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January 26, 2024 License Number: 1108974 (245G) Marlin Martin, Authorized Agent Valhalla Place Brainerd dba BHG Brainerd Treatment Center 5001 Spring Valley Road Suite 600 Dallas, TX 75244-8217 Licensing Report Numbers: 202210171 and 202301680
Dear Marlin Martin: This matter arises from an Order of Conditional License, dated October 2, 2023, issued after a licensing review conducted on June 27, 28, 29, 30, July 5 and 7, 2023 (See attached Exhibit A). On October 16, 2023, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration of the Order of Conditional License. You included information in the reconsideration request for nine of the twenty-seven violations in the Order of Conditional License, and you described corrective measures that have been taken. However, you did not dispute the accuracy of the citations. All the citations contained in the Order of Conditional License are therefore final and not included in the scope of this review. A. CONDITIONAL LICENSE DISPUTED, DHS’ RESPONSE and DISPOSITION Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program. In the request for reconsideration, you request that the conditional license be reconsidered or, in the alternative, that the timeline for the conditional license be reduced to twelve months because the program has taken exhaustive and comprehensive efforts to resolve the issues related to compliance. You outlined responses the program has taken in the response to nine of the violations in the Order of Conditional License, and you submitted supporting documentation. The Commissioner appreciates that the program has taken steps to ensure compliance. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and determined that a conditional license is warranted. The Conditional Order cites twenty-seven citations reflecting that the program has failed to comply with multiple requirements. You did not challenge the accuracy of any of the citations, and the citations support the need for a conditional license because they demonstrate a history of serious and chronic licensing violations that indicate a failure to follow procedure and practice requirements which affect the health, safety, and rights of clients. The nature and severity of the cited violations is a basis for the conditional license. The citations involved a failure to follow multiple requirements which affected the health and safety of the persons served, including: a failure to ensure client records were accurate and protected against loss, tampering, and unauthorized disclosure; a failure to ensure client documentation is accurate; a failure to comply with specific measures to reduce the possibility of diversion; a failure to complete initial services plans as required; a failure to complete vulnerable adult determinations as required; and a failure to comply with background studies requirements regarding three staff persons. Background study requirements are in place to ensure the safety of the clients served by the program. Accurate documentation and determinations in client files are necessary to demonstrate that services are being provided, that the services being provided are relevant, how the client is responding to services, and whether the services are effective. Additionally, rules and regulations are in place to ensure that public funds received by license holders are allocated properly and used for the benefit of the clients for which the funds are intended. The license holder also failed to meet requirements related to staff and oversight which resulted in violations that were severe in number and nature, including: two violations for a failure to provide staff orientation and annual training; a failure to ensure monthly on-site supervision was provided by a registered nurse; and a failure to comply with requirements regarding the unsupervised use of methadone hydrochloride. Requirements regarding staff training and orientation are in place to ensure staff are familiar with policies and procedures related to client safety and well-being and that staff are qualified and able to provide care to those clients. Requirements regarding supervision by a registered nurse and unsupervised use of methadone hydrochloride are in place to protect the health and safety of clients served by the program. Due to the need to monitor the program for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on October 2, 2023. The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. B. TERMS OF THE CONDITIONAL LICENSE In addition to the Substance Use Disorder treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from the date of this reconsideration decision, you must notify current clients and all parties who refer clients to the program of the conditional status of the license. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. The notification must be approved by DHS Licensing prior to being sent to clients and all other parties. Therefore, the draft notice must be submitted to DHS Licensing for approval within 10 days of receipt of this reconsideration decision. While the license in on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving treatment services. The notification to new clients must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Documentation of notification of the conditional status must be maintained in each client’s file. 2. Within 15 days from the date of this reconsideration decision, you must identify a Compliance Officer who will be responsible for correcting the violations identified in the conditional license order, completing the terms identified in the order, and monitoring ongoing compliance with requirements for Substance Use Disorder treatment programs. The Compliance Officer cannot also hold the position of Treatment Director or Alcohol and Drug Counselor Supervisor and must know and understand the requirements of Minnesota Statutes, chapters 245A, 245G, and 260E, and sections 626.557 and 626.5572. The Compliance Officer must be approved by DHS Licensing. 3. Within 15 days from the date of this reconsideration decision, you must submit a description of how a registered nurse will provide supervision as defined in section 148.171, subdivision 23 to staff members who have been delegated the task of administration of medication or assisting with self-medication. The description must identify how supervision will be provided, including a minimum of monthly on-site supervision or more often if warranted by a client's health needs. The description must also address how supervision will be documented, including documenting review of medication administration records and documenting supervision provided to address missing documentation. The description must be approved the DHS Licensor and be included in the policies and procedure manual upon approval. 4. Within 30 days from the date of this reconsideration decision, you must develop and submit a plan for managing client record documentation. This plan must be approved by DHS Licensing and must include: a. A description of how you will ensure that client record is protected against loss, tampering, or unauthorized disclosure; b. A description of how you will ensure that entries into the client record are accurate; and c. A description of how you will ensure that corrections to entries are made in a way in which the original entry may still be read; and d. Name and title of those responsible to carry out the duties of the plan. 5. Within 30 days from the date of this reconsideration decision, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by DHS Licensing and must include: a. A description of how you will ensure that background study requirements are met on an ongoing basis, including identifying who will be responsible for managing staff background studies, and documentation that the responsible person has received training on these duties; and b. A description of how you will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation that the person has received training on these duties. The plan must identify the material which will be used to complete each required orientation and training item and include forms which will be used to document staff orientation and training. 6. Within 30 days of receipt of this reconsideration decision, you must develop a self-monitoring plan for an ongoing approach for monitoring compliance with applicable rules and statutes requirements. The self-monitoring plan must include the following: a. Name and title of those responsible to carry out the duties of the plan; and b. A procedure that includes a sample review of patient records requirements, personnel files, a medication administration records, grievances, and monitoring of the implementation of policies and procedures monthly. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the monthly reviews and corrective actions taken must be submitted to your licensor quarterly, by the 15th of the month for April, July and October, or until otherwise determined by DHS Licensing during the duration of the conditional license. Your licensor will monitor your compliance with all applicable laws and rules. Verification of compliance may include unannounced visits. Failure to comply with the requirements in Minnesota Statutes, chapter 245A (Human Services Licensing Act), Minnesota Statutes, chapter 245C (Human Services Background Study Act), Minnesota Statutes, chapter 245G (Chemical Dependency Based Treatment), Minnesota Statutes, section 626.557, and with the terms of your conditional license may result in further negative action, including revocation of your license. This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, you may contact Maura McGarry, Unit Supervisor, at 651-431-6671. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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