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December 04, 2023 Dana Nelson, Authorized Agent AICDC Withdrawal Management 1800 Chicago Ave Minneapolis, MN 55404-2592 License Number 1100408 (245F) CORRECTION ORDER Dear Dana Nelson: On September 18, 19, and 20, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 1800 Chicago Ave, Minneapolis, MN 55404-2592. As a result of this visit, DHS determined that you are in violation of 18 of the withdrawal management 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 did not meet requirements governing the use of law enforcement. The central log of each incident involving law enforcement from July through August 2023 was reviewed. Documentation of an incident on July 26, 2023 did not include the time that law enforcement arrived. Statute Violated: Minnesota Statutes, section 245F.09, subdivision 4. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 use of law enforcement meets all applicable requirements. 2. Violation: The license holder did not meet requirements governing grievance procedures. Two of four grievances reviewed from July through August 2023 did not include an initial response within 24 hours of receipt. Statute Violated: Minnesota Statutes, section 245F.10, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Personnel Files 3. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements as follows: a. The personnel files were missing documentation of the following orientation: i. The specific license holder and staff responsibilities for patient confidentiality (personnel files numbered 2, 3, and 5); ii. Standards governing the use of protective procedures and eight hours of training on the program’s protective procedures policy (personnel files numbered 2 through 5); iii. Patient ethical boundaries (personnel file numbered 3); iv. Patient rights, including the rights of patients admitted under Minnesota Statutes, chapter 253B (personnel file numbered 5); v. Infection control procedures (personnel files numbered 2, 3, and 5); vi. Mandatory reporting under Minnesota Statutes, sections 245A.65 and 626.557 and chapter 260E, including specific training covering the facility’s policies concerning obtaining patient releases of information (personnel files numbered 2 through 5); vii. The program abuse prevention plan (personnel files numbered 2 through 5); viii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2 through 5); ix. HIV minimum standards (personnel files numbered 2, 3, and 5); x. Motivational counseling techniques and identifying stages of change (personnel files numbered 2 through 5); xi. The specific job functions for which the staff member was hired (personnel files numbered 1 and 6); xii. Program policies and procedures (personnel files numbered 2, 3, and 5); and xiii. Patient needs (personnel files numbered 2, 3 and 5); and Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3 and 245F.16, subdivisions 1 and 2, paragraphs (a) and (b). Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff mentioned above have completed the missing trainings. 4. Violation: Two of two personnel files reviewed for requirements governing annual training (personnel files numbered 1 and 5) did not meet requirements. Documentation of annual training for the calendar year 2023 was missing for the following: a. Infection control procedures; b. Mandatory reporting under Minnesota Statutes, sections 245A.65 and 626.557 and chapter 260E, including specific training covering the facility’s policies concerning obtaining patient releases of information; c. HIV minimum standards; and d. Motivational counseling techniques and identifying stages of change. Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3 and 245F.16, subdivision 2, paragraphs (a) and (c). Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 annual training meets all applicable requirements. Within 30 days of receipt of this order, submit verification that the staff identified above have completed the trainings identified above. 5. Violation: Three of six personnel files reviewed for requirements governing personnel file contents did not meet requirements. The following was not contained in the personnel file: a. Documentation of the staff member’s current professional license (personnel files numbered 2 and 6); and b. An annual job performance for the calendar year 2023 (personnel files numbered 1 and 6). Statute Violated: Minnesota Statutes, section 245F.17. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 personnel file contents meet all applicable requirements. Within 30 days of receipt of this order, submit verification that the staff identified above have current professional licensure. Patient Files 6. Violation: Five of five patient files reviewed for requirements governing patient orientation (patient files numbered 1 through 5) did not meet requirements as follows: a. The patient was oriented to an outdated grievance procedure and was not provided with a written copy of the procedure upon admission; and b. Did not receive orientation to the HIV minimum standards. Statute Violated: Minnesota Statutes, section 245A.19 and 245F.10, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient orientation meets all applicable requirements. 7. Violation: Five of five patient files reviewed did not meet requirements governing individual abuse prevention plans (IAPP) as follows: a. Th person receiving services did not participate in the development of the IAPP to the full extent of their abilities (patient file numbered 1); and b. The IAPP was not reviewed and evaluated as part of the service plan review (patient files numbered 1 through 5). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 abuse prevention plans meet all applicable requirements. 8. Violation: Five of five patient files reviewed for requirements governing follow-up screenings (patient files numbered 1 through 5) did not meet requirements. A follow-up screening was not conducted between 4 and 12 hours after service initiation to collect information relating to acute intoxication, other health complaints, and behavioral risk factors that the patient may not have communication at service initiation. Statute Violated: Minnesota Statutes, section 245F.12, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that follow-up screenings meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of the follow-up screening from two patient files that meet all requirements. 9. Violation: Four of five patient files reviewed for requirements governing hourly observation did not meet requirements as follows: a. Hourly observations were missing as follows: i. Nine hours on September 05, 2023 (patient file numbered 2); ii. One hour on September 07, 2023 (patient file numbered 2); iii. Eight hours on September 08, 2023 (patient file numbered 2); iv. Nine hours on September 12, 2023 (patient file numbered 2); v. Sixteen hours on September 13, 2023 (patient file numbered 2); vi. Eight hours on September 14, 2023 (patient file numbered 2); vii. Sixteen hours on September 15, 2023 (patient file numbered 4); viii. Eight hours on September 16, 2023 (patient file numbered 3); ix. Eight hours on September 17, 2023 (patient files numbered 1 and 3); x. Five hours on September 17, 2023 (patient file numbered 4); and xi. Sixteen hours on September 18, 2023 (patient files numbered 1 and 3); and b. Hourly observations were marked for a patient for 4 hours prior to admit on September 14, 2023 (patient file numbered 4). Statute Violated: Minnesota Statutes, section 245F.12, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 hourly observations meet all requirements. Within 30 days of receipt of this order, submit documentation demonstrating that all staff have been trained on the requirements for hourly observations. 10. Violation: Three of five patient files reviewed for requirements governing comprehensive assessment and assessment summaries did not meet requirements as follows: a. A comprehensive assessment and comprehensive assessment summary were not completed within 72 hours of admission and there was no documentation as to why the assessment was not completed within 72 hours of admission (patient file numbered 3); b. The comprehensive assessment did not contain the following information: i. Cultural background (patient files numbered 2 and 4); ii. Amount of substances used (patient file numbered 4); iii. Frequency of use (patient file numbered 2); iv. For each substance used within the previous 30 days, the absence or presence of previous withdrawal symptoms (patient file numbered 4); v. Specific problem behaviors exhibited by the patient when under the influence of substances (patient file numbered 4); vi. Current medical treatment needed or being received (patient file numbered 4); vii. Whether or not the concerns need to be referred to an appropriate health care professional (patient file numbered 4); and viii. Mental health history, including symptoms, and the effect on the patient’s ability to function (patient file numbered 2); and ix. For a patient identified as having opioid use disorder, did not receive commissioner approved educational information of the following (patient file numbered 4): 1. Risks 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 of naloxone to respond to opioid overdose; and c. The comprehensive assessment contained inconsistent information on the circumstances of relapse (patient file numbered 4). Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 comprehensive assessments and assessment summaries meet all applicable requirements. 11. Violation: Five of five patient files reviewed for requirements governing individualized stabilization plans did not meet requirements as follows: a. The plan was not individualized for each patient (patient files numbered 3 through 5); b. The plan was not based on the patient’s initial health assessment (patient file numbered 4); c. Did not identify medical needs and goals to be achieved while the patient was receiving services (patient files numbered 1 and 4); d. Did not include the amount and frequency of stabilization services (patient files numbered 1 through 5); and e. Did not specify the participation of others in the stabilization planning process (patient files numbered 1 through 5). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 stabilization plans meet all applicable requirements. 12. Violation: Three of five patient files reviewed for requirements governing progress notes did not meet requirements as follows: a. A progress note was not entered into the patient’s file immediately following a significant event on August 16, 2023 (patient file numbered 5); and b. Progress notes did not include documentation of the following: i. The patient’s involvement in the stabilization services, including the type and amount of each stabilization service (patient files numbered 1, 2, 4 and 5); ii. The monitoring and observations of the patient’s medical needs (patient file numbered 4); iii. Referrals made to other services or agencies (patient files numbered 1 and 5); and iv. Specify the participation of others (patient file numbered 4) and c. Progress notes from September 14 and 15, 2023 were not signed and dated by the staff person completing the documentation (patient file numbered 4). Statute Violated: Minnesota Statutes, sections 245F.07, subdivision 2 and 245F.19, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 progress notes meet all applicable requirements. 13. Violation: Three of three patient files reviewed for requirements governing discharge plans did not meet requirements. Discharge plans did not contain documentation of the following: a. The plan for follow-up, aftercare, or other post-stabilization services (patient files numbered 4 and 5); and b. Progress toward treatment objectives (patient file numbered 2). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 discharge plans meet all applicable requirements. 14. Violation: Four of five patient files reviewed for requirements governing stabilization services did not meet requirements. There was no documentation of the provision of the following stabilization services: a. Care coordination as follows: i. Coordination with significant others to assist in the stabilization planning process (patient file numbered 4); ii. Coordination with and follow-up to appropriate medical services (patient file numbered 1); and iii. Referrals to substance use disorder services as indicated by the comprehensive assessment (patient files numbered 4 and 5). Statute Violated: Minnesota Statutes, section 245F.08, subdivisions 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization services meet all applicable requirements. 15. Violation: One of five patient files reviewed for requirements governing confidentiality (patient file numbered 4) did not meet requirements. The patient file contained a release of information that did not specify who information may be disclosed to, as required in the Code of Federal Regulations, title 42, sections 2.1 to 2.67. Statute Violated: Minnesota Statutes, section 245F.19, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all patient records are protected against unauthorized disclosure in compliance with the Code of Federal Regulations, title 42, sections 2.1 to 6.27. 16. Violation: Three of five patient files reviewed for requirements governing patient property management (patient files numbered 2, 4 and 5) did not meet requirements. At the time of disbursement of the patient’s funds or other property, the patient’s signature, or the signature of the conservator or payee, was not obtained. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c). Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 patient property management meets all applicable requirements. 17. Violation: Five of five patient files reviewed for requirements of the order of conditional license (patient files numbered 1 through 5) did not meet requirements. License holder did not comply with term 1 of the Order of Conditional License that DHS issued on February 24, 2023. No copy of the notification of the conditional status of the license, including patient and/or legal representative(s) signature was maintained in the patient file. Statute Violated: Minnesota Statutes, section 245A.06, subdivision 1. Corrective Action Required: Immediately and throughout the duration of the conditional license, the license holder must ensure that all terms of the conditional license are being followed. Within 30 days of receipt of this order, submit documentation of patient notification of the conditional license from two patient files that meets all requirements. 18. Violation: Five of five client files reviewed for requirements governing administration of medications did not meet requirements in the following ways: a. The medication administration record did not contain the signatures and titles of each staff administering medication (patient files numbered 1 through 5); b. A progress note dated September 09, 2023 indicates that the patient was administered diazepam, however this was not recorded on the Medication Administration Form (patient file numbered 5); and c. Medications were not given as ordered and guidelines for documenting problems with medication administration, including failure to administer, patient refusal of a medication, adverse reactions, or errors were not followed for the following: i. Thiamine and Folic Acid on August 16, 17, and 18, 2023 (patient file numbered 5); ii. Thiamine and Folic Acid on September 14, 2023 (patient file numbered 4); iii. Thiamine and Folic Acid on September 15, 2023 (patient files numbered 3 and 4); iv. Thiamine and Folic Acid on September 16 and 17, 2023 (patient files numbered 3); v. Gabapentin on September 15, 16, and 18, 2023 (patient file numbered 1); vi. Duloxetine on September 15, 16, and 18, 2023 (patient file numbered 1); vii. Hydrochlorothiazide on September 17, 2023 (patient file numbered 1); viii. Buprenorphine on September 05, 06, 07, 08, and 09, 2023 (patient file numbered 5); and ix. Gabapentin on September 05, 06, 07, 08, and 09, 2023 (patient file numbered 5). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245F.13, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on February 24, 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 medication administration meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that all staff administering medications have been trained on the Medication Administration Policy/Procedure. 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 withdrawal management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F. · 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, Unit Supervisor Licensing Division Office of Inspector General
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