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November 22, 2023 Guled Mohamoud, Authorized Agent Twin Cities Health Services 3255 Hennepin Ave Minneapolis, MN 55408-3470 License Number 1094287 (245G) CORRECTION ORDER Dear Guled Mohamoud: On August 21 through 22, 2023, Department of Human Services (DHS) licensors conducted a modified licensing review at your facility located at 3255 Hennepin Ave, Minneapolis, MN 55408. As a result of this visit, DHS determined that you are in violation of 13 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. Policies, Practices, and Procedures 1. Violation: The license holder’s description of treatment services did not define the program’s treatment week. Statute Violated: Minnesota Statutes, section 245G.12. Repeat Violation: In the Order of License Revocation issued on May 31, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the description of treatment services meets all applicable requirements. 2. Violation: The license holder’s program abuse prevention plan (PAPP) did not meet requirements. The PAPP referenced the program’s former address and did not include an assessment and evaluation of the current location for the following: a. The condition and design of the building as it relates to the safety of the clients; b. The existence of areas in the building which are difficult to supervise; c. The location of the program in a particular neighborhood or community; and d. The type of grounds and terrain surrounding the building. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Repeat Violation: In the Order of License Revocation issued on May 31, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. The violation was corrected during the licensing review, no further corrective action is required. 3. Violation: The license holder failed to have at least one staff member on the premises when clients were present for the week of June 19, 2023, who had a current American Red Cross standard first aid certificate or an equivalent certificate and at least one staff member of the premises who had a current American Red Cross community, American Heart Association, or equivalent CPR certificate. License holder confirmed that staff were not CPR/first aid trained. Two staff members did receive these certifications on August 18, 2023. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program meets all applicable staffing requirements. Personnel Files 4. Violation: One personnel file was reviewed for requirements governing individuals with a temporary permit (personnel file numbered 1) and did not meet requirements. Supervision provided by a licensed alcohol and drug counselor was not documented for the weeks of June 9, 16, 23, and 30, 2023. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications meet all applicable requirements. Client Files 5. Violation: Two of three client files reviewed for requirements governing confidentiality did not meet requirements. Records were not protected against loss, tampering or unauthorized disclosure as follows: a. A progress note dated June 1, 2023 documented that program staff spoke with housing staff and there was no release of information (client file numbered 2); and b. An individual not identified as program staff documented in the client record (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Repeat Violation: In the Order of License Revocation issued on May 31, 2023 you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that confidentiality of client records meets all applicable requirements. 6. Violation: One client file reviewed for requirements governing client rights protection (client file numbered 3) did not meet requirements in the following ways: a. The client was not given a written statement of the client’s rights as identified in Minnesota Statutes, section 148F.165 on the day of service initiation; and b. The client was oriented to an outdated grievance procedure. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3 and 245G.15, subdivisions 1 and 2. Repeat Violation: In the Order of License Revocation issued on May 31, 2023 and Correction Orders dated March 30, 2021 and December 10, 2019, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all applicable requirements are met for client rights protection. 7. Violation: One of two client files reviewed for requirements governing service initiation (client file numbered 9) did not meet requirements in the following ways: a. An initial services plan was not completed within 24 hours of the day of service initiation; and b. A determination of whether the client is a vulnerable adult was not completed within 24 hours of service initiation. Statute Violated: Minnesota Statutes, section 245G.04. Repeat Violation: In the Order of License Revocation issued on May 31, 2023 and Correction Orders dated March 30, 2021 and December 10, 2019, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client service initiation meets all applicable requirements. 8. Violation: One client file reviewed for requirements governing client orientation (client file numbered 3) did not meet requirements. Client records did not contain the following documentation: a. Orientation to HIV minimum standards approved by the commissioner; b. Information on tuberculosis education on a form approved by the commissioner; and c. Orientation to the program’s internal reporting procedures. Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c), and 245G.09, subdivision 3. Repeat Violation: In the Order of License Revocation issued on May 31, 2023 and Correction Orders dated March 30, 2021 and December 10, 2019, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 9. Violation: Two of nine client files reviewed for requirements governing comprehensive assessments and comprehensive assessment summaries did not meet requirements in the following ways: a. The comprehensive assessment and comprehensive assessment summary were not completed within three days on which a treatment session had been provided of the day of service initiation (client file numbered 3); b. The comprehensive assessment did not contain the following information: i. A person-centered reason for the delay and the planned completion date of the comprehensive assessment (client file numbered 3); ii. Ability to understand written treatment materials, including rules and client rights (client file numbered 3); iii. Leisure time activities that have been associated with substance use (client file numbered 4); and iv. A client identified as having opioid use disorder (client file numbered 4) did not receive education concern the following: 1. Risk for opioid use disorder and dependence; 2. Treatment options, including the use of a medication for opioid use disorder; 3. The risk of and recognizing opioid overdose; and 4. The use, availability, and administration naloxone to respond to opioid overdose; and c. The comprehensive assessment contained inconsistent information for the following: i. Previous attempts at treatment for substance misuse or substance use disorder (client file numbered 3); ii. Frequency of use (client files numbered 3 and 4); and iii. Duration of use (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1, paragraph (a) and (b) and 2, paragraph (a). Repeat Violation: In the Order of License Revocation issued on May 31, 2023 and Correction Orders dated March 30, 2021 and December 10, 2019, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessment and comprehensive assessment summaries meet all applicable requirements. 10. Violation: Five of eight client files reviewed for requirements governing individual treatment plans (ITPs) did not meet requirements in the following ways: a. The ITP was completed prior to the completion of the comprehensive assessment summary; and therefore, could not address each issue identified the assessment summary (client files numbered 3, 5, and 6); b. The ITP was not completed within five calendar days on which a treatment session has been provided from the day of service initiation (client file numbered 10); c. The ITP did not include specific methods to address each identified need in the comprehensive assessment summary (client file numbered 3); and d. The ITP was not updated based on new information gathered about the client’s condition, the client’s level of participation, and on whether methods identified had the intended effect (client file numbered 2). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 1 and 2. Repeat Violation: In the Order of License Revocation issued on May 31, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 11. Violation: Two of two client files reviewed for requirements governing documentation of treatment services did not meet requirements in the following ways: a. The treatment service was not documented in the client record within seven days of the provision of the treatment service (client file numbered 2). The treatment service was provided on July 17, 2023 and documentation was not completed until August 08, 2023; and b. The group notes consisted of a full day of programming and did not document the type and amount of each treatment service provided to the client for the following dates: i. June 21, 26 and 27 and July 11, 2023 (client files numbered 2); and ii. August 15, 2023 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Repeat Violation: In the Order of License Revocation issued on May 31, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation of treatment services meets all applicable requirements. 12. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan reviews did not include the following: a. Indicate the span of time covered by the review for the week of August 06, 2023 (client file numbered 3); b. Address whether the methods to address goals were effective for the weeks of May 28 and July 02, 2023 (client file numbered 2); c. Include monitoring of any physical and mental health problems for week of May 28 and June 25, 2023 (client file numbered 2); and d. Document staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change for the week of June 25, 2023 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: In the Order of License Revocation issued on May 31, 2023 and Correction Orders dated March 30, 2021 and December 10, 2019, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 13. Violation: Two of two client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The services discharge summary was not completed within five days of the client’s service termination (client file numbered 1); and b. The services discharge summary did not include the client’s progress toward achieving each goal identified in the individual treatment plan (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: In the Order of License Revocation issued on May 31, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that services discharge summaries meet all applicable requirements. RECOMMENDATIONS The following recommendations are provided to call your attention to an area where your facility is in minimum compliance with the requirements of statutes or laws, but it would be advisable to strengthen your efforts in these areas: 1. Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a) requires a license holder to offer treatment coordination services provided one-to-one by an individual who meets the staff qualifications in Minnesota Statutes, section 245G.11, subdivision 7. Through review of client charts and interviews with staff, it was determined that treatment coordination is being provided by an alcohol and drug counselor (ADC); however, the ADC job description did not include the duties of treatment coordination. It is recommended that the ADC job description be updated to reflect these duties. 2. Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a) requires license holders to identify the primary and secondary person or position to whom internal reports may be made in the policy and procedures on internal reporting. The program’s Vulnerable Adult Policy identifies the Treatment Director as the primary contact and the Clinical Director as the secondary contact if the Treatment Director is involved in the alleged or suspected maltreatment. As the Clinical Director reports to the Treatment Director, it is recommended that the policy be updated to have a secondary contact for internal reporting with a higher degree of authority than the primary contact. Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow these 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. 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, section 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 651-431-6671 Sincerely, Maura McGarry, Supervisor Licensing Division Office of Inspector General
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