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February 8, 2024 Jacqueline Schultz, Authorized Agent Professional Recovery Organization 700 Commerce Drive, Suite 245 Woodbury, MN 55125 License Number 1104866 CORRECTION ORDER Dear Jacqueline Schultz: On October 24 and 25, 2023, Department of Human Services (DHS) licensors conducted a licensing review at Professional Recovery Organization located at 700 Commerce Drive, Suite 245, Woodbury, MN 55125. As a result of this visit, DHS determined that you are in violation of 11 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, and Procedures 1. Violation: The license holder did not have a written standing order protocol by a physician to maintain a supply of naloxone on site and a procedure for monitoring the supply of naloxone including replenishing and destroying as required. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3, and 245G.08, subdivision 6, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the standing order protocol and control of drugs procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a written standing order protocol and a procedure for monitoring the supply of naloxone that demonstrates compliance. Personnel Files 2. Violation: Two of two personnel files reviewed for personnel policy requirements contained inaccurate information (personnel file numbered 1 and 2). The job description contained repealed section of statute 626.556 and excluded chapter 260E. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 13. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel policies meet requirements.
3. Violation: One personnel file reviewed for alcohol and drug counselor supervisor qualifications did not meet requirements (personnel file numbered 2). No documentation to demonstrate at least three or more years of experience providing individual and group counseling to individuals with substance use disorder. Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 4, paragraph (a), and 245G.13 subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the alcohol and drug counselor supervisor meets requirements. Within 30 days of receipt of this order, submit a resume that contains qualifications that meet requirements and a job description. 4. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. No documentation of orientation on client needs (personnel files numbered 1 and 2); b. No documentation of orientation provided within 72 working hours of first providing direct contact services to a vulnerable adult for the following: 1) The program abuse prevention plan (personnel files numbered 1 and 2); 2) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 1); and 3) Drug and alcohol policy (personnel files numbered 1 and 2). 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 staff orientation meets all applicable requirements. Within 60 days of receipt of this order, submit documentation that the drug and alcohol policy was reviewed with the above staff. 5. Violation: Two of two personnel files reviewed for requirements governing annual and additional trainings (personnel files numbered 1 and 2) did not meet requirements. No documentation for the following: a. The Program abuse prevention plan for calendar years 2022 and 2023; b. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar year 2023; c. Specific training covering the facility's policies for obtaining client releases of information for calendar years 2022 and 2023; d. Reporting of prenatal exposure to controlled substances for calendar years 2022 and 2023; e. Training on the administration of naloxone; and f. 12 hours of specific training in co-occurring disorders within six months of employment. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, 245G.08, subdivision 5, and 245G.13, subdivision 2, paragraphs (c) and (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance with paragraph items (a) through (e) listed above. Within 60 days of receipt of this order, submit documentation that demonstrates compliance with paragraph item (f) listed above. 6. Violation: Two of two personnel files reviewed for requirements governing personnel file contents did not contain: a. A completed application for employment signed by the staff member and containing the staff member's qualifications for employment (personnel files numbered 1 and 2); b. Documentation of inquiries required by sections 604.20 to 604.205 for staff members who provided psychotherapy services made to the staff members’ former employers regarding substantiated sexual contact with a client (personnel file numbered 1 and 2); and c. A written annual review of the employee's job performance. The license holder provided a performance review completed on 06/08/2023 but did not provide documentation for any performance review completed in 2022 (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. 7. Violation: Two of two personnel files reviewed for requirements governing personnel file contents (personnel files numbered 1 and 2) did not contain verification that the information collected about a person was correct before initiating a background study request to DHS. Statute Violated: Minnesota Statutes, section 245C.05, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files 8. Violation: Three of three client files reviewed for requirements governing initial services plans (client files numbered 1, 2, and 3) were not person-centered and client specific. The three initial services plans were identical. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of two person-centered, client-specific individual service plans that demonstrate compliance. 9. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. A description of the circumstances on the day of service initiation (client files numbered 1, 2, and 3); b. The amounts of substance used for alcohol (client file numbered 1); c. The frequency and duration of use of alcohol and nicotine (client file numbered 1); d. The circumstances of relapse for a substance used within the previous 30 days of service initiation (client file numbered 1); e. Level of family support (client files numbered 1 and 3); and f. Leisure time activities that have been associated with substance use (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 10. Violation: One of three client files reviewed for requirements governing individual treatment plans did not meet requirements (client file numbered 1). The individual treatment plan was not updated based on new information gathered about the client's condition and on whether methods identified had the intended effect (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 11. Violation: One of three client files reviewed for requirements governing treatment plan reviews, dated 07/30/2023, 09/17/2023, and 10/01/2023 did not document whether the methods to address the goals were effective. file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 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:
1. By secure email to: Kayla.Northrop@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Kayla Northrop Licensing Division PO Box 64242 St. Paul, MN 55164-0242YOUR 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 made before the deadlines provided below 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 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 Kayla.Northrop@state.mn.us or at 651-431-5843. Sincerely, Kayla Northrop, Licensor Licensing Division Office of Inspector General
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