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December 29. 2023 Kevin Lindberg, Authorized Agent Serenity Haven 106 Maple Avenue East Mora, MN 55051 License Number 1064343 (245G) Report Number 202210059 CORRECTION ORDER Dear Kevin: On December 4 through 7, 2023, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility located at 206 East Maple Avenue, Mora, MN 55051. As a result of this visit, DHS determined that you are in violation of 29 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. Practices, Policies, Procedures, and Postings 1. Violation: The license holder failed to protect client records against unauthorized disclosure in compliance with Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67: a. Information was disclosed without a signed consent to disclosure (client files numbered 2 and 4); and b. The consent to disclosure forms did not meet requirements of Code of Federal Regulations, title 42, chapter 1, part 2, subpart C, section 2.31: 1) Consent forms did not include the names of the individuals or entities to which disclosure was to be made (client files 1 and 2); and 2) Consent forms did not include how much and what kind of information was to be disclosed, including an explicit description of the substance use disorder information that may be disclosed (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client records are protected against unauthorized disclosure. Within 30 days of receipt of this order, submit a description of action taken to ensure this requirement is met, including documentation that all staff received training on confidentiality requirements following receipt of this order. 2. Violation: The license holder failed to develop program policies and procedures necessary to maintain compliance with licensing requirements, and to monitor implementation of policies and procedures by program staff: a. The license holder had two different versions of the policies and procedure manual. The policies and procedures manual identified by the license holder as current, including corrections which resulted from the last licensing review, was locked in the treatment director’s office at the time of the licensing review. The policies and procedures manual which was immediately accessible to staff and clients was identified as the previous version; and b. Treatment services procedures were not consistent with policies and applicable requirements: 1) Treatment service documentation indicated services were provided off-site; however, the treatment services description stated all services were provided at the licensed location; 2) Treatment service documentation indicated the clients attended activities as part of group treatment, which the license holder identified during the review as therapeutic recreation. However, the treatment services description stated recreation provided by the program was not a treatment service; 3) The treatment services description stated four hours of group were provided weekly; however, the group facilitator identified during the review that breaks occurred during each group, and less than four hours were actually provided weekly; 4) The Health Care Services policy stated a 60 minute nursing group will be held weekly; however, that service was not in the treatment services description, and the license holder stated it was not accurate; and 5) The license holder’s non-residential peer recovery services included a support group facilitated by a peer recovery specialist and attended by multiple clients; however, the treatment services description stated peer recovery is provided in one-to-one sessions. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program policies and procedures are in compliance with licensing requirements and that implementation of policies and procedures is monitored. Within 30 days of receipt of this order, submit an electronic version of the current policies and procedures manual which meets all applicable requirements. 3. Violation: The license holder did not ensure that the designated treatment director was responsible for all aspects for the delivery of treatment services. During the licensing review, the treatment director was unable to answer questions about the delivery of treatment services in both the residential and non-residential programs, including: a. Whether or not treatment services were provided off-site from the licensed location; b. Whether or not breaks were taken during groups; and c. Whether or not the non-residential program specialized in the treatment of co-occurring disorders under section 245G.20. Statute Violated: Minnesota Statutes, section 245G.01, subdivision 27. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment director is responsible for all aspects of the delivery of treatment service. 4. Violation: The license holder did not maintain and store records on the premises where the treatment service was provided or coordinated, and in a manner that allowed for review by the commissioner as identified in section 245A.04, subdivision 5: a. Client records were stored electronically on a staff member’s computer, which was not on-site during the review (client files numbered 2, 9, 11, and 12). The records were not accessible to other staff and could not be provided to licensors until the following day; b. Client records were stored outside of the client file in two staff members’ desks and were not accessible to licensors until the following day (client file numbered 1 and 2); and c. The license holder was not aware of how to access requested client records (client files numbered 5 through 8). The license holder was unsure if the records were electronic or paper, or where the records were stored. Statute Violated: Minnesota Statutes, section 245A.041, subdivisions 3 and 4, and 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record maintenance and storage meets all applicable requirements. Within 30 days of receipt of this order, submit a description of how this violation has been corrected. 5. Violation: The license holder did not ensure that client rights were protected, as identified in Minnesota Statutes, section 144.651,. Clients were required to perform services for the facility which were not appropriately goal-related in their individual medical record. The Rules of Conduct stated all clients were required to perform chores in order to receive passes to leave the facility, and a posting at the facility stated all clients needed to complete 10 hours of chores weekly. The license holder included a method on all clients’ treatment plans to perform therapeutic chores; however, the methods were not individualized to address client-specific goals. In addition, there was not a process to monitor for methods being appropriately goal-related, and clients were not overseen by a qualified staff member while completing chores to ensure they were therapeutic. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 11, 2022, 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 rights are protected. Within 30 days of receipt of this order, submit a description of how this violation has been corrected, including submitting a revised Rules of Conduct policy. 6. Violation: The license holder failed to follow their vulnerable adult reporting policies and procedures in the following ways: a. The license holder did not notify the common entry point of suspected maltreatment within 24 hours of awareness of suspected maltreatment, in accordance with their policy and statute requirements. The license holder became aware of suspected maltreatment on September 9, 2022 and reported it to the Minnesota Adult Abuse Reporting Center on September 13, 2022; b. The license holder did not complete an internal review when an external report of alleged or suspected maltreatment was made by the designated facility reporter on September 20, 2022; and c. The license holder did not give written notices to staff who made internal reports of alleged or suspected maltreatment on September 9, 2022 and September 19, 2022. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), and 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult maltreatment reporting procedures are followed and meet all applicable requirements. 7. Violation: The maltreatment of minors policy in both of the policy manuals and used for staff training was not consistent with current statutes. It included out-of-date language and references to repealed statutes, sections 626.556 and 626.5561. Statute Violated: Minnesota Statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of minors policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy as part of the corrective action ordered for violation number 2. 8. Violation: The license holder failed to designate a responsible staff member when the treatment director was not on-site. At the time of the licensing review, the treatment director was not on-site, and it was not clear who the responsible staff member was. The treatment director stated there was not a procedure for designating a responsible staff member. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure there is a designated responsible staff member during all hours of operation. The responsible staff member must know and understand the implications of chapters 245G and 260E, and sections 245A.65, 626.557, and 626.5572. 9. Violation: Schedule II drugs were not stored in a separately locked compartment, permanently affixed to the medication cart. The drugs were in an electronic lock box attached to the medication cart; however, it did not have batteries, and therefore could not be locked. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 6. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that Schedule II drugs are stored in a separately locked compartment, permanently affixed to the medication cart or the physical plant. 10. Violation: The license holder was unable to provide documentation that the governing body or the governing body’s delegate reviewed the program abuse prevention plan within the last year using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. The license holder stated they had documentation but could not locate it. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the governing body or the governing body's delegated representative review the program abuse prevention plan at least annually and that the review meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of a review of the program abuse prevention plan, completed either within the past year prior to the licensing review or since the review, that meets all applicable requirements. 11. Violation: The visiting hours were not accurate. The hours which were posted and listed in policy were Saturday and Sunday from 9:00am to 5:00pm; however, the license holder stated visitors are not allowed on Saturdays from 9:00am to 1:00pm while clients are attending group. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that visiting hours are set, posted, and accurate. Within 30 days of receipt of this order, submit a revised visiting hours policy as part of the corrective action ordered for violation number 2. 12. Violation: The grievance procedure posted at the facility included an incorrect address and phone number for the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure in the policy manual and posted at the facility are accurate. Within 30 days of receipt of this order, submit a revised grievance procedure as part of the corrective action ordered for violation number 2. Personnel Files 13. Violation: One of three personnel files reviewed for requirements governing naloxone training (personnel file numbered 1) did not receive training on the process for administration of naloxone. The staff member’s personnel file documented that training was received; however, the license holder stated the documentation was false and the training was not received. Statute Violated: Minnesota Statutes, sections 245G.08, subdivision 5, and 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that naloxone training is received and that documentation of training is accurate. Within 30 days of receipt of this order, submit new documentation that the staff member identified in the violation above has received training since the licensing review. 14. Violation: One of three personnel files reviewed for requirements governing orientation (personnel file numbered 2) did not contain documentation orientation was received: a. Within 24 working hours of starting on: 1) Policies and procedures; 2) Client confidentiality; 3) Client needs; and 4) HIV minimum standards; b. Within 72 hours of first providing direct contact services to a vulnerable adult on: 1) Reporting requirements and definitions in sections 626.557 and 626.5572; 2) The program abuse prevention plan; and 3) All 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. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that staff orientation is received as required. 15. Violation: Two of two personnel files reviewed for requirements governing annual training (personnel files numbered 2 and 3) did not contain documentation of training on reporting prenatal exposure to controlled substances. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that annual training is received as required. Within 30 days of receipt of this order, submit documentation that the staff members identified in the violation above have received training since the licensing review on reporting prenatal exposure to controlled substances. 16. Violation: One personnel file was reviewed for requirements governing training in co-occurring disorders (personnel file numbered 1) and did not contain documentation the staff member obtained 12 hours of training on co-occurring disorders. Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 2, paragraph (e), and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that co-occurring disorders training is received as required. Within 30 days of receipt of this order, submit documentation that the staff member identified in the violation above has completed 12 hours of training on co-occurring disorders. 17. Violation: One of three personnel files reviewed for requirements governing written annual performance reviews (personnel file numbered 1) did not contain a written review for 2023. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that performance reviews are completed as required. Within 30 days of receipt of this order, submit documentation that a performance review has been completed for the staff member identified in the violation above. The review may have been completed within the past year prior to the licensing review, or completed since the licensing review. 18. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not contain: a. Completed applications for employment (personnel files numbered 1 and 2); b. Documentation of inquiries required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel file numbered 1); and c. Documentation that the staff members met the qualification requirements in section 245G.11. During the review, it was demonstrated that the qualifications were met; however, the files did not contain documentation of: 1) Alcohol and drug counselor license (personnel file numbered 1); 2) Recovery peer credential (personnel files numbered 2 and 3); and 3) High school diploma or equivalent (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel files are maintained, and that contents meet all applicable requirements. Within 30 days of receipt of this order, submit a plan for maintaining a complete personnel file for each staff member, including how and where records will be stored, and who will be responsible for maintaining them. Client Files 19. Violation: Four of four client files reviewed for requirements governing orientation to the personal electronic device policy (client files numbered 1 through 4) did not contain documentation the clients were informed of the policy and the clients’ right to refuse being photographed or recorded. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that clients are informed of the personal electronic device policy and the clients’ right to refuse being photographed or recorded. Within 30 days of receipt of this order, submit documentation from one recently admitted client file which demonstrates compliance. The personal electronic device policy must also be submitted as part of the corrective action ordered for violation number 2. 20. Violation: Three of four client files reviewed for requirements governing initial services plans did not meet requirements in the following ways: a. The plan was not person-centered and client specific (client file numbered 2); b. The plan did not address immediate health and safety concerns which were identified (client file numbered 3); and c. The plan did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements. 21. Violation: Two of three client files reviewed for requirements governing individual abuse prevention plans did not meet requirements in the following ways: a. The plan did not include a statement of the specific measures that would be taken to minimize the risk of abuse to that person, including the specific actions the program would take, or document that the client did not need specific risk reduction measures in addition to those identified in the program abuse prevention plan (client file numbered 1); and b. The plan did not identify referrals made when the client was susceptible to abuse outside the scope or control of the licensed services (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), and 245G.04, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. 22. Violation: Four of four client files reviewed for requirements governing comprehensive assessments and summaries did not meet requirements in the following ways: a. It could not be determined if the combined assessment and summary forms were completed within 3 calendar days from the day of service initiation: 1) The form was dated 23 days after service initiation; however, it was not signed and therefore not complete (client file numbered 2); and 2) The form contained conflicting dates and the completion date could not be determined. The signature was dated August 18, 2022, prior to the date on the form, October 19, 2022, and to the day of service initiation, October 17, 2022 (client file numbered 1); b. The comprehensive assessments did not include information about the clients’ needs that relate to substance use and personal strengths that support recovery, including: 1) A description of the circumstances on the day of service initiation (client files numbered 1 through 4); 2) A list of previous attempts at treatment for compulsive gambling (client file numbered 2); 3) A list of previous attempts at treatment for mental illness (client files numbered 1, 2, and 3); 4) A list of substance use history: i) The list not include amounts and frequency of substances used (client files numbered 2 and 4); ii) The list did not include duration of use (client file numbered 2); and iii) The list was not complete (client files numbered 1, 2, and 3). The list was limited to the top substances used and did not include the full history of use; 5) The presence or absence of previous withdrawal symptoms for each substance used in the previous 30 days (client files numbered 1 and 2); 6) The clients’ desire for family involvement in the treatment program (client files numbered 1 and 3); 7) Family history of substance use and misuse (client file numbered 3); 8) Mental health symptoms and the effect on the clients’ ability to function (client files numbered 1 through 4); 9) Current mental health treatment (client file numbered 2); 10) Psychotropic medications needed to maintain stability (client file numbered 2); 11) A description of how use affected the clients’ ability to function appropriately in: i) A work setting (client file numbered 1); and ii) Educational settings (client files numbered 1 and 3); 12) A description of any risk-taking behavior, including behavior that put the clients at risk of exposure to blood-borne or sexually transmitted diseases (client files numbered 2 and 4). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1, paragraph (a), and 2, paragraph (a). Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. New requirements effective January 1, 2024 are identified in Minnesota Statutes, section 245G.05, subdivisions 1 and 3. 23. Violation: Four of four client files reviewed for requirements governing individual treatment plans did meet requirements in the following ways: a. The plan was not completed within five calendar days on which a treatment session had been provided from the day of service initiation (client file numbered 4). It was completed four days late; b. The plan was not signed by the client and did not document the client's involvement in the development of the plan (client file numbered 4); c. The plan did not address each issue identified in the assessment summary (client file numbered 3); d. The goals and methods did not include amount, frequency, and anticipated duration of treatment service (client files numbered 1 through 4); e. The plan did not include resources to refer the client to when needs were to be addressed concurrently by another provider (client file numbered 3); f. The plan did not include goals the client must reach to complete treatment and terminate services (client file numbered 3); and g. The plans were not updated based on new information gathered about the client's condition and on whether methods identified have the intended effect (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 2. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order dated May 18, 2021 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan from one recently admitted client file which demonstrates compliance. New treatment plan requirements effective January 1, 2024 are identified in Minnesota Statutes, section 245G.06, subdivisions 1 and 1a. 24. Violation: Four of four client files reviewed for requirement governing client record documentation did not meet requirements in the following ways: a. Documentation of treatment services: 1) Was not signed; therefore, it could not be determined if services were documented within seven days of providing the treatment service (client file numbered 2); 2) Did not include type of service (client files numbered 1 through 4); and 3) Included an inaccurate amount of service: i) The license holder identified that breaks were taken during groups; however, documentation did not adjust the amount to reflect breaks in service; (client file numbered 1); and ii) The group note for October 28, 2023 had two conflicting amounts (client file numbered 2); b. The client record did not contain documentation of client absence from treatment services, including the reason for the absences (client files numbered 1). The file did not contain documentation of any treatment services during the week ending October 29, 2022; however, it also did not contain documentation of absences during that week; and c. Entries in the client record: 1) Were not signed (client files numbered 1 and 2); 2) Did not include the job title or position of the staff person who made the entry (client file numbered 4); 3) Was not signed by the staff person who made the entry (client file numbered 2). The file contained a pre-typed orientation note, and the staff signature for the entry said it was “for” another staff person. The staff person who signed the note did not complete the orientation; and 4) Included an inaccurate date (client file numbered 1). A treatment plan review was entered for the week ending December 24, 2022; however, the date on the signature line was December 10, 2022, prior to the span of time covered by the entry. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraphs (b) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation, including documentation of treatment services, meets all applicable requirements. 25. Violation: Two of three client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. Treatment plan reviews were not entered in the clients’ files weekly or after each treatment service, whichever was less frequent: 1) Treatment plan reviews were not signed; therefore, it could not be determined when they were completed (client file numbered 2); and 2) Treatment plans were not completed the weeks ending July 29, 2023, August 5, 12, 19, and 26, 2023, and September 2, 2023 (client file numbered 3); b. Treatment plan reviews did not: 1) Address each goal in the treatment plan and whether the methods to address the goals are effective (client file numbered 2); 2) Include monitoring of mental health problems (client files numbered 1 and 2); and 3) Document staff recommendations for changes in the methods identified in the treatment plan (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order dated May 18, 2021 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews are completed and meet all applicable requirements. New requirements effective January 1, 2024 are identified in Minnesota Statutes, section 245G.06, subdivisions 3 and 3a. 26. Violation: Two of two client files reviewed for requirements governing license holders specializing in the treatment of a person with co-occurring disorders (client files numbered 1 and 2) did not contain documentation of collaboration with continuing care mental health providers and involvement in treatment planning meetings. Statute Violated: Minnesota Statutes, section 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that requirements for the treatment of a person with co-occurring disorders are met. Within 30 days of receipt of this order, submit a description of how the requirement will be met going forward. 27. Violation: Two of two client files reviewed for requirement governing medication administration documentation did not meet requirements in the following ways: a. Medication was not administered as prescribed (client file numbered 1). A medication was prescribed on November 30, 2022; however the license holder did not transcribe the medication onto the administration record until December 7, 2022 and the client did not have access to the medication; b. The medication administration record had blank spaces and did not document whether or not medication was administered as prescribed on November 1, 3, and 6, 2022 (client file numbered 1); and c. Guidelines were not followed for informing a nurse of problems with self-administration of medication when a medication was: 1) Refused October 7 through 11, 2023 and October 20 through 22, 2023 (client file numbered 2); and 2) Not administered as prescribed on October 24 and 27, 2022 (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.01, subdivision 2, and 245G.08, subdivision 5, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on March 11, 2022, 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 medications are administered as prescribed and that administration of medication is documented and meets all applicable requirements. If the guidelines for informing a nurse of problems with self-administration of medication are revised, the revised policy must be submitted as part of the corrective action ordered for violation number 2. 28. Violation: Six of seven client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. Summaries were not completed within five days of the clients’ service termination: 1) The summary was due August 28, 2023 and was not completed (client file numbered 7); 2) The summary was due September 19, 2023 and was completed December 5, 2023, after the client file was requested for review (client file numbered 3); 3) The summary was due September 17, 2023 and was completed November 13, 2023 (client file numbered 5); and 4) Summaries were not signed; therefore it could not be determined when they were complete (client files numbered 2 and 6); b. Summaries did not include: 1) Services provided (files numbered 1, 2, and 3); 2) Strengths while participating in treatment (client file numbered 3); 3) The client's progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 3); 4) The client's living arrangements at service termination (client file numbered 3); 5) Referrals made with specific attention to continuity of care for mental health (client file numbered 3); and 6) Service termination diagnosis (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order dated May 18, 2021 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service discharge summaries are completed and meet all applicable requirements. Within 30 days of receipt of this order, submit a service discharge summary which demonstrates compliance from one recently discharged non-residential client file. 29. Violation: Two of two client files reviewed for requirements governing client property management did not include documentation of receipt of the clients’ property at the time of receipt, including the clients’ signature: a. The license holder did not document receipt of clients’ medication (client files numbered 1 and 2); and b. The file documented that property was put into storage and it could not be determined when it was documented (client file numbered 2). The documentation had two client signature lines; however, both were signed on the client’s discharge date, when the property was returned. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c). Repeat Violation: You were previously found in violation of this same statute in a: · Correction Order that DHS issued on March 11, 2022 · Correction Order that DHS issued on September 18, 2018 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client property management is documented and meets all applicable requirements. Recommendations The following recommendations are not requirements of Minnesota Statutes or laws governing your services or facility. These recommendations are being made to assist you with achieving and maintaining compliance with applicable requirements on an ongoing basis. Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow 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 may contact your licensor for more information if you choose to implement these recommendations. 1. It is recommended that the identified compliance officer, required under section 256B.04, subdivision 21, paragraph (g), be someone who does not currently hold a clinical staff position. The compliance officer must be one of the controlling individuals, defined in section 245A.02, subdivision 5a, which may include an officer or the organization, a managerial official, or the president and treasurer of the board of directors. If you decide to change the identified compliance officer, please contact your licensor for a Change in License Information Form. 2. It is recommended that you develop a self-monitoring procedure to check for compliance with applicable requirements in client files, personnel files, and policies and procedures. Specifically, it is recommended that the compliance officer: a. Develop procedures to monitor implementation of policies and procedures by program staff; b. Conduct a review of a current client file and a recently discharged client file each month to evaluate compliance; and c. Conduct a review of a sample of the personnel files each month to evaluate compliance. 3. It is recommended that you begin consistently using your chosen Electronic Health Records system for completion of required client file documentation for all client files going forward. Corrective action required 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: Mallory.Fuchs@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Mallory Fuchs 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 and the cited violations. Your request must: · Be in writing. · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order. · Supply information that is accurate or more complete. · 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. If you are mailing your request, 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, 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 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 Maura McGarry, Unit Supervisor, at 651-431-6671. Sincerely, Leah Wachter, Senior Licensor Licensing Division Office of Inspector General
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