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November 22, 2023 Asha Akubar, Authorized Agent Addiction Counseling Center 1433 E Franklin Ave, Suite 7A Minneapolis, MN 55404 License Number 1085289 CORRECTION ORDER Dear Asha: On 11/13/2023, a Department of Human Services (DHS) licensor conducted a modified licensing review at your facility located at 1433 E Franklin Ave, Suite 7A, Minneapolis, MN 55404. As a result of this visit, DHS determined that you are in violation of 6 of the provisions governing Substance Use Disorder treatment services under Minnesota Statutes, chapter 245G. 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. Policies, Practices, and Procedures 1. Violation: The license holder’s grievance procedure did not contain the current telephone number for the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, paragraph (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that demonstrates compliance. 2. Violation: The license holder did not have documentation the plan for transfer of clients and records upon closure was reviewed in calendar year 2022 and 2023 by a controlling individual. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a review of the plans for transfer of clients and records upon closure meets all applicable requirements. Within 30 days of receipt of this order, you must review and submit documentation of compliance. 3. Violation: The license holder did not have a written standing order protocol by a physician to maintain a supply of naloxone on site and a procedure for monitoring the supply of naloxone including replenishing and destroying as required. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3, and 245G.08, subdivision 6, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the standing order protocol and control of drugs procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a written standing order protocol and a procedure for monitoring the supply of naloxone that demonstrates compliance. Personnel files 4. Violation: One personnel file reviewed for requirements governing staff orientation (personnel file numbered 2) did not contain documentation that training was completed on the programs internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 1, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. 5. Violation: Two of two personnel files reviewed for requirements governing annual, biennial, and additional training did not meet requirements in the following ways: a. No documentation of annual training in calendar years 2022 and 2023 (personnel files numbered 1 and 2): 1) Vulnerable adult maltreatment reporting; 2) Program abuse prevention plan; and 3) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; b. Annual training was completed late in calendar year 2023 (personnel file numbered 1): 1) Obtaining client releases of information; 2) Reporting of maltreatment of minors, according to 260E; 3) Reporting of prenatal exposure to controlled substances; and 4) HIV minimum standards; c. No documentation of biennial training in calendar years 2022 and 2023 (personnel files numbered 1 and 2): 1) Emergency procedures (including behavioral); and 2) Client rights; and d. Additional training for the process for administration of naloxone was not completed in calendar year 2023 (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.08, subdivision 5, and 245G.13, subdivision 2, paragraph (c) and (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above staff received training that demonstrates compliance. 6. Violation: Two of two personnel files reviewed for requirements governing personnel file contents (personnel files numbered 1 and 2) did not contain a written annual review of the employee’s job performance in 2022. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel file contents meet all applicable requirements. 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: 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 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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 treatment 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, Licensor Licensing Division Office of Inspector General
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