|
November 17, 2023 Idman Mohamed, Authorized Agent Abria Recovery 13401 County Road 5 Burnsville, MN 55337 License Number: 1103458
Dear Idman Mohamed: This letter supersedes the correction order reconsideration decision letter issued on September 27, 2023, which must be destroyed. This letter is being issued to correct an error in the previous letter issued on September 27, 2023. On May 30, 2023, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on May 9, 2023. You requested reconsideration of: citation 1, paragraphs a and d and paragraph e, clause 2; citation 2; citation 3; citation 4; and citation 11. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 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 August 30, 2022 (client file numbered 3); 15) Two hours on September 13, 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 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 3); 30) Two hours on February 6, 2023 (client file numbered 3); 31) Two hours on February 13, 2023. d. One personnel file reviewed for qualifications of a license 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 245B.05, subdivision 5, paragraph (c), clause (5): 2) Documentation did not include a multidisciplinary case review completed monthly (client files numbered 2 and 3). Request for Reconsideration. With regard to paragraph a, you indicate that a DHS licensor confirmed the staff member’s qualifications and permitted them to begin delivering services to clients. You also indicate there was no mention of the commissioner list at that time. With regard to paragraph d, you indicate you are requesting a review of that item given its relevance to the qualifications of staff members in violation 1, paragraph a. With regard to paragraph e, clause 2, you indicated you sent documentation regarding client file number 3 to the DHS licensor via email after the exit interview, and the licensor indicated the documentation met requirements. You acknowledge the need for documentation of a multidisciplinary case review for client file number 2. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245A.04, subdivision 1, paragraph (i), at the time of application for licensure or renewal of a license under this chapter, the applicant or license holder must acknowledge on the form provided by the commissioner if the applicant or license holder elects to receive any public funding reimbursement from the commissioner for services provided under the license that meet specified conditions. Pursuant to Minnesota Statutes, section 245A.191, when a substance use disorder treatment provider licensed under this chapter, and governed by the standards of chapter 245G or Minnesota Rules, parts 2960.0430 to 2960.0490, agrees to meet the applicable requirements under section 254B.05, subdivision 5, to be eligible for enhanced funding from the behavioral health fund, the applicable requirements under section 254B.05 are also licensing requirements that may be monitored for compliance through licensing investigations and inspections. Noncompliance with the requirements identified may result in specified sanctions. With regard to paragraph a, the telephone recordings from the previously assigned licensor, who is no longer employed by DHS, were reviewed. The recordings did not contain documentation regarding the conversation you mentioned, and you did not provide documentation from the program’s previous Program Director that the conversation occurred. With regard to paragraph d, personnel file numbered 5 did not meet qualifications to provide treatment services as documented in the list maintained by the commissioner. There is therefore sufficient evidence to support violations, and they are affirmed. With regard to paragraph e, the information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation as to paragraph e. Citation 2: Violation: The license holder’s treatment services description failed to include a description detailing which services were provided off-site. Request for Reconsideration. You indicate that during the on-site visit and the exit interviews, there was no discussion about the off-site provision of treatment services, and DHS licensors did not review the program policy manual during their visit. You indicate the manual was provided later. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.07, subdivision 4, the license holder may provide services at any of the license holder’s licensed locations or at another suitable location including a school, government building, medical or behavioral health facility, or social service organization, upon notification and approval of the commissioner. If services are provided off site from the licensed site, the reason for the provision of services remotely must be documented. The license holder may provide additional services as specified off-site if the license holder includes a policy and procedure detailing the off-site location as part of the treatment service description and the program abuse prevention plan. Treatment services were provided off-site per individual and group notes, and the program failed to include a description detailing which services were provided off-site as required by the statute. There is therefore sufficient evidence to support the citation, and it is affirmed. Citation 3: Violation: The license holder’s maltreatment of minors reporting policy contained repealed sections of statute. Request for Reconsideration. You acknowledge that the policy manual contained repealed sections of statute, but you indicate the sections have now been removed. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.12 a license holder must develop a written policies and procedures manual, indexed according to section 245A.04, subdivision 14, paragraph (c), that provides staff members immediate access to all policies and procedures and provides a client and other authorized parties access to all polices and procedures. The manual must contain procedures for reporting the maltreatment of minors according to chapter 260E, and vulnerable adults according to the applicable law. The information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation. Citation 4: Violation: Two of two client files reviewed for requirements governing client rights protection (client files numbered 1 and 3) did not meet requirements. Client rights and grievance policy were not reviewed at service initiation. Request for Reconsideration. You indicate that while the client rights and grievance policy was missing from client file numbered 3 in your electronic system (Procentive), the facility maintained paper copies. You indicate you provided those copies to the DHS licensor. You indicate that for client file numbered 1, there were uploaded documents to indicate the client received orientation on client rights, but the document was entitled “Individual Rights.” You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, sections 245G.09, subdivision 3, paragraph (1), client records must contain documentation that the client was given information on client rights and responsibilities, grievance procedures, tuberculosis and HIV, and that the client was provided an orientation to the program abuse prevention plan required under applicable law. If the client has an opioid use disorder, the record must contain documentation that the client was provided educational information according to applicable law. Under 245G.15, subdivisions 1, a client has the rights identified in applicable law. The license holder must give each client on the day of service initiation a written statement of the client’s rights and responsibilities. A staff member must review the statement with a client at that time. Under subdivision 2, on the day of service initiation, the license holder must explain the grievance procedure to the client or the client’s representative. The grievance procedure must be posted in a place visible to clients, and made available upon a client’s or former client’s request. The grievance procedure must require that: 1) a staff member helps the client develop and process a grievance; 2) current telephone numbers and addresses of the Department of Human Services, Licensing Division; the Office of Ombudsman for Mental Health and Developmental Disabilities; the Department of Health Office of Health Facilities Complaints; and the Board of Behavioral Health and Therapy, when applicable, be made available to a client; and 3) a license holder responds to the client’s grievance within three days of a staff member’s receipt of the grievance, and the client may bring the grievance to the highest level of authority in the program if not resolved by another staff member. You acknowledge that the client rights and grievance policy for client file numbered 3 was missing from Procentive. There is therefore sufficient evidence to support the citation, and it is affirmed with the modification that client file numbered 1 is removed from the citation because that file contained the required documents. Citation 11: 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); and b. Documentation did not include staff signature and job title (client files numbered 1, 2, and 3). Request for Reconsideration. You indicated the program could not confirm or deny the violation and that the program is requesting an updated version of the violation to include information about the staff member who provide the treatment service.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.06, subdivision 2a, the license holder must ensure that the staff member who provides the treatment service documents in the client record the date, type, and amount of each treatment service provided to a client and the client’s response to each treatment service within seven days of providing the treatment service. With regard to paragraph a, treatment service documentation indicates that: · For client 1, a 1/18/2023 group note did not indicate the type of service provided. · For client 2, the note for service provided on 9/1/2022 by the CPRS (mindfulness walk) was entered by the LADC. · For client 2, group notes dated 7/22/2022, 8/4/2022, 8/19/2022, 8/24/2022, 8/26/2022, 9/1/2022, and 9/2/2022 do not include the type of service provided. · For client 3, the note for 9/6/2022 group by a staff person was not signed within 7 days (signed 2/20/2023). · For client 3, the note for 9/15/2022 1:1 had conflicting time periods (2:20-2:55 and 2:20-2:50) and a group note for the same date indicated the client was in group at the same time (12:20-2:50). · For client 3, the 9/13/2022 group note did not include the type of service provided. With regard to paragraph b, although the citation did not specify the staff, the information was verbally provided during the exit interview. At that time, the authorized agent and the treatment director specifically asked which staff did not sign their job title, and the information was provided to them. Also, client record documentation indicated: · GAIN-SS form was not signed (client 1, 2, and 3). · For client 2, group notes dated 8/10/2022, 8/17/2022 and 8/24/2022 contained a staff signature, but not a job title. · For client 3, a group note dated 9/7/2022 contained a staff signature, but not a job title. There is therefore sufficient evidence to support the citation, and it is affirmed and modified to include the details of the citation.
Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support: citation 1 as to paragraphs a and d; citation 2, citation 4 with a modification, and citation 11 with a modification, and they are affirmed. The Commissioner finds it is appropriate to rescind the following: citation 1 as to paragraph e, clause 2; and citation 3. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
|
