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December 21, 2023 Kathy McKay, Authorized Agent Clay County Receiving Center 715 North 11th Street, Suite 303 Moorhead, Minnesota 56560 License Number 1106922 Withdrawal Management Program License Number 808589 Detoxification Program CORRECTION ORDER Dear Kathy McKay: On September 25, 26, and 27, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 715 North 11th Street, Suite 203, Moorhead, Minnesota, 56560. As a result of this visit, DHS determined that you are in violation of the Withdrawal Management statutes under Minnesota Statute, chapter 245F and Detoxification Services under Minnesota Rules, parts 9530.6510 through 9530.6590 (Rule 32). 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. Throughout the correction order, references to the statute or rule requirements will be identified as follows: · Withdrawal Management Program as (245F); and · Detoxification Program as (Rule 32) Policies, Procedures, and Practices 1. Violation: The license holder did not meet requirements governing the documentation of denied admissions (245F). Documentation of denied admissions were reviewed from June 2022 through September 2023 and did not contain the following information: a. The time of the admission request; and b. Where the individual was referred and the reason why a referral was not made. Statute Violated: Minnesota Statute, section 245F.05, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the documentation of denied admissions meets all applicable requirements. 2. Violation: The license holder’s grievance procedure (245F and Rule 32) did not meet requirements. The grievance procedure did not contain the following: a. The current addresses of the Department of Human Services Licensing Division, Department of Health Office of Health Facilities Complaints, Board of Behavioral Health and Therapy, Board of Medical Practice, Board of Nursing, and the Office of the Ombudsman for Mental Health and Developmental Disabilities; and b. The current telephone number for Board of Behavioral Health and Therapy. Rule and Statute Violated: Minnesota Rules, part 9530.6540 and Minnesota Statute, 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. Within 30 days of receipt of this order, submit a revised grievance procedure that meets all applicable requirements. 3. Violation: The license holder did not follow their own policy for HIV training in substance use disorder treatment programs (245F and Rule 32). Patients were not provided education on the HIV minimum standards contained in the HIV-1 Guidelines for substance use disorder treatment and care programs in Minnesota. Statute Violated: Minnesota Statute, section 245A.19. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation to the HIV minimum standards meets all applicable requirements. Personnel Files 4. Violation: One of six personnel files reviewed for requirements governing background studies (245F) did not meet requirements. Staff Person (SP4) began a position allowing direct contact with persons served by the program on June 01, 2022. During the licensing review, a licensor noted that the staff member (personnel file numbered 4) had two different last names listed on documents. However, the license holder did not initiation a new background study or notify the commissioner of the name change for SP4. Statute Violated: Minnesota Statute, section 245C.04, subdivision 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with background study requirements in Minnesota Statutes, chapter 245C. 5. Violation: Two of three personnel files reviewed for requirements governing annual training (personnel files numbered 2 and 3) did not meet requirements (245F). No documentation of annual training for calendar year 2023 for the following topics: a. Infection control procedures; b. Mandatory reporting under sections 245A.65 and 626.557 and chapter 260E, including: i. Specific training covering the facility’s policies concerning obtaining patient releases of information; ii. The program abuse prevention plan; and iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and c. HIV minimum standards. Statute Violated: Minnesota Statute, sections 245A.65, subdivision 3 and 245F.16, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual training meets all applicable requirements. 6. Violation: One of three personnel files reviewed for requirements governing biannual training (personnel file numbered 6) did not meet requirements (Rule 32). There was no written record of at least 30 hours of continuing education for a staff member working directly with clients. Rule Violated: Minnesota Rules, part 9530.6570, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that biannual training meets all applicable requirements. 7. Violation: One of three personnel files reviewed for requirements governing personnel file contents (personnel file numbered 6) did not meet requirements. The personnel file did not contain the following: a. Documentation of the staff member’s current professional license or registration (245F); and b. An annual job performance evaluation for the calendar year 2021 (Rule 32). Rule and Statute Violated: Minnesota Rules, part 9530.6575 and Minnesota Statutes, section 245F.17. Corrective Action Required: Immediately and on an ongoing basis, the license holder muse ensure that personnel file contents meet all applicable requirements. Patient Files Patient files reviewed are identified in the following manner: · 245F: patient files numbered 1 and 2 · Rule 32: patient file numbered 3 8. Violation: Two of three patient files (patient files numbered 1 and 2) reviewed for requirements governing patient rights did not meet requirements. The license holder did not give each patient, upon admission, a written statement of patient rights as identified in Minnesota Statutes, section 148F.165. Statute Violated: Minnesota Statute, section 245F.10, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation to patients rights meets all applicable requirements. 9. Violation: Two of two patient files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways: a. IAPPs were not developed for each new person as part of the initial individual program plan or service plan required under Minnesota Statutes, chapter 245F (patient files numbered 1 and 2); b. IAPPs did not include an individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and the person’s risk of abusing other vulnerable adults (patient files numbered 1 and 2); and c. IAPP was not revised following a review of the IAPP, using the individual assessment and any reports of abuse relating to the person (patient file numbered 1). Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit individual abuse prevention plans from two patient files that meet all requirements. 10. Violation: Two of two patient files reviewed for requirements governing medical services (patient files numbered 1 and 2) 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 communicated at service initiation.
Statute Violated: Minnesota Statute, section 245F.12, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services 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. 11. Violation: Two of two patient files reviewed for requirements governing individualized stabilization plans (patient files numbered 1 and 2) did not meet requirements as follows: a. The Individual stabilization plan was not signed by the staff member making the entry; therefore, unable to determine if the stabilization plan was completed within 12 hours of admission; and b. The individualized stabilization plan did not: i. Specify the participation of others in the stabilization planning process and specific services; and ii. Document the patient’s participation in developing the content of the stabilization plan and any updates. Statute Violated: Minnesota Statute, sections 245F.07, subdivision 1 and 245F.19, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual stabilization plans meet all applicable requirements. Within 30 days of receipt of this order, submit individual stabilization plans from 2 patient files that meet all requirements. 12. Violation: Two of two patient files reviewed for requirements governing stabilization services did not meet requirements as follows a. The patient’s medical record did not include documentation justifying the clinical rationale for not offering the following services (patient file numbered 2): i. Individual or group motivational counseling sessions; and ii. Peer recovery support services; and b. There was no documentation of the provision of care coordination services in the patient’s file (patient file numbered 1). Statute Violated: Minnesota Statutes, sections 245F.07, subdivision 2 and 245F.08, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization services meet all applicable requirements. 13. Violation: Two of two patient files reviewed for requirements governing discharge plans (patient files numbered 1 and 2) did not meet requirements. Discharge plans did not include a stabilization summary and final evaluation of the patient’s progress toward treatment objectives. Statute Violated: Minnesota Statute, section 245F.07, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. Within 30 days of receipt of this order, submit discharge plans from two patient files that meet all 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 rules, statutes, or laws, but it would be advisable to strengthen your efforts in these areas: 1. Minnesota Rules, part 9560.6580 and Minnesota Statutes, section 245F.18 requires a license holder to develop a written policy and procedure manual. The program is dually licensed to provide both detoxication and withdrawal management services and has two separate policy and procedure manuals for each type of service. Through conversation with program staff, it was identified that regardless of which license the patient was admitted under, all the patients are receiving the withdrawal management services and staff are directed to follow the written policy and procedure manual for the 245F program. It is recommended that the two separate policy manuals be combined to reflect program practices. 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. You must correct the violations cited above. Submit requested documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email to: Jennifer.White@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Jennifer White Licensing Division PO Box 64242 St. Paul, MN 55164-0424 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 and detox facility program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F and Minnesota Rule 32. · 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 Maura McGarry, Supervisor, at 651-431-6671 Sincerely, Jennifer White, Licensor Licensing Division Office of Inspector General
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