visit, the DHS licensing determined that your program failed to comply with the laws and rules that apply to licensed Substance Use Disorder programs, citing 22 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature and Severity: Your program failed to follow requirements that affected the health, safety, and rights of persons served: o The program failed to comply with background study requirements (violation numbered 1). o The program failed to ensure client rights were protected (violation numbered 2). o The program failed to ensure staff requirements for designating a responsible staff person and first aid certification were met (violation numbered 3). o The program failed to meet requirements for billing for services (violation numbered 4). o The program failed to provide training related to administration of medication training (violation numbered 5). o The program failed to ensure staff were qualified (violation numbered 6). o The program failed to complete individual abuse prevention plans as required (violation numbered 7). o The program failed to comply with client service initiation and orientation requirements (violation numbered 8). o The program failed to complete treatment plan reviews as required (violation numbered 9). o The program failed to complete comprehensive assessments and comprehensive assessment summaries as required (violation numbered 10). o The program failed to document treatment services as required (violation numbered 16). · Chronicity: Your program failed to correct prior violations cited in a Correction Order that DHS issued on September 29, 2021. Of the 22 violations in this Order, 18 are repeat violations. Furthermore, in a Correction Order that DHS issued on September 29, 2021, the program was recommended to develop and implement measures to strengthen its efforts. The license holder failed to implement recommendations relating to: o Staff training on Minnesota Statutes, Chapter 245G; o Self-monitoring plan for auditing compliance with Minnesota Statutes, Chapter 245G; and o Central Tracking log for documentation timelines. Due to the serious and chronic 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 services 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: The license holder failed to comply with the following background study requirements: a. The license holder failed to request background studies on five staff persons (SP) (personnel files numbered 8 through 11) before they began working in positions allowing direct contact with persons served. 1) SP (personnel numbered 8) was hired and began working in a position allowing direct contact with persons served by the program on December 7, 2018. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request for the SP. 2) SP (personnel numbered 9) is a controlling individual, in a position allowing direct contact with persons served by the program since March 14, 1991. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request for the SP. 3) SP (personnel numbered 10) was hired and began working in a position allowing direct contact with persons served by the program on April 19, 2022. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request for the SP. 4) SP (personnel numbered 11) was hired and began working in a position allowing direct contact with persons served by the program on July 5, 2023. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request for the SP. b. The license holder has multiple programs but failed to affiliate two SP (personnel files numbered 4 and 13) on both active rosters. 1) SP (personnel numbered 4) was hired and began working in a position allowing direct contact with persons served by the program on December 20, 2022. At the time of the licensing review and investigation on July 27, 2023, the license holder had not affiliated the SP with license number 802845. 2) SP (personnel numbered 13) was hired and began working in a position allowing direct contact with persons served by the program on June 5, 2023. At the time of the licensing review and investigation on July 27, 2023, the license holder had not affiliated the SP with license number 802845. c. The license holder did not submit a background study request to DHS for an individual who previously had a cleared study that expired (personnel files numbered 5 ,7, and 12). 1) SP (personnel numbered 5) was hired and began working in a position allowing direct contact with persons served by the program on December 17, 2020. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. 2) SP (personnel numbered 7) was hired and began working in a position allowing direct contact with persons served by the program on December 15, 2022 At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. 3) SP (personnel numbered 12) was hired and began working in a position allowing direct contact with persons served by the program on February 24, 2018. At the time of the licensing review and investigation on July 27, 2023, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. Statute Violated: Minnesota Statutes, sections 245C.03, subdivision 1, 245C.04, subdivision 1, paragraphs (a), (b), and (g), and 245C.07, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 2. Violation: The license holder failed to monitor the implementation of their policies and procedures to ensure client rights were protected under MN Statute 144.651. The license holder’s implementation of their policy Client Statuses at Pathway House, violated client’s rights in the following ways: a. Violation of the right to refuse care under MN Statute 144.651, subdivision 12. During an interview with a client and staff person at the time of the licensing review and investigation, it was identified that clients are given a (1) on the accountability sheet if the client misses medication time. Two (1s) received within 24 hours results in the client’s movement being restricted to the house; and b. Violation of services to the facility under MN Statute 144.651, subdivision 23. Household chores are a part of the client statuses as Pathway House protocol, and this includes cleaning staff and client bathrooms, grounds keeping, cleaning the kitchen, etc. This is a standard of practice within the facility and ties to the accountability sheet to determine the level client of status of independence. Services within the facility must be for therapeutic purposes and appropriately goal-related in their individual medical record. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and 245G.15, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 3. Violation: The license holder failed to meet staff requirements in the following ways: a. The treatment director failed to designate a responsible staff member who, when present at the facility, is responsible for the delivery of treatment service during all hours of operation; and b. The license holder failed to ensure that when clients were present at least one staff person 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 who has a current American Red Cross community, American Heart Association, or equivalent CPR certificate. A DHS licensor reviewed a sample of three days. The license holder was unable to provide documentation that the requirement was met during the following time periods: 1) 12am to 8am and 4pm to 12am on June 13, 2023; 2) 12am to 8am and 4pm to 12am on June 18, 2023; and 3) 12am to 8am and 4pm to 12am on July 4, 2023. Statute Violated: Minnesota Statutes, section 245G.10, subdivisions 3 and 5. 4. Violation: The license holder failed to meet requirements for receiving public funding reimbursement from the commissioner for services provided. The license holder failed to provide the 15 hours of weekly clinical services required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b) to clients receiving public funding reimbursement for medium intensity residential treatment (client file numbered 3). The file documented the client received: a. No hours of services the week ending February 19, 2023; b. 3.25 hours of services the week ending February 26, 2023; c. 3.25 hours of services the week ending March 5, 2023; and d. 4 hours of services the week ending March 12, 2023. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 5. Violation: Three of three personnel files reviewed for requirements governing administration of medication training (personnel files numbered 2, 4, and 6) failed to include documentation that staff members were trained according to a formalized training program that is taught by a registered nurse. The training was being taught by, and documentation was signed by, the treatment director who is not a registered nurse. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (b). 6. Violation: Two of two personnel files reviewed for requirements governing staff qualifications failed to meet requirements in the following ways: a. The personnel file did not contain the staff person’s temporary permit (personnel files numbered 1 and 3); and b. The license holder failed to document weekly supervision of individuals with temporary permits. 1) May, 2022 to May 2023 (personnel file numbered 1); and 2) September, 2022 (personnel file numbered 3). The license holder, during the licensing review and investigation, did verify staff member’s temporary permit (personnel files numbered 1 and 3) and placed copies in the personnel files. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11 and 245G.13, subdivision 3. 7. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans (IAPPs) failed to meet requirements in the following ways: a. The IAPP was not completed within 24 hours of the day of service initiation (client files numbered 2 and 6); b. According to MN Statutes 626.557, the license holder failed to comply with the following (client file numbered 1): 1) The assessment of the person’s risk of abusing other vulnerable adults was identified as no risk and documentation contained in the client’s file identified the client as a predatory offender; 2) The facility failed to identify a vulnerable adult had committed a violent crime or an act of physical aggression towards others and the IAPP did not detail the measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility, if unsupervised; and 3) There was no documentation demonstrating that the person receiving services had participated in the development of the IAPP (client files numbered 1 through 4, and 6). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), and 626.557, subdivision 14, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 8. Violation: Two of five client files reviewed for requirements governing service initiation and orientation failed to meet requirements in the following ways: a. The statement of client rights and responsibilities were not given to the client on the day of service initiation (client files numbered 2 and 6); b. The client was not oriented to internal and external reporting policies, including the telephone number for the Minnesota Adult Abuse Reporting Center and the program abuse prevention plan within 24 hours of admission to the program, or 72 hours for persons who would benefit more from a later orientation (client file numbered 2 and 6); and c. The license holder did not seek consent for the disclosure of suspected maltreatment upon admission (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (c), 245G.09, subdivision 3, and 245G.15, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 9. Violation: Five of five client files reviewed for requirements governing treatment plan reviews failed to meet requirements for the following: a. No documentation in the client file of weekly treatment plans or after each treatment service, whichever is less frequent for the following. 1) April 21 and 28, May 5, 12, 19, and 26, June 2, 9, 16, 23, and 30, and July 7, 14, and 21, 2023, which spanned the entire duration of the client’s placement (client numbered 1); 2) June 16, 23, and 30, and July 7 and 21, 2023 (client file numbered 2); 3) March 5 and 12, 2023 (client file numbered 3); and 4) July 7, 2023 (client file numbered 6); b. The March 20, 2023, treatment plan review did not address whether the methods to address the goals were effective (client file numbered 4); c. The April 11, 2023, treatment plan review did not document staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 4); and d. The April 11 and May 17, 2023, treatment plan review continued to include a goal of job searching when a job was obtained according to the March 27, 2023, review (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 10. Violation: Five of five 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 summary was not completed within 3 calendar days from the day of service initiation (client files numbered 2 and 6); and b. There was no documentation of the following: 1) Any previous attempts at treatment for compulsive gambling was blank (client file numbered 2); 2) Frequency and duration of use (client files numbered 1 and 6); 3) Each substance used within the previous 30 days, the information must include the date of the most recent use and address the absence or presence of previous withdrawal symptoms. was blank (client file numbered 4); 4) A description how use affected the client’s ability to function appropriately in a work and educational settings was blank (client files numbered 1, 3, 4, and 6); 5) A description of the client’s ability to understand written treatment materials, including rules and client rights (client files numbered 3 and 6); and 6) Whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client files numbered 1, 3, 4, and 6). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1, paragraph (a), 2, (a), and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 11. Violation: Four of five client files reviewed for requirements governing individual treatment plans failed to meet requirements in the following ways: a. The individual treatment plans were not completed within 10 calendar days from the date of service initiation (client files numbered 1, 2, 3 and 6); b. An individual treatment plan was not signed by the alcohol and drug counselor (client file number 2); and c. Treatment plan methods did not describe the amount and frequency of treatment services (client files numbered 1 and 6). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 2, 245G.07, subdivision 1, paragraph (b), and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 12. Violation: One of five client files reviewed for requirements governing documentation of the client’s use of medication (client file numbered 1) failed to record the client’s use of medication, including staff signatures with date and time, for the dates of July 10, 15, 16, 18 through 21, and 23 through 31, 2023. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245G.08, subdivision 5, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 13. Violation: One of two personnel files reviewed for requirements governing orientation training failed to meet requirements. There was no documentation to demonstrate the staff person (personnel file numbered 4) received orientation within 24 working hours of starting. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 14. Violation: One of two personnel files reviewed for requirements governing annual training and every two-year training (personnel file numbered 3) failed to contain documentation of any annual or every two-year training records. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (c), (d), and (e), and 260E. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 15. Violation: Five of five client files reviewed for requirements governing initial services plan failed to meet requirements in the following ways: a. The initial services plan was not completed within 24 hours of the day of service initiation (client files numbered 2 and 6); and b. The initial services plan was not person-centered and client specific (client files numbered 1 through 4, and 6). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1, and 245G.09, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 16. Violation: Three of four client files reviewed for documentation of treatment services received in weeks sampled (client files numbered 1, 2 and 4) failed to meet requirements in the following ways: a. The client file did not contain documentation of the following treatment services: 1) Group counseling on June 28, 2023 (client files numbered 1 and 2); 2) Group counseling on July 19, 2023 (client file numbered 2); and 3) Group counseling on March 20 and March 27, 2023 (client file numbered 4); and b. Groups were led by one staff and documented by a different staff in the client record: 1) April 3, 2023 (client file numbered 4); 2) April 20, 2023 (client file numbered 1); 3) April 24, 2023 (client files numbered 1 and 4); and 4) July 19, 2023 (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 2a. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 17. Violation: The license holder failed to meet requirements governing grievance procedures and practices in the following ways: a. The grievance procedure did not include the current phone number for the Minnesota Department of Human Services, Licensing Division; and b. The license holder failed to document a response within three days of a staff member’s receipt of the grievance for two out of nine grievances reviewed (grievances dated August 18, 2022 and May 3, 2023). Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 18. Violation: Six of six personnel files reviewed for requirements governing the contents of personnel files failed to contain: a. A job description (personnel files numbered 1 through 4, 6, and 7); b. A completed job application signed by the staff member and containing the staff member’s qualifications for employment (personnel files 2, 4, 6, and 7); and c. Written annual review of the staff member’s job performance in 2022 (personnel files numbered 1 and 3). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 19. Violation: Three of five client files reviewed for requirements governing client record documentation (client files numbered 1, 2, and 6) failed to meet requirements in the following ways: a. A note was not entered following a significant event impacting the client’s treatment plan (client files numbered 1, 2 and 6); b. The client record did not contain documentation of a therapy appointment the client attended (client numbered 6); and c. Each entry was not signed, dated and inclusive of the job title or position of the staff person making the entry (client files numbered 1, 2, and 6). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 20. Violation: Three of three client files reviewed for requirements governing discharge summaries failed to meet requirements in the following ways: a. The client was discharged on June 3, 2023 and there was no discharge summary contained in the file at the time of the review (client file numbered 5); b. The discharge summaries were not completed within five days of the client’s service termination (client file numbered 3 and 4); c. The discharge summary did not include needs while participating in treatment and services provided (client file numbered 4); and d. The discharge did not include the client’s progress toward achieving each of the goals identified in the individual treatment plan. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 21. Violation: The license holder failed to maintain accurate client records. Group notes included template information relating to relapse prevention groups that discharged clients were required to attend for 8-12 weeks. The treatment director confirmed this was no longer the program’s practice, at the time of the licensing review and investigation (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on September 29, 2021, you were previously found in violation of this same statute. 22. Violation: The license holder failed to monitor the implementation of their policies. The license holder had two internal and external maltreatment reporting policies posted that indicated different primary and secondary persons/positions to whom internal reports may be made. This violation was self-corrected at the time of the licensing review and investigation. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245A.65, subdivision 1, paragraph (d). Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected 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. Submit documentation to your licensor as outlined in the Conditional License terms below: 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 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 14 days of receipt of this order, you must notify current clients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by your DHS Licensor prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving services. The notification to new clients must specify the length of time of the conditional status of your 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. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file. Within 30 days of receipt of this order, you must submit to your DHS Licensor, a copy of the notice and a list of all referral sources that received the notice. 2. Within 14 days of receipt of this order, you must contact Paula Halverson, DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager, to schedule a training on requirements for Substance Use Disorder residential treatment programs under Minnesota Statutes, Chapter 245G. Individuals required to attend are the Treatment Director, ADC Supervisor, Compliance Officer, Registered Nurse, Authorized Agent and Human Resource designee. Training must be completed within 45 days of receipt of this order. 3. Within 14 days of receipt of this order, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Treatment Director or ADC Supervisor. If providing treatment services, the Compliance Officer may only allocate 50 percent of their working hours to treatment services. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. 2 years of professional experience in the following: 1) A regulatory or compliance position, and 2) Involved in direct care as a substance use counselor, or 3) The development and implementation of mental health or substance use disorder treatment planning in a DHS licensed 245G Substance Use Disorder program. b. Working knowledge of Minnesota Statutes, Chapter 245A (Human Services Licensing) and Chapter 245G (Substance Use Disorder). c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field. 4. Within 30 days of the receipt of this order, you must develop, and submit to DHS, a self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The plan must: a. Identify the Compliance Officer and other persons that may be responsible for assisting the Compliance Officer with monitoring, and these individuals must demonstrate compliance with all applicable laws, rules and statutes; b. Require a sample review of resident records, personnel files, required treatment services, treatment plans and reviews, internal reviews, and grievances on a monthly basis; and c. Require that the Compliance Officer conduct a monthly review of License Holder’s policies and procedures to ensure that they are in compliance with Minnesota Statutes, Chapters 245A and 245G, and that staff are implementing those policies and procedures in compliance with Minnesota Statutes, Chapters 245A and 245G. The self-monitoring plan must be submitted to and approved by the program’s DHS Licensor within 30 days of receipt of this order.. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, beginning on January 15, 2024, and continuing every three months thereafter, on or before the 15th of that month, for 2 years from the effective date of the conditional license. 5. Within 30 days from receipt of this order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the program’s DHS Licensor and must include: a. Identification of the specific individual designated for Human Resources (HR) duties and responsibilities. The person must not be the treatment director, LADC supervisor, or clinical staff person who is involved with the day to day treatment services; b. A description of how the program 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; c. A description of how the program will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; and d. A description of how the program 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 responsible person has received training on these duties. 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 two years 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 programs are required to follow Minnesota Statutes, chapter 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 Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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