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March 22, 2024 Brenda Nelson, Authorized Agent Generations Recovery Services 1821 University Ave W Ste 104 St. Paul, MN 55104 License Number 1090552 (245G) CORRECTION ORDER Dear Brenda Nelson: On January 24 and 25, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 1821 University Ave W Ste 104, St. Paul, MN 55104. As a result of this visit, DHS determined that you are in violation of the substance use disorder treatment statutes under Minnesota Statute, chapter 245G. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not develop written policies and procedures necessary to maintain compliance with licensing requirements and did not monitor the implementation of policies and procedures, as follows: a. The policy and procedure manual did not contain the following: 1) A procedure for monitoring the available supply of naloxone on site, replenishing the naloxone supply when needed, and destroy naloxone; and 2) The methods to report a known tuberculosis infection according to Minnesota Statutes, section 144.4804; b. The Client Death Guidelines and 245D.09 Staff Requirements policy contained statute requirements that are not applicable; c. The 245G.09 Client Records and Discharge Summary policy contained references to repealed statute requirements; and d. There were two conflicting versions of the following: 1) Grievance procedure; 2) Program Abuse Prevention Plan; 3) Procedures for reporting the maltreatment of minors according to Minnesota chapter 260E; and 4) Procedures for reporting the maltreatment of vulnerable adults according to Minnesota Statutes, sections 245A.65, 626.557, and 626.5572. Statute Violated: Minnesota Statutes, sections 245A.04, subdivisions 14, paragraphs (a) and (b) and 16, 245A.242, subdivision 2, 245A.65, subdivision 2, paragraph (a), 245A.66, subdivision 1, 245G.08, subdivision 6, 245G.12, and 245G.15, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program’s written policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit the revised policies identified above that meet all applicable requirements. 2. Violation: The service initiation policy did not contain specific service initiation criteria. The program serves adolescents; however, the service initiation criteria stated that all clients must be at least 18 years of age. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service initiation policy meets all applicable requirements. Within 30 days of the receipt of this order, submit a revised service initiation policy that meets all applicable requirements. 3. Violation: The treatment services description did not meet requirements as follows: a. Contained conflicting information on the hours of operation; and b. Contained a description of peer recovery support services; however, through conversation with program staff it was determined that these services are not offered. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 4 and 245G.12. Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment services description meets all applicable requirements. Within 30 days of the receipt of this order, submit a revised treatment services description that meets all applicable requirements. 4. Violation: The written plan for staff orientation in the Staff Development Plan contained conflicting timelines for completing orientation. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel policies meet all applicable requirements. Within 30 days of receipt of this order, submit a revised written staff orientation plan that meets all applicable requirements. 5. Violation: The license holder did not have access to a licensed mental health professional to provide diagnostic assessment and treatment planning assistance. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that there is access to and document the availability of a license mental health professional. Within 30 days of receipt of this order, submit documentation of the availability of a license mental health professional to provide diagnostic assessment and treatment planning assistance. Personnel Files 6. Violation: The license holder did not comply with background study requirements. The license holder did not initiate a background study on one staff person (personnel file numbered 1) before they began in a position allowing direct contact with a person served by the program. Staff person was hired and began working in a position allowing direct contact with a person served by the program on September 13, 2022 and was terminated on September 27, 2022. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g). Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with background study requirements in Minnesota Statutes, chapter 245C. 7. Violation: One personnel file was reviewed for requirements governing staff orientation (personnel file numbered 1) and did not meet requirements as follows: a. Orientation training was not documented for the following: 1) Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; and 2) The program abuse prevention plan; and b. The New Employee Orientation did not identify a date of completion, therefore unable to determine if required staff orientation was completed within 24 working hours of starting for the following: 1) Specific job responsibilities; 2) Client confidentiality; 3) Client needs; and 4) HIV minimum standards. 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 that staff orientation meets all applicable requirements. 8. Violation: One personnel file reviewed for requirements governing staff development (personnel file numbered 2) did not meet requirements. There was no documentation of the following: a. Annual trainings for calendar years 2022 and 2023: 1) Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of client information; and 2) HIV minimum standards; and b. Every two year trainings for calendar year 2023: 1) Client confidentiality rules and regulations; 2) Client ethical boundaries; 3) Emergency procedures; and 4) Client rights as specified in Minnesota Statutes, sections 148F.165 and 253B.03 Statute Violated: Minnesota Statutes, sections 2454A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (a) through (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff identified above has completed the missed trainings. 9. Violation: One personnel file reviewed for requirements governing personnel file contents (personnel file numbered 1) did not meet requirements. The following documentation was missing: a. A completed application for employment signed by the staff member; and b. Inquiries required by Minnesota Statutes, sections 604.20 to 604.205 made the staff member’s former employer regarding substantiated sexual contact with a client. Statute Violated: Minnesota Statutes, section 245G.13 subdivision 3.
Client Files 10. Violation: Two of two client files reviewed for requirements governing client orientation (client files numbered 1 and 2) did not meet requirements. The client did not receive orientation to the HIV minimum standards within 72 hours of admission to the program; and Statute Violated: Minnesota Statutes, sections 245A.19, and 245G.09, subdivision 3. Corrective Action Required: Immediately and an on ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 30 days of receipt of this order, submit a revised client intake packet that meets all applicable requirements. 11. Violation: Two of two client files reviewed for requirements governing initial service plan did not meet requirements as follows: a. The initial services plan was not completed within 24 hours of the day of service initiation (client file number 2); and b. The initial services plan did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan (client file number 1). Statue Violated: Minnesota Statutes section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that initial service plans meet all applicable requirements. 12. Violation: One of two client files reviewed for requirements governing vulnerable adult determinations (client file numbered 2) did not meet requirements. The vulnerable adult determination was not completed within 24 hours of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult determinations meet all applicable requirements. 13. Violation: Two of two client files reviewed for requirements governing comprehensive assessments did not meet requirements as follows: a. The comprehensive assessment did not contain the following information: 1) The duration of use (client file numbered 2); 2) For each substance used within the last 30 days, the absence or presence of previous withdrawal symptoms (client file numbered 2); 3) History or presence of physical or sexual abuse (client files numbered 1 and 2); and 4) Screening tools approved by the commissioner pursuant to section 245.4863 to identify whether the client screens positive for co-occurring disorders (client files numbered 1 and 2). a. The comprehensive assessment contained inconsistent information (client file numbered 1) for the following: 1) Specific problem behaviors exhibited by the client when under the influence of substances ; and 2) The social network in relation to expected support for recovery. Statute Violated: Minnesota Statutes section 245G.05 subdivision 1, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that comprehensive assessments meet all applicable requirements. 14. Violation: Two of two client files reviewed for requirements governing individual treatment plans did not meet requirements as follows: a. The goals and methods did not include the amount and frequency of treatment service (client file numbered 1); b. The plan did not include anticipated duration of treatment service (client file numbered 2); and c. The individual treatment plan was not updated based on new information gathered about the clients condition and on whether methods identified have the intended effect (client files numbered 1 and 2); Statute Violated: Minnesota Statutes, section 245G.06 subdivisions 1 and 2. Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 15. Violation: Two of two client files reviewed for requirements governing the documentation of treatment services did not meet requirements. The following notes did not include the client’s response to each treatment service: a. Individual Progress Note dated September 01 and 27, 2023 (client file numbered 1); b. Individual Progress Note dated October 22, 2023 (client file numbered 2); and c. Simple Group Note dated November 30, 2023 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and an on an ongoing basis, the license holder must ensure that documentation of treatment services meets all applicable requirements. Within 30 days of receipt of this order, submit individual progress notes from two client files that meet all applicable requirements. 16. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. No documentation of treatment plan reviews for the weeks starting on: 1) August 07, September 11, and September 25, 2023 (client file numbered 1); 2) October 02, October 23, October 30, November 06, November 13, November 20, and November 27, 2023 (client files numbered 1 and 2); b. The treatment plan review did not contain the following: 1) The span of time covered by the reviewed for the week starting on September 02, 2023 (client file numbered 1); 2) The treatment plan did not address whether the methods were effective for the weeks starting on: 1. August 14 and 21, 2023 (client file numbered 1); and 2. October 16, 2023 (client file numbered 2); 3) The participation of others for the week starting on August 14, 2023 (client file numbered 1); and 4) Document whether the client agreed with staff recommendations for changes in the methods identified in the treatment plan for weeks starting on October 16, 2023 (client files numbered 1 and 2); Statute Violated: Minnesota Statutes, section 245G.03, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on May 10, 2021 you were previously found in violation of this same statutes. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 17. Violation: Two of two client files reviewed for requirements governing service discharge summaries did not meet requirements as follows: a. The service discharge summary was not completed (client file numbered 2); and b. The service discharge summary was not completed within five days of the client’s service termination (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements. 18. Violation: One of two client files reviewed for requirements governing the location of service provision (client file numbered 1) did not meet requirements. The license holder did not document the reason for the provision of services remotely, as the service was provided through telehealth, in the Individual Progress Note dated September 01, 2023. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4. Corrective Action Required: Immediately an on an ongoing basis, the license hold must ensure that client documentation meets all applicable requirements. You must correct the violations cited above. Submit requested documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email to: Jennifer.Eppel@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Jen Eppel Licensing Division PO Box 64242 St. Paul, MN 55164-0242 RECOMMENDATION The following recommendation(s) are not requirements of the licensing rules and statutes that govern your services or facility. DHS has provided the recommendations below to call your attention to areas where your facility is in minimum compliance with the requirements of applicable rules or statutes. DHS recommends that you comply with the following recommendations to ensure that you continue to meet the requirements of applicable licensing rules and statutes. Your failure to follow these recommendations will not result in a fine or action against your license at this time. However, should your failure to follow these recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and DHS could issue a fine or other licensing action. 1. Recommendation: During the review, it was identified that one person holds the role of treatment director, alcohol and drug counselor supervisor, alcohol and drug counselor, and compliance officer. Through conversation with program staff, it was identified that this individual is unable to dedicate adequate time to the duties of compliance officer, as evidenced by citations above. It is recommended that whoever holds the role of Compliance Officer allocate no more than 50% of their working hours to directly providing treatment services. Statute: Minnesota Statutes, section 245A.02, subdivision 5a, paragraph (a). 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 treatment 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 me at 651-431-6671. Sincerely, Maura McGarry, Unit Supervisor Licensing Division Office of Inspector General
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