March 15, 2024                    CERTIFIED MAIL

Margot Kelsey, Authorized Agent

Northern Minnesota Addiction Wellness Center

401 Clausen Ave SW Apt. 4

Bemidji, MN 56601

License Number:        1103246 (245G)

Licensing Investigation Report Numbers:   202204566

ORDER OF CONDITIONAL LICENSE

Dear Margot Kelsey:

The Department of Human Services (DHS) is placing your license to provide substance use disorder services at Northern Minnesota Addiction Wellness Center at 4851 Stacy Ann Dr. NW, Bemidji, MN 56601, on conditional status for two years, beginning March 21, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Substance Use Disorder licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

On December 4 through 7, 2023, DHS licensors conducted a licensing review and investigation at your facility located at 4851 Stacy Ann Dr. NW, Bemidji, MN 56601. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed substance use disorder programs, citing 25 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of persons served by the program.

· Nature and Severity: Your program failed to follow requirements that affected the health, safety, and rights of persons served as described below:

· The program failed to comply with background study requirements (violation numbered 1).

· The program failed to ensure client rights were protected (violation numbered 2).

· The program failed to comply with maltreatment reporting and internal reviews of alleged or suspected maltreatment reports (violations numbered 3 and 4).

· The program failed to meet requirements for billing for services (violation numbered 5).

· The program failed to ensure peer recovery support services were provided individually to a client (violation numbered 6).

· The program failed to ensure staff qualifications (violation numbered 7).

· The program failed to comply with staff orientation, annual, two-year and additional training as required (violations 8, 9, and 10).

· The program failed to ensure documentation of treatment services as required (violation 12).

Due to the nature and severity nature of these violations, and the conditions in the program, which impact the health and safety of persons in your care, your license to provide Substance Use Disorder is placed on a conditional status.

Licensing Violations

DHS determined that your program failed to follow licensing rules and statutes, as described below.

1. Violation: The license holder failed to comply with laws governing background studies as evidenced by the following:

a. One personnel file did not contain documentation that the license holder verified information collected about a person before initiating a background study request (personnel file numbered 4);

b. License holder failed to initiate a new background study on a staff person (personnel file numbered 3) following a legal name change as required; and

c. The license holder failed to ensure staff persons had cleared background studies as described in the fine order issued on January 24, 2024.

Statute Violated: Minnesota Statutes, section 245C.05, subdivision 2, paragraph (a) and 245C.04, subdivision 7.

2. Violation: When conducting a licensing investigation, it was determined through staff interviews that the license holder failed to protect client rights identified in section 144.651 relating to courteous treatment. It was confirmed that a staff person became visibly upset, was raising their voice, and needed to remove themselves from a meeting relating to the discharge of a client.

Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1.

3. Violation: The license failed to meet requirements governing procedures for reporting the maltreatment of vulnerable adults:

a. The vulnerable adult maltreatment reporting policy did not meet requirements in the following ways:

1) The license holder had two different versions of the vulnerable adult maltreatment reporting policy;

2) The policy identified the “ABC President” as the primary person who will ensure that, when required, internal reviews are completed, and there was no such person or position; and

3) The policy did not include that reporters are informed about whether the facility reported the incident to the common entry point in a manner that protects the confidentiality of the reporter, pursuant to Minnesota Statutes, section 626.557, subdivision 4a; and

b. The license holder failed to report alleged maltreatment to the Common Entry Point. At the time of the licensing investigation, the license holder stated they reported the alleged maltreatment to DHS, but DHS has no record of receiving their report.

Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1, paragraphs (a) and (b), 245G.12, clause (9).

4. Violation: The license holder failed to meet requirements governing internal reviews of reports of alleged or suspected maltreatment of vulnerable adults. Reports dated June 15, 2022, June 30, 2022, July 6, 2022, and October 30, 2022, were reviewed by the license holder and did not include an evaluation of whether:

a. Policies and procedures were followed;

b. Policies and procedures were adequate;

c. There is a need for additional staff training;

d. The reported event is similar to past events with the vulnerable adults or the services involved; and

e. There is a need for corrective action by the license holder to protect the safety of vulnerable adults.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b).

5. Violation: The license holder failed to meet requirements for receiving public funding reimbursement from the Commissioner for services provided in the following ways:

a. The license holder failed to provide the 30 hours of weekly clinical services required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b) to clients receiving public funding reimbursement for high intensity residential treatment. The file documented the client received:

1) 27 hours for week ending October 14, 2023 (client file numbered 3);

2) 24 hours for week ending October 14, 2023 (client file numbered 1);

3) 26 hours for week ending October 21, 2023 (client file numbered 3);

4) 24 hours for week ending October 21, 2023 (client file numbered 1);

5) 28 hours for week ending October 28, 2023 (client file numbered 3);

6) 18 hours for week ending October 28, 2023 (client file numbered 1);

7) 21 hours for week ending November 4, 2023 (client file numbered 3);

8) 25 hours for week ending November 11, 2023 (client file numbered 3);

9) 29 hours for week ending November 18, 2023 (client file numbered 3);

10) 17 hours for week ending November 25, 2023 (client file numbered 3); and

11) 21 hours for week ending December 2, 2023 (client file numbered 3).

Statute Violated: Minnesota Statutes, section 245A.191, paragraph (a).

6. Violation: The license holder failed to meet requirements governing peer recovery support services (PRSS). PRSS were not provided individually, the service was provided in a group setting as determined by group sign in sheets for the following dates:

a. October 11, 18, 25, and November 8, 15, 22, and 29, 2023); and

b. October 16, 23, November 6, 13, 20, and December 4, 2023

Statute Violated: Minnesota Statutes, section 245G.07, subdivision 2, clause (8).

7. Violation: Nine of nine personnel files reviewed for staff qualifications failed to meet requirements in the following ways:

a. The personnel file failed to document verification that the staff person with direct contact was at least 18 years of age at the time of hire (personnel file numbered 4);

b. The treatment director personnel file (personnel file numbered 8) did not contain the following:

1) A resume demonstrating at least one year of work experience in direct service to an individual with substance use disorder or one year of work experience in the management or administration of direct service to an individual with substance use disorder;

2) Proof of a baccalaureate degree or three years of work experience in administration or personnel supervision in human services; and

3) Verification that the treatment director knows and understand the implications of chapters 245G, 245A, 260E, and sections 626.557, and 626.5572.

c. The alcohol and drug counselor supervisor personnel file (personnel file numbered 9) did not contain the following:

1) Verification of three or more years' experience providing individual and group counseling to individuals with substance use disorder; and

2) Verification that the alcohol and drug counselor supervisor knows and understand the implications of chapters 245G, 245A, 260E, and sections 626.557, and 626.5572;

d. The alcohol and drug counselor personnel file (personnel file numbered 10) did not contain documentation of licensure or exemption from licensure under chapter 148F;

e. The paraprofessionals and others providing treatment services personnel files did not contain documentation of the following:

1) Knowledge of client rights, according to section 148F.165, and staff member responsibilities at the time of hire (personnel files numbered 5 and 6); and

2) Other licensed professional personnel file (personnel file numbered 6) did not contain verification of current licensure.

f. The recovery peer qualifications personnel file (personnel files numbered 1 and 2) did not contain the following documentation:

1) High school diploma or its equivalent;

2) Have a minimum of one year in recovery from substance use disorder;

3) Hold a current credential from the Minnesota Certification Board, the Upper Midwest Indican Council on Addictive Disorders, or the National Association for Alcoholism and Drug Abuse Counselors; and

4) Supervision in areas specific to the domains of the recovery peer’s role by an alcohol and drug counselor.

Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 1, 3, 4, 5, paragraph (a), 6, 8 and 245G.13, subdivision 3.

8. Violation: Seven of seven personnel files reviewed for requirements governing orientation training failed to meet requirements. There was no documentation of orientation training for the following:

a. Within 24 working hours of starting for each new staff member based on a written plan that, a minimum, training related to specific job responsibilities, policies and procedures, client confidentiality, HIV minimum standards, and client needs (personnel files numbered 4 through 10);

b. Within 72 hours of first providing direct contact services including reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572, the license holder’s program abuse prevention plan, and all internal policies and procedures relating to the prevention and reporting of maltreatment of individuals receiving services (Personnel files numbered 4 through 10); and

c. The program’s drug and alcohol policy (personnel files numbered 4 through 9).

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivision 1, clause (7).

9. Violation: Six of six personnel files reviewed for requirements governing annual training and every two-year training failed to meet requirements in the following ways:

a. The personnel file did not contain documentation of the following required annual training:

1) Mandatory reporting as specified in sections 245A.65, 626.557, and 626.5572, and chapter 260E for calendar year (CY) 2021 and 2022 (personnel files numbered 8 and 9); and CY 2023 (personnel files 5, 6, 8 through 10);

2) The license holder’s program abuse prevention plan for CY 2021 and 2022 (personnel files numbered 8 and 9) and CY 2023 (personnel files numbered 5, 6, 8, and 9);

3) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services CY 2021 and 2022 (personnel files numbered 8 and 9) and CY 2023 (personnel files numbered 5, 6, 8, and 9);

4) Specific training covering the facility’s policies for obtaining client releases of information for CY 2021 and 2022 (personnel files numbered 8 and 9) and CY 2023 (personnel files numbered 5, 6, 8, and 9);

5) Maltreatment of minors reporting requirements and definitions in chapter 260E for CY 2021 and 2022 (personnel files numbered 8 and 9) and CY 2023 (personnel files numbered 5, 6, 8, and 9);

6) Reporting to prenatal exposure to controlled substances for CY 2021 and 2022 (personnel files numbered 8 and 9) and CY 2023 (personnel files numbered 5, 6, 8, and 9); and

7) HIV minimum standards (personnel files numbered 5, 6, and 8 through 10); and

b. The personnel file did not contain documentation of every two-year training in client confidentiality rules and regulations, client ethical boundaries, and emergency procedures and client rights as specified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03 CY 2022 (personnel files numbered 7 through 9) and CY 2023 (personnel files numbered 6).

Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (c), (d), and (e).

10. Violation: Five of five personnel files reviewed for requirements governing additional staff training did not meet requirements. There was no documentation to demonstrate the staff person received 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 4, 6, and 8 through 10).

Statute Violated: Minnesota Statutes, sections 245G.13, subdivision 2, paragraph (f).

11. Violation: Six of six personnel files reviewed for requirements governing the contents of personnel files failed to contain:

a. A completed job application signed by the staff member and containing the staff member’s qualifications for employment (personnel files 4 to 6, 9 and 10);

b. Documentation of an inquiry required by Minnesota Statutes, section 604.20 to 604.205, for staff who provide psychotherapy services (personnel files 9 and 10); and

c. Written annual review of the staff member’s job performance as follows:

1) 2021 and 2022 (personnel file numbered 9); and

2) 2023 (personnel files numbered 5, 7, and 9).

Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3, clauses (1) and (3).

12. Violation: Two of two client files reviewed for requirements governing documentation of treatment services received failed to meet requirements in the following ways:

a. The staff member who provided the treatment service is not the staff member who documented in the client record for the following group notes:

1) October 5, 2023, Chemical Health (client file numbered 3);

2) October 5, 2023, Therapeutic Recreation (client file numbered 3);

3) October 9, 2023, Social Skills (client file numbered 3);

4) October 11, 2023, Process Group (client file numbered 3);

5) October 12, 2023, Chemical Health (client file numbered 3);

6) October 14, 2023, Social Skills (client file numbered 1);

7) October 16, 2023, Therapeutic Recreation (client file numbered 3);

8) October 18, 2023, Process Group (client files numbered 1 and 3);

9) October 19, 2023, Therapeutic Recreation (2 separate groups) (client file numbered 3);

10) October 19, 2023, Chemical Health (client file numbered 3);

11) October 22, 2024, Movie Group (client file numbered 1);

12) October 25, 2023, Process Group (client files numbered 1 and 3);

13) October 25, 2023, Primary (client files numbered 1 and 3);

14) October 26, 2023, Chemical Health (client file numbered 3);

15) October 26, 2023, Therapeutic Recreation (client file numbered 3);

16) October 30, 2023, Movie Group (client file numbered 1);

17) October 31, 2023, Movie Group (client file numbered 1);

18) November 5, 2023, Movie Group (client file numbered 3);

19) November 7, 2023, Movie Group (client file numbered 3);

20) November 7, 2023, Art (client file numbered 3);

21) November 11, 2023, Social Skills (client file numbered 3);

22) November 13, 2023, Process Group (client file numbered 3);

23) November 15, 2023, Process Group (client file numbered 3);

24) November 18, 2023, Process Group (client file numbered 3);

25) November 21, 2023, Process Group (client file numbered 3); and

26) November 30, 2023 Chemical Health (client file numbered 3);

b. Group sign-in sheets were missing for November 18 and 21, 2023, Process Group (client file numbered 3);

c. Treatment services provided to the client were not documented within seven days of providing the treatment service (client file numbered 3):

1) October 2, 2023, signed on October 12, 2023;

2) October 20, 2023, signed on November 7, 2023;

3) October 26, 2023, signed on November 7, 2023;

4) October 27, 2023, signed on November 7, 2023;

5) October 30, 2023, signed on November 16, 2023;

6) November 6, 2023, signed on November 15, 2023; and

7) November 22, 2023, signed on December 5, 2023;

d. Group counseling size exceeded 16 clients (client file numbered 3):

1) October 13, 2023, CBT/DBT;

2) October 18, 2023, Process Group;

3) October 20, 2023, CBT/DBT; and

4) October 25, 2023, Primary; and

e. October 20, 2023, Health Education note was present in the client record; however, the client response was not recorded and the note was not signed or dated (client file numbered 3).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivision2a, 245G.09, subdivision 3 and 245G.10, subdivision 4.

13. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPR) failed to meet requirements for the following:

a. The client file did not contain documentation of weekly TPR for weeks ending:

1) October 14, 21, and 28, 2023 (client file numbered 1); and

2) November 28, 2023 (client file numbered 2); and

3) October 15, 22, and November 5, 2023 (client file numbered 3);

b. The TPR was completed on December 1, 2023, for a week of treatment service ending December 3, 2023 (client file numbered 3);

c. The effectiveness of methods to address treatment plan goals was not documented (client files numbered 1 through 3);

d. None of the TPRs monitored for physical health (client file numbered 3);

e. The TPR did not monitor for mental health for week of treatment service ending November 12, 2023 (client file numbered 3);

f. Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change was not documented (client files numbered 1 through 3);

g. There was no review and evaluation of the individual abuse prevention plan (IAPP) with TPR’s dated November 28 and December 1, 2023 (client file numbered 3); and

h. There was no documentation of collaboration with continuing care mental health providers (client file numbered 3).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 3 and 245G.09, subdivision 3.

14. Violation: Two of two client files reviewed for requirements governing service initiation and orientation failed to meet requirements in the following ways:

a. The client was not given a written statement of rights under section 144.651, nor were rights reviewed with the client (client files numbered 1 and 3);

b. There was no documentation that the grievance procedure was explained to the client (client files numbered 1 and 3);

c. The file did not document that the client was oriented to internal and external reporting policies (client files numbered 1 and 3); and

d. The release of information form for consent to disclosure of suspected maltreatment under Minnesota Statutes, section 626.557, subdivision 3a, did not specify that the consent was for the purpose of reporting suspected maltreatment (client files numbered 1 and 3).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (c), 245G.09, subdivision 3, and 245G.15, subdivision 1.

15. Violation: Two of two client files reviewed for requirements governing initial services plan failed to address immediate health and safety concerns (client files numbered 1 and 3).

Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1 and 245G.09, subdivision 3.

16. Violation: Two of two client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 and 3) failed to include an assessment of the person’s risk of abusing other vulnerable adults.

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b).

17. Violation: Two of two client files reviewed for requirements governing comprehensive assessments and comprehensive assessment summary failed to meet requirements. The comprehensive assessment did not comply in the following ways:

a. The assessment and assessment summary was not completed within 3 calendar days from the day of service initiation and no documentation of a reason for the delay and the planned completion date (client file numbered 3);

b. The frequency of usage not documented (client files numbered 1 and 3);

c. The current medical treatment needed or being received related to the diagnosis was not included in its entirety (client file numbered 3);

d. The mental health history did not address the effect on the client’s ability to function (client file numbered 3);

e. Psychotropic medications needed to maintain stability. Assessment addresses that the client is on psychotropic medications and indicates “see below” with no further additional information (client file numbered 3); and

f. The narrative summary did not support the risk descriptions in dimension 1 (client file numbered 3).

Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1 and 2, paragraphs (a) and (b), and 245G.09, subdivision 3.

18. Violation: Three of three files reviewed for requirements governing individual treatment plans (ITP) failed to meet requirements in the following ways:

a. The ITP was not completed within 10 calendar days from the day of service initiation (client file numbered 3);

b. Family involvement was not included in the ITP and it was indicated in the comprehensive assessment (client file numbered 3);

c. Risk ratings were not included (client file numbered 3);

d. Amount, frequency and anticipated duration were not included (client files numbered 1 through 3);

e. Resources to refer the client to when needs are to be addressed concurrently by another provider were not included (client files numbered 2 and 3);

f. Goals the client must reach to complete treatment and terminate services were not addressed (client files numbered 1 through 3); and

g. The treatment plan was not updated based on a November 9, 2023, behavioral contract, to document active interventions to stabilize mental health symptoms (client file numbered 3).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2, and 245G.09, subdivision 3.

19. Violation: Two of three client files reviewed for requirements governing discharge summaries failed to meet requirements in the following ways:

a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 5); and

b. The discharge summary did not contain the following:

1) Client’s needs (client file numbered 4);

2) Progress toward achieving each of the goals identified in the treatment plan (client files numbered 1 and 4);

3) Living arrangements at service termination (client file numbered 4);

4) Referrals made with specific attention to continuity of care for mental health (client file numbered 4); and

5) The service termination diagnosis (client file numbered 4).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 4 and 245G.09, subdivision 3.

20. Violation: Two of three client files reviewed for client property management failed to meet requirements in the following ways:

a. There was no documentation of the disbursement of funds or other property at the time of discharge (client file numbered 3); and

b. Medication was not returned to the client at service termination, regardless of the of the client’s service termination status. During the licensing investigation, it was determined that the client file did not contain documentation from a prescriber requiring the prescribed medication to be held from the client (client file numbered 5).

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c), and 245G.21, subdivision 3, clause (4).

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated March 29, 2022.

21. Violation: The license holder failed to meet requirements governing the treatment services description in the following ways:

a. The description of treatment services did not accurately define the current program’s treatment week;

b. The description did not identify which services meet the definition of group counseling under Minnesota Statutes, section 245G.01, subdivision 13a;

c. The description did not identify the groups and topics on which a guest speaker could provide services under the direct observation of an alcohol and drug counselor.

Statute Violated: Minnesota Statutes, section 245G.12, clause (10).

22. Violation: The license holder failed to meet requirements governing grievance procedures and practices in the following ways:

a. The grievance procedure did not require that a staff member helps the client develop and process a grievance;

b. The phone number and address for the Minnesota Board of Behavioral Health and Therapy was not current;

c. The phone number for the Department of Health Facilities Complaints was not correct, the number included was for the Minnesota Department of Health; and

d. Twenty out of twenty grievances reviewed from October 25, 2021, through July 24, 2023, did not include a response to the client; rather, documentation identified “Exec Board looked at” or “Acknowledged by Board.”

Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2.

23. Violation: The license holder failed to have a written standing order protocol that permits the license holder to maintain a supply of opiate antagonists on site.

Statute Violated: Minnesota Statutes, section 245A.242, subdivision 2.

24. Violation: The license holder failed to set and post a notice of visiting rules and hours that included evening hours.

Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2.

25. Violation: The license holder’s plan for the transfer of clients and records upon closure failed to meet requirements governing plan for transfer of clients and records upon closure in the following ways:

a. The policy did not provide for notifying affected clients of the closure at least 25 days prior to closure, including information on how to access their records;

b. The policy did not specify arrangements the program will make to transfer clients to another provider or county agency for continuation of services and to transfer the case record with the client; and

c. The signed agreement indicating that a county or a similarly licensed provider has agreed to accept and maintain the program's closed case records did not also provide for follow-up services as necessary to affected clients.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a.

Immediate corrective action required

You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected the violations.

If you fail to demonstrate substantial compliance with Substance Use Disorder requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Submit documentation to your licensor as outlined in the Conditional License terms below:

1. By secure email to: Jennifer.White@state.mn.us; or

2. By Mail to: Commissioner, Department of Human Services

ATTN: Jennifer White

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Additionally, DHS will not approve a request to open a new licensed program from the date of this order until the time your conditional license expires.

CONDITIONAL LICENSE TERMS

In addition to the Substance Use Disorder licensing rules and statutes, you are required to comply with the following terms:

1. Within 14 days of receipt of this order, you must notify current clients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by your DHS Licensor prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request.

While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving services. The notification to new clients must specify the length of time of the conditional status of your 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. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file.

Within 30 days of receipt of this order, you must submit to your DHS Licensor, a copy of the notice and a list of all referral sources that received the notice.

2. Within 14 days of receipt of this order, you must contact Maura McGarry, DHS Licensing Substance Use Disorder supervisor, to schedule a training on requirements for substance use disorder residential treatment programs under Minnesota Statutes, Chapter 245G. Individuals required to attend are the Treatment Director, ADC Supervisor, Compliance Officer, Registered Nurse, Authorized Agent and Human Resource designee. Training must be completed within 45 days of receipt of this order.

3. Within 14 days of receipt of this order, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Treatment Director or ADC Supervisor. If providing treatment services, the Compliance Officer may only allocate 50 percent of their working hours to treatment services. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor:

a. 2 years of professional experience in the following:

1) A regulatory or compliance position, and

2) Involved in direct care as a substance use counselor, or

3) The development and implementation of mental health or substance use disorder treatment planning in a DHS licensed 245G substance use disorder program.

b. Working knowledge of Minnesota Statutes, Chapter 245A (Human Services Licensing) and Chapter 245G (substance use disorder).

c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field.

4. Within 30 days of the receipt of this order, you must develop, and submit to DHS, a self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The plan must:

a. Identify the Compliance Officer and other persons that may be responsible for assisting the Compliance Officer with monitoring, and these individuals must demonstrate compliance with all applicable laws, rules and statutes;

b. Require a sample review of resident records, personnel files, required treatment services, treatment plans and reviews, internal reviews, and grievances on a monthly basis; and

c. Require that the Compliance Officer conduct a monthly review of License Holder’s policies and procedures to ensure that they are in compliance with Minnesota Statutes, Chapters 245A and 245G, and that staff are implementing those policies and procedures in compliance with Minnesota Statutes, Chapters 245A and 245G.

The self-monitoring plan must be submitted to and approved by the program’s DHS Licensor within 30 days of receipt of this order. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, beginning on January 15, 2024, and continuing every three months thereafter, on or before the 15th of that month, for 2 years from the effective date of the conditional license.

5. Within 30 days from receipt of this order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the program’s DHS Licensor and must include:

a. Identification of the specific individual designated for Human Resources (HR) duties and responsibilities. The person must not be the treatment director, LADC supervisor, or clinical staff person who is involved with the day-to-day treatment services;

b. A description of how the program 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;

c. A description of how the program will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; and

d. A description of how the program 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 responsible person has received training on these duties.

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

· Clearly state that you are requesting reconsideration of the conditional license

· List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· State why you believe your license should not be on a conditional status

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 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

Conditional license stayed pending reconsideration

If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all Substance Use Disorder laws and rules.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· Substance Use Disorder treatment programs are required to follow Minnesota Statutes, chapter 245G

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4.

· If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4.

· Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order.

Questions

If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671.

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/