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December 4, 2023 Cassie Kasowski, Authorized Agent Beth’s Place 1606 30th Ave. S. Moorhead, MN 56560 License Number 1098356 Report Number 202302756 CORRECTION ORDER Dear Cassie: On September 25 to 28, 2023, Department of Human Services (DHS) licensors conducted an unannounced licensing review and licensing investigation at your facility located at 1606 30th Ave. S. As a result of this visit, DHS determined that you are in violation of 12 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 corrective 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. 1. Violation: The license holder failed to monitor implementation of policies and procedures by program staff, protect client records against unauthorized disclosure, and protect client rights. The license holder’s use of social media, on three separate occasions between October 1, 2022 and March 25, 2023, was inconsistent with the program’s social media policy and violated: a. Client rights identified in section 148F.165 relating to stereotyping, misuse of the client relationship, and exploitation of the client; and b. Client rights identified in section 144.651 relating to courteous treatment, treatment privacy, and confidentiality of records. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (a), 245G.09, subdivision 1, paragraph (a), and 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all program practices meet all applicable requirements. 2. Violation: The treatment coordinator had not completed 30 hours of classroom instruction on treatment coordination for individuals with substance use disorder (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 7 and 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment coordination provider qualifications meet all applicable requirements. Within thirty days of receipt of this order, submit documentation demonstrating how the treatment coordinator meets the definition of a coordinator. 3. Violation: The license holder’s medical services did not meet requirements in the following ways: a. There was no standing order protocol for emergency overdose treatment requirements pursuant to section 245A.242; and b. There was no policy that contained a procedure for monitoring the available supply of naloxone on site, replenishing the naloxone supply when needed, and destroying naloxone. Statute Violated: Minnesota Statutes, section 245G.08, subdivisions 3 and 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services meet all applicable requirements. Within thirty days of receipt of this order, submit a standing order protocol and policy that meet all applicable requirements. 4. Violation: Two of two personnel files reviewed for annual training and development did not meet requirements: a. No documentation that the staff member had been trained annually in 2021 and 2022 on the license holder’s program abuse prevention plan, as only years were identified for annual review, not specific dates (personnel file numbered 3); and b. No documentation of 12 hours of training in co-occurring disorders that includes competencies related to philosophy, trauma-informed care, screening, assessment, diagnosis and person-centered treatment planning, documentation, programming, medication, collaboration, mental health consultation, and discharge planning was not obtained before employment or within six months of employment (personnel files numbered 2 and 3). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all annual training and development meets all applicable requirements. 5. Violation: Two of three client files reviewed for requirements governing service initiation and orientation (client files numbered 1 and 3) did not contain consent to disclosure of suspected maltreatment pursuant to section 626.557, subdivision 3a. Statute Violated: Minnesota Statutes, section 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all service initiation and orientation meet all applicable requirements. 6. Violation: One of three client files reviewed for requirements governing individual treatment plans (ITP) (client file numbered 2) did not meet requirements: a. The ITP was not signed by client; and b. No documentation of the client’s involvement in the development of the plan Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 1, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all service individual treatment plans meet all applicable requirements. 7. Violation: Three of three client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements: a. Client record documented a treatment service provided that was signed late by staff on June 1 and June 8, 2023 (client file numbered 3); b. Treatment plan reviews were not signed by staff for dates September 18 to September 22, 2023 (client file numbered 2); and c. Treatment plan reviews did not include a review and evaluation of the individual abuse prevention plan (IAPP) and the client had an IAPP (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.65, and 245G.06, subdivisions 2a, and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all documentation of treatment services and treatment plan reviews meets all applicable requirements. 8. Violation: One of two client files reviewed for requirements governing discharge summaries (client file numbered 3) did not contain the client’s specific living arrangements at service termination. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all discharge summaries meet all applicable requirements. 9. Violation: The license holder provided the following additional treatment services that were not included in the description of treatment services: a. Peer recovery support services; b. Use of guest speakers; and c. Telehealth. Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 2 and 4, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that description of treatment services meets all applicable requirements. Within thirty days of receipt of this order, submit a treatment services description that meets all applicable requirements. 10. Violation: The license holder’s policy for reporting the maltreatment of minors and vulnerable adults did not meet requirements in the following ways: a. The maltreatment of minors reporting policy did not reference chapter 260E, it referenced an old statute; b. The vulnerable adult maltreatment reporting policy did not identify the primary and secondary person(s) or position(s) to whom internal reports may be made, as only one person was listed for both; and c. The vulnerable adult maltreatment reporting policy did not identify the primary and secondary person or position who will ensure that, when required, internal reviews are completed, as only one person was listed for both. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraphs (a) and (b), and 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that reporting policies meet all applicable requirements. Within thirty days of receipt of this order, submit reporting policies that that meet all applicable requirements. 11. Violation: Policy identified a person other than the treatment director who must designate a staff member who, when present in the facility, is responsible for the delivery of treatment service during all hours of operation. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff requirements meet all applicable requirements. Within thirty days of receipt of this order, submit a revised policy that meets all applicable requirements. 12. Violation: The license holder’s grievance procedure did not meet requirements. The procedure contained an incorrect phone number for the Minnesota Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all grievance procedures and practices meet all applicable requirements. Within thirty days of receipt of this order, submit a revised grievance procedure and client handout relating to grievances. 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 me: 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 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 Program must maintain compliance with the licensing statutes and rules, specifically 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 651-431-2446. Sincerely,
Molly Lang, Substance Use Disorder Senior Licensor Licensing Division Office of Inspector General
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