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February 9, 2024 David Backus, Authorized Agent Evergreen Recovery 1400 Energy Park Dr., Ste. 21 Saint Paul, MN 55108 License Number: 1079365 Licensing Investigation Numbers: 202304586 202307511 202308728
CORRECTION ORDER Dear David: On January 24, 2024, Department of Human Services (DHS) licensors conducted licensing investigations 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 seven 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: One client file was reviewed for requirements governing determination of vulnerable adult status (client file numbered 1) and did not meet requirements. A determination of vulnerable adult status was not completed again after an incident that would have been required to be reported under Minnesota Statutes, section 626.667, if one or more of the adults involved in the incident had been a vulnerable adult. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all determinations are made according to all applicable requirements. 2. Violation: Two of two client files reviewed for requirements governing documentation of treatment services and treatment plan reviews did not meet requirements in the following ways: a. Peer Recovery Support Service (PRSS) services did not meet requirements in the following ways (client file numbered 1): 1) November 29 and December 12, 2022, notes were not signed by the staff member providing the service; 2) October 17 and 31, 2022, notes did not include the client’s response to the service; and 3) Services on December 8 and 20, 2022, did not align with PRSS treatment services description; b. A significant event was not documented the day the event occurred. An entry dated December 5, 2022, was not signed until December 14, 2022, and was not labeled as a late entry (client file numbered 1); c. Treatment plan reviews did not contain the span of time covered by the review. The span of time is displayed as a title in the electronic record, but does not display on the document when in print view or when printed (client files numbered 1 and 2); and d. Information about client progress in treatment plan reviews did not reflect information documented in PRSS notes relating to anger, aggressiveness, and decompensating mental health (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 2a, 2b, and 3, 245G.07, subdivision 2, and 245G.09, subdivision 1. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated January 30, 2024 · Correction Order dated August 10, 2021 · Correction Order November 6, 2020 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all treatment services and treatment plan reviews meet all applicable requirements. 3. Violation: One client file was reviewed for requirements governing service discharge summary (client file numbered 1) and did not meet requirements. The service discharge was not completed within 5 days of discharge. The client was discharged on January 10, 2023, and the summary was signed on February 7, 2023. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (a). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated January 30, 2024 · Correction Order November 6, 2020 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all service discharge summaries meet all applicable requirements. 4. Violation: One of two staff persons reviewed for staff qualifications (personnel file numbered 2) did not meet requirements. There was no license verification contained in the file. This violation was self-corrected at the time of the licensing investigation. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all verifications of staff qualification meet all applicable requirements. 5. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. Orientation documentation required to be completed within 24 hours was not signed or dated (personnel file numbered 1); b. There was no documentation of orientation to the license holder’s program abuse prevention plan (personnel files numbered 1 and 2); and c. There was no specific documentation of orientation to all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 1. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated January 30, 2024 · Correction Order November 6, 2020 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all staff orientation meets all applicable requirements. 6. Violation: Two of two personnel files reviewed for background study data according to Minnesota Statutes, chapter 245C (personnel files numbered 1 and 2) did not meet requirements. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 30, 2024. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personnel files meet all applicable requirements. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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 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 Paula Halverson, Unit Manager at 651-431-5653, as soon as possible. Molly Lang, Senior Licensor Licensing Division Office of Inspector General
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