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January 26, 2024 Kevin Joyce, Authorized Agent Oakridge Treatment Center LLC 550 Main St Ste 230 New Brighton, MN 55112 License Number: 1082638 Licensing Investigation Numbers: 202304177 202307455 202308235 202308510 202308545
CORRECTION ORDER Dear Kevin Joyce, A licensing investigation, including an onsite visit on November 6, 2023, of Oakridge Treatment Center LLC, located at 4800 48th St NE, Haverhill, MN, 55906, was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment services licensed under Minnesota Statutes 245G. As a result of this licensing investigation a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Practice 1. Citation: Minnesota Statutes, section 245G.12. Violation: The license holder’s practice for standing orders is not client specific (C1). The license holder’s medical director signs standing orders for all clients upon a yearly review of the standing order list and the standing orders are then initiated by the signature of a registered nurse. The medical director does not evaluate the appropriateness of the standing orders for each client individually. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must monitor the implementation and procedures of their policies. Within 30 days of receipt of this order, submit a policy that details how standing orders will be appropriately obtained for each client. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder failed to follow their staffing pattern as outlined in the program abuse prevent plan (PAPP). On the following dates, clients overdosed at the facility and the license holder did not have staff on shift as outlined in the PAPP: a. September 3, 2023 the program was understaffed a minimum of one recovery specialists 8:00 to 9:00 pm and two recovery specialists 11:30 pm to 7:00 am; b. September 25, 2023 the program was understaffed a minimum of one recovery specialists from 7:00 am to 1:00 pm; and c. October 5, 2023 the program was understaffed a minimum of two recovery specialists from 11:30 pm to 7:00 am. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the staffing pattern is adhered to as outlined in the program abuse prevention plan and meets all applicable requirements.
Client 3. Citation: Minnesota Statutes, section 245G.06, subdivision 5, paragraph (c). Violation: One client file was reviewed for requirements governing administration of medications (C1) and did not meet requirements. The medication administration record did not include a record of administration, including staff signatures with date and time for the following medications: a. Nicoderm patch May 1, 2023; and b. Trazodone May 3, 2023 and May 8, 2023. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure administration of medications meets all applicable requirements. 4. Citation: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). Violation: One client file was reviewed for the requirements governing service discharge summary (C2) and did not meet requirements. The service discharge summary did not include the following: a. Referrals; b. The reasons for and circumstances of service termination; and c. The reasons for discharge and the procedures for the decision to discharge must be documented and comply with the requirements in section 245G.14, subdivision 3 when a client is discharged at staff request. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the service discharge summary meets all applicable requirements. 5. Citation: Minnesota Statutes, section 626.557, subdivision 14, paragraph (b). Violation: Three of four client files reviewed for requirements governing abuse prevention plans (C3 through C5) did not meet requirements. On September 25, 2023 clients C3 and C4 overdosed on fentanyl requiring life saving measures and client C5 required medical attention as a result of fentanyl use while at the facility. The license holder did not update the client’s individual abuse prevention plans after the incident. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure abuse prevention plans meets all applicable requirements. If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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 Ginny Benson 1. By secure email to: ginny.benson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Ginny Benson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible. Ginny Benson, Senior Licensor Licensing Division Office of Inspector General
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