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January 4, 2024 David Backus, Authorized Agent Evergreen Recovery 1400 Energy Park Drive, Suite 21 Saint Paul, MN 55108 License Number: 1079365
Dear David Backus: On August 29, 2023, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on August 9, 2023. You requested reconsideration of: citation 1, paragraph b; citation 9, paragraphs a and b; citation 11, paragraphs a and b; and citation 13. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 1: Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided as required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b), clause (1). b. Notes entered on January 10 and January 23, 2023 documented individual sessions, but were billed as treatment coordination (client file numbered 2). Request for Reconsideration. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245A.04, subdivision 1, paragraph (i), at the time of application for licensure or renewal of a license under this chapter, the applicant or license holder must acknowledge on the form provided by the commissioner if the applicant or license holder elects to receive any public funding reimbursement from the commissioner for services provided under the license that meet specified conditions. Pursuant to Minnesota Statutes, section 245A.191, when a substance use disorder treatment provider licensed under this chapter, and governed by the standards of chapter 245G or Minnesota Rules, parts 2960.0430 to 2960.0490, agrees to meet the applicable requirements under section 254B.05, subdivision 5, to be eligible for enhanced funding from the behavioral health fund, the applicable requirements under section 254B.05 are also licensing requirements that may be monitored for compliance through licensing investigations and inspections. Noncompliance with the requirements identified may result in specified sanctions. The information submitted with the reconsideration request shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind the citation only as to paragraph b. Citation 9: Violation: Three of three personnel files reviewed for recovery peer qualifications did not meet requirements in the following ways: a. There was no documentation that the staff had a minimum of one year in recovery from substance use disorder (personnel files numbered 1, 6, and 7); and b. Staff persons lacked credentials and there was no supervision in areas specific to the domains of the recovery peer's role by an alcohol and drug counselor (personnel files numbered 6 and 7). Request for Reconsideration. You indicate in your reconsideration request that each staff had a minimum of one year in recovery and each signed the acknowledgement of Problematic Substance Use as part of employee onboarding. You also indicate the certified peer recovery specialists had documentation on the MN Certification Board website and in their files. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.11, subdivision 8, a recovery peer must meet the qualifications in section 245I.04, subdivision 18 (which requires that recovery peer have a minimum of one year in recovery from substance use disorder and hold a current credential from the Minnesota Certification Board, the Upper Midwest Indian Council on Addictive Disorders, or the National Association for Alcoholism and Drug Abuse Counselors that demonstrates skills and training in the domain of ethics and boundaries, advocacy, mentoring and education, and recovery and wellness support); and provide services according to the scope of practice established in section 245I.04, subdivision 19, under the supervision of an alcohol and drug counselor. With regard to paragraph a, at the time of the licensing review personnel files numbered 6 and 7 did not contain documentation that staff had a minimum of one year in recovery from substance use disorder. However, personnel file numbered 1 was not reviewed for the requirement and should be excluded from the violation. There is therefore sufficient evidence to support the violation, and it is affirmed with the modification that personnel file numbered 1 is removed from the violation. With regard to paragraph b, at the time of the licensing review, no documentation of credentials was provided for personnel file numbered 6 but was provided for personnel file numbered 7. Also, personnel files numbered 6 and 7 showed no supervision in areas specific to domains of the recovery peer’s role. The program was given 24 hours after the licensing review to produce documents related to the violation, and no documents were submitted. There is therefore sufficient evidence to support the violation, and it is affirmed. Citation 11: Violation: Six of eight personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. There was no documentation that staff (personnel files numbered 2 and 3) were provided training related to: 1) Specific job responsibilities; 2) Policies and procedures; 3) Client confidentiality; 4) HIV minimum standards; 5) Vulnerable adult maltreatment reporting requirements; 6) The license holder’s program abuse prevention plan; and 7) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and b. There was no documentation that staff (personnel files numbered 2, 3, and 5 through 8) were provided training related to client needs. Request for Reconsideration. You indicate that personnel file numbered 3 contained documentation that the staff person was provided training related to the items listed in the violation. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245A.65, subdivision 3, the license holder shall ensure that each new mandated reporter, as defined in section 626.5572, subdivision 16, who is under the control of the license holder, receives an orientation within 72 hours of first providing direct contact services as defined in section 245C.02, subdivision 11, to a vulnerable adult and annually thereafter. The orientation and annual review shall inform the mandated reporters of the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Pursuant to Minnesota Statutes, section 245G.13, subdivision 1, a license holder must have written personnel policies that are available to each staff member, and the policies must meet the requirements specified. During the licensing review, information was requested from the program, and the program was given 24 hours after the onsite review to provide any further documents. The program did not provide documentation that demonstrated compliance at the time of the licensing review, and no documentation was received within 24 hours after the onsite review. There is therefore sufficient evidence to support the citation, and it is affirmed. Citation 13: Violation: Seven of eight personnel files did not contain: a. A completed job application signed by the staff member and containing the staff member’s qualifications for employment (personnel files numbered 2, 4, 6, 7, and 8); b. Documentation related to the staff member's background study data, according to chapter 245C (personnel files numbered 6 and 7); c. For a staff member who provides psychotherapy services, employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employer regarding substantiated sexual contact with a client (personnel files numbered 2, 3, and 8); and d. Written annual review of the staff member’s job performance as follows: 1) There was no documentation of an annual review (personnel files numbered 1, 2, and 6); and 2) The annual review was late in 2022 (personnel file numbered 4). Request for Reconsideration. You indicate in your request for reconsideration that a signed job application and a resume documenting the staff member’s qualifications was contained in personnel files numbered 2, 4 and 8. You submitted documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.13, subdivision 1, a license holder must have written personnel policies that are available to each staff member. The personnel policies must meet specified requirements. Pursuant to subdivision 3, the license holder must maintain a separate personnel file for each staff member. At a minimum, the personnel file must conform to the requirements of this chapter. A personnel file must contain the following: (1) a completed application for employment signed by the staff member and containing the staff member's qualifications for employment; (2) documentation related to the staff member's background study data, according to chapter 245C; (3) for a staff member who provides psychotherapy services, employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employer regarding substantiated sexual contact with a client; (4) documentation that the staff member completed orientation and training; (5) documentation that the staff member meets the requirements in section 245G.11; (6) documentation demonstrating the staff member's compliance with section 245G.08, subdivision 3, for a staff member who conducts administration of medication; and (7) documentation demonstrating the staff member's compliance with section 245G.18, subdivision 2, for a staff member that treats an adolescent client. At the time of the licensing review, personnel files numbered 2 and 4 did not have an application in the personnel file. The program was given 24 hours after the licensing review to produce additional documentation, and no documentation was received. Personnel file numbered 8 was cited in error and should be excluded from the citation. There is therefore sufficient evidence to support the citation, and it is affirmed with the modification that personnel file numbered 8 is removed from the citation. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the following, and they are affirmed: citation 9 as to paragraph a with the modification that personnel file numbered 1 is removed from the citation; citation 9 as to paragraph b; citation 11; and citation 13 with the modification that personnel file 8 is removed from the citation. The Commissioner finds it is appropriate to rescind the following: citation 1 only as to paragraph b. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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