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January 30, 2024 David Backus, Authorized Agent Evergreen Recovery 1400 Energy Park Dr., Ste. 21 Saint Paul, MN 55108 License Number 1079365 Report Number 202303357 AMENDED CORRECTION ORDER NOTICE: This Amended Correction Order supersedes a Correction Order issued August 9, 2023, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on August 9,2023. This Amended Order reflects the final decision on the request for reconsideration issued on January 4, 2024. Dear David: On May 11, 12, 15, and 16, 2023, Department of Human Services (DHS) licensors conducted a licensing investigation and an unannounced modified licensing review at your facility located at 1400 Energy Park Dr., Ste. 21. As a result of this visit, DHS determined that you are in violation of thirteen 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 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. 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). The license holder’s practice for billing did not include a correlated entry in the client file as follows: 1) February 15, 17, 19, 21, 24, and 25, 2023 - peer recovery support (client file numbered 1); 2) February 17, 2023 - group (client file numbered 1); 3) January 20, 2023 - group (client file numbered 2); and 4) January 21 and 22, 2023 - peer recovery support (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they are billed. The noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. The public funding Service Rate Grid is located at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG . Within 30 days of receipt of this order, submit a plan for maintaining compliance on an ongoing basis. 2. Violation: A grievance was filed on September 6, 2021 and there was no documentation that the license holder responded to the grievance. 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 client rights protection practices meet all applicable requirements. 3. Violation: An internal report of suspected maltreatment was received by the facility and there was no documentation that a written notice was given to the reporter. Statute Violated: Minnesota Statutes, section 626.557, subdivision 4a, paragraphs (b) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must meet all applicable internal reporting requirements. 4. Violation: One of two client files reviewed for requirements governing comprehensive assessments (client file numbered 2) did not include a complete list of previous attempts at treatment for substance misuse or substance use disorder. Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on November 6, 2020, 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 comprehensive assessments meet all applicable requirements. 5. Violation: One of two client files reviewed for requirements governing documentation of treatment services and treatment plan reviews (client file numbered 1) did not meet requirements in the following ways: a. The treatment plan reviews were not person centered, as the top portion of each review contained solely template language including asterisks prompting key areas to be completed by the counselor; b. Treatment plan reviews were not entered into the client file weekly or after each treatment service, whichever was less frequent as follows: 1) February 6 to 13, 2023 electronically signed April 19, 2023; 2) February 13 to 20, 2023 electronically signed May 9, 2023; 3) February 20 to 27, 2023 electronically signed May 9, 2023; 4) February 27 to March 13, 2023 (two-week period) electronically signed May 11, 2023; 5) March 20 to 27, 2023 (missed week prior) electronically signed March 21, 2023; 6) March 27 to April 3, 2023 electronically signed May 11, 2023; 7) April 3 to 10, 2023 electronically signed May 11, 2023; 8) April 10 to 17, 2023 electronically signed May 11, 2023; 9) April 17 to 24, 2023 electronically signed May 9, 2023; 10) April 24 to May 1, 2023 electronically signed May 9, 2023; and 11) May 1 to 8, 2023 electronically signed May 8, 2023; a. The client’s record contained another client’s information, did not consistently include the job title or position of the staff person making the entry, and late entries were not labeled as late entries; b. Treatment plan reviews did not: 1) Indicate the span of time covered by the review and each of the six dimensions; 2) Address each goal in the treatment plan and whether the methods to address the goals are effective; and 3) Include monitoring of any mental health problems and the client was to be referred to a mental health professional according to the Comprehensive Assessment and the GAIN-SS. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a, 2b (c), 3. Repeat Violation: In Correction Orders that DHS issued on November 6, 2020 and August 10, 2021, 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 treatment services and treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit documentation demonstrating how the program will ensure that the staff member responsible for the above listed deficiencies (SP8) meets the requirements in 245G.11, subdivision 4. 6. Violation: The license holder failed to: a. Protect client records against unauthorized disclosure, in that another client’s information was entered across various record contents including treatment plan reviews and a medication listing (client file numbered 1); and b. Ensure that content and format of records was uniform and entries in each record was uniform and entries in each record were signed and dated by the staff person making the entry (client files numbered 1 and 2) Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Repeat Violation: In Correction Orders that DHS issued on November 6, 2020 and August 10, 2021, 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 all client records meet all applicable requirements. 7. Violation: One of two client files reviewed for requirements governing service discharge summary (client file numbered 1) did not meet requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination (signed May 14, 2023 and the client was discharged on May 8, 2023 – one day late); and b. The discharge summary identified inaccurate information that the client was discharged without staff approval, when in fact the client was transferred to a higher level of care consistent with program and probation officer recommendation. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b). Repeat Violation: In a Correction Order that DHS issued on November 6, 2020, 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 all service discharge summaries meet all applicable requirements. 8. Violation: The license holder failed to submit compliant background studies, on or by January 1, 2023, for direct care staff who had modified studies during the COVID-19 pandemic (personnel files numbered 1, 4, 9, and 10). Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraphs (a) and (b). Corrective Action Required: Immediately and on and ongoing basis, the license holder must ensure that background studies meet all applicable requirements. 9. Violation: Two of two 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 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). Statute Violated: Minnesota Statutes, section 245G. 11, subdivision 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all peer recovery staff qualifications meet all applicable requirements. Within 30 days of receipt of this order, submit a statement describing how the violations above have been corrected. 10. Violation: The personnel file reviewed for student intern requirements (personnel file numbered 5) did not contain documentation of verification that the individual was enrolled in a program specializing in alcohol and drug counseling or mental health counseling at an accredited educational institution and is authorized by a licensing board to provide services under supervision of a licensed professional. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all student intern staff qualifications meet all applicable requirements. 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. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on November 6, 2020, you were previously found in violation of these same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation which demonstrates that the violations identified above have been corrected. 12. Violation: Five of six personnel files reviewed for annual training and staff development did not contain documentation demonstrating that the staff person: a. Was trained annually on mandatory reporting, the license holders program abuse prevention plan, internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services, policies for obtaining client releases of information, reporting of maltreatment of minors, reporting of prenatal exposure to controlled substances, and HIV Minimum Standards (personnel files numbered 2, 4, and 6); b. Was trained every two years in client confidentiality rules and regulations, client ethical boundaries, emergency procedures, and client rights as specified in sections 144.651, 148F.165, and 253B.03 (personnel file numbered 4); and c. Had a minimum 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 (personnel files numbered 3 and 8). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (a) through (e), and 260E. Repeat Violation: In a Correction Order that DHS issued on November 6, 2020, you were previously found in violation of these same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all annual training and staff development meets all applicable requirements. Within 30 days of receipt of this order, submit documentation which demonstrates that the violations identified above have been corrected. 13. Violation: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Statute Violated: Six 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, and 7); 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 and 3); 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). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personnel files meet all applicable requirements. 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: 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 Final Agency Decision As stated, above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated August 9, 2023. As such, the decision is not subject to appeal. 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 651-431-5653. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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