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April 5, 2024 Michael McHugh, Authorized Agent Midwest Recovery 2626 E 82ND ST STE 305 Bloomington, MN 55425 License Number 1105254 (Fairbault) License Number 1104211 (Brooklyn Center) License Number 1081840 (Red Wing) Report Number 202203917 CORRECTION ORDER Dear Michael: On January 29, 30, 31, February 1, 2, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facilities located at the following: · Midwest Recovery, 303 1st Ave NE, Faribault, MN 55021, license number 1105254 · Midwest Recovery Primer Paso, 3300 County Road 10 Suite 100, Brooklyn Center, MN 55429, license number 1104211, report number 202203917 · Midwest Recovery, 217 Plum St. Suite 130, 140, Red Wing, MN 55066, license number 1081840 As a result of this visit, DHS determined that you are in violation of the substance use disorder treatment statutes under Minnesota Statutes, chapter 245G. As a result, DHS is issuing this order which requires you to take the corrective action as described under each violation. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder (1105254 and 1081840) did not meet requirements for receiving public funding reimbursement from the commissioner for services provided: a. A mental health diagnostic assessment was not completed within ten days of admission (client files numbered 3, 4, 5, 6 and 7); b. A monthly multidisciplinary case review was not documented (client files 3, 4, 5, 6, and 7); c. Family education was not offered; and d. Counseling staff did not receive eight hours of co-occurring disorder training annually (personnel files numbered 1, 3, 5, and 7). Statute Violated: Minnesota statutes, section 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they are billed. Additionally, the noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. Policies, Practices, and Procedures 2. Violation: The license holder’s grievance procedure (1105254, 1104211, 1081840) did not contain the current address and telephone number for the Board of Behavioral Health and Therapy or the required amount of time a license holder must respond to the client upon receipt of the grievance.
Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, paragraph (2) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that demonstrates compliance. 3. Violation: The license holder did not have a supply of naloxone on site (1105254 and 1081840) 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 procedure for monitoring the supply of naloxone that demonstrates compliance. 4. Violation: The license holder’s treatment services description (1105254) did not meet requirements in the following ways: a. Client education was not being offered and did not include information on TB education on a form approved by a commissioner; b. The amount and type of services provided was not included; c. Which services that meet the definition of group counseling were not identified; d. Topics and groups on which a guest speaker could provide treatment services were not identified; and e. The program’s treatment week was not defined. Statute Violated: Minnesota statutes, sections 245G.07, subdivision 1, paragraph (2), and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that demonstrates compliance. Client Files Client files reviewed are identified in the following manner: · Client files numbered 1 and 2 (1104211) · Client files numbered 4 and 5 (1105254) · Client files numbered 3, 6 and 7 (1081840) 5. Violation: Six of seven client files reviewed for requirements governing client rights protection and client orientation did not meet requirements. There was no documentation of orientation to the following: a. A written statement of client’s rights and responsibilities identified in section 148F.165 (client file numbered 7); b. The staff reviewed the statement with the client (client file numbered 7); c. Grievance procedure was explained and documented (client file numbered 7); d. The commissioner approved education on HIV minimum standards (client files numbered 1, 2, 3, 4, 5, and 7); e. The Commissioner approved education on Tuberculosis (client files numbered 1, 2, 3, 4, 5, and 7); f. Personal electronic device (client file numbered 7); g. Maltreatment of vulnerable adults (client file numbered 7); h. Program abuse prevention plan (client file numbered 7); i. Consent to the disclosure of suspected maltreatment per 626.557 (client file numbered 2); and j. Confidentiality (client file numbered 3). Statute Violated: Minnesota statutes, sections 245A.19, 245A.65, subdivisions 1 and 2, 245G.09, subdivision 3, paragraph (1), and 245G.15, subdivisions 1, 2, and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 30 days of receipt of this order, submit one client file that demonstrates compliance. 6. Violation: Five of seven client files reviewed for requirements governing initial services plans (client files numbered 3 through 7) were not person centered and client specific. Documentation of treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan were identical. Statute Violated: Minnesota statutes, sections 245G.04, subdivision 1 and 245G.09, subdivision 3, paragraph (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. 7. Violation: Seven of seven client files reviewed for requirements governing comprehensive assessments and summaries did not meet requirements. There was no documentation of the following: a. The assessment was not updated as clinically necessary to ensure compliance (client file numbered 5); b. The assessment did not include information about the client’s needs that relate to substance use and personal strengths that support recovery, including: 1) A description of the circumstances on the day of service initiation (client files numbered 5 and 7); 2) A list of previous attempts at treatment for substance misuse or substance use disorder (client file numbered 7); 3) A list of substance use history including amounts (client file numbered 7); 4) Frequency and duration of use (client files numbered 2 and 7); 5) For each substance used within the previous 30 days, the date of the most recent use was not included (client file numbered 7); 6) History or presence of physical or sexual abuse (client files numbered 1, 6 and 7); 7) Medical concerns or diagnoses (client files numbered 3 through 7); 8) Mental health history, including symptoms, and the effect on the client’s ability to function (client files numbered 2, 5, and 7); 9) Current mental health treatment (client file numbered 7); 10) An assessment (GAIN-SS) to identify whether the client screens positive for co-occurring disorders (client file numbered 1); 11) Social network in relation to expected support for recovery (client file numbered 7); 12) Leisure time activities that have been associated with substance use (client files numbered 1, 2, 3, 5, and 7); 13) Whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client file numbered 1); c. The client was identified as having an opioid disorder and did not receive the following educational information (client file numbered 6): 1) Risks for opioid disorder and dependence; 2) Treatment options, including the use of a medication for opioid use disorder; 3) The risk of and recognizing opioid overdose; and 4) The use, availability, and administration of naloxone to respond to opioid overdose; d. The comprehensive assessment summary did not contain the following: 1) Documentation that the summary was completed within 3 calendar days on which a treatment session has been provided from the day of service initiation (client files numbered 2 and 7); 2) A determination of whether the client has a substance use disorder (client file numbered 1); and 3) Information relevant to treatment service planning and recorded in the dimensions (client file numbered 1). Statute Violated: Minnesota statutes, sections 245G.05, subdivision 1, paragraph (a), and subdivision 2, paragraph (a), (b), and (c), and 245G.09, subdivision 3, paragraph (3) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments and summaries meets all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that demonstrates compliance. 8. Violation: Seven of seven client files reviewed for requirements governing individual treatment plans (ITP) did not meet the requirements in the following ways: a. ITPs were not completed within 5 calendar days on which a treatment session had been provided from the day of service initiation (client files numbered 1, 2, 6, and 7); b. ITP dated 4/24/23 was not signed by the client (client file numbered 3); c. ITP was not signed by an alcohol and drug counselor on 4/24/23 (client file numbered 3), 8/2/23 (client filed numbered 6), and 7/25/23 (client file numbered 7); d. ITP did not document the client’s involvement in the development of the plan (client file numbered 3); e. ITP dated 7/26/23 (client file numbered 4) and 8/10/23 (client file numbered 5) did not include how the family would be involved in treatment when the client chooses; f. Plan contents did not include a current risk rating or specific methods to address each identified need (client file numbered 7); g. Resources to refer the client when needs are to be addressed concurrently by another provider were not provided (client files numbered 3, 4, 6 and 7); and h. Goals the client must reach to complete treatment and terminate services were not documented (client files numbered 2 and 5). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 2, and 245G.09, subdivision 3, paragraph (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meets all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan that demonstrates compliance. 9. Violation: Seven of seven client files reviewed for requirements governing client record documentation did not meet requirements. Documentation did not include the following: a. The date, type, and amount of each treatment service provided (client files numbered 3 through 7); b. The client’s response to each treatment service (client files number 3, 4, 5 and 6); c. A note entered following a significant event on the day the event occurred (client file numbered 7); and d. Staff signature and job title (client files numbered 1 through 5). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2a and 2b. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 10. Violation: Seven of seven client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. TPRs were not entered in the clients file weekly or after each treatment service: 1) 1/1-1/7/22, 1/15-1/21/22, 1/22-1/28/22, and 1/8-1/14/22 was completed late (client file numbered 1); 2) 11/6-11/12/23 completed late (client file numbered 2); 3) 9/11-9/15/23, 9/18-9/22/23, 9/4-9/8/23 was completed late (client file numbered 4); 4) 8/7-8/11/23, 11/27-12/1/23, with 8/21-8/25/23, 10/16/10/20/23, 10/30-11/3/23, and 11/20-11/24/23 completed late (client file numbered 5); and 5) 7/3-7/9/23 (client file numbered 7); b. The span of time covered by the review was not documented (client file numbered 6); c. Documentation of whether the methods to address the goals were effective (client files numbered 2, 3, and 6); d. Documentation of the participation of others (client files numbered 4 and 5); e. Staff recommendations for changes in the methods and whether the client agrees with the change were not documented (client file numbered 2); and f. No documentation of collaboration with continuing care mental health providers (client files numbered 6 and 7). Statute Violated: Minnesota statutes, sections 245G.06, subdivision 3, and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan review that demonstrates compliance. 11. Violation: Five of six client files reviewed for requirements governing discharge summaries did not meet requirements. Documentation did not include: a. Client needs while participating in treatment (client files numbered 6 and 7); b. Clients progress toward achieving each of the goals identified in the ITP (client files numbered 1 and 4). Additionally, there was no documentation supporting that the client was offered treatment services from 1/31/22 until discharge on 6/2/22 (client file numbered 1) (202203917); c. A risk description (client files numbered 4 and 5); d. The reasons for and circumstances of service termination (client file numbered 4); and e. Continuing care recommendations including referrals made for continuity of mental health (client file numbered 7) Statute Violated: Minnesota statutes, section 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meets all applicable requirements. Within 30 days of receipt of this order, submit a discharge summary that demonstrates compliance. Personnel Files Personnel files reviewed are identified in the following manner: · Personnel files numbered 1 and 2(1104211) · Personnel files numbered 3 through 6(1105254) · Personnel files numbered 7 and 8(1081840) 12. Violation: Six of eight personnel files reviewed for requirements governing background studies (personnel files numbered 1, 2, 3, 6, 7, and 8) were not affiliated on the correct roster. Statute Violated: Minnesota statutes, section 245C.07, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure background studies meet all applicable requirements. Within 30 days of receipt of this order, submit a background study for each staff that shows affiliation with the correct roster. 13. Violation: Two of seven personnel files reviewed for staff qualifications for persons providing treatment services did not meet requirements in the following ways: a. The license holder did not have documentation showing that the recovery peer received ongoing supervision in areas specific to the domains of the recovery peer’s role by an alcohol and drug counselor (personnel file numbered 8); and b. No documentation that the student intern was enrolled in an education program (personnel file numbered 7). Statute Violated: Minnesota statutes, section 245G.11, subdivision 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff qualifications for persons providing treatment services meet all applicable requirements. 14. Violation: Five of seven personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. Orientation was not provided within 24 hours for the following (personnel files numbered 2, 3, 5, and 7): 1) Staff members specific job responsibilities; 2) Policies and procedures; 3) Client confidentiality; and 4) Client needs; b. Orientation was not provided within 72 hours for the following: 1) HIV minimum standards (personnel files numbered 2, 3, 5, and 7); 2) Vulnerable adults’ maltreatment, including reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 2, 3, 5, and 7); 3) Program abuse prevention plan (personnel files numbered 2, 3, 5, and 7); and 4) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2, 3, 5, 7, and 8). Statute Violated: Minnesota statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivision 1, paragraph (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. 15. Violation: Two of two personnel files reviewed for requirements governing annual, biennial, and additional training did not meet requirements in the following ways: a. No documentation of annual training in calendar year 2022 and 2023 (personnel files numbered 1, 2, 3 and 5): 1) Vulnerable adults’ maltreatment reporting was completed late; 2) Program abuse prevention plan; 3) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was completed late; 4) Facility’s policies for obtaining client releases of information was completed late; 5) Reporting of maltreatment of minors, according to 260E; 6) Reporting of prenatal exposure to controlled substances; and 7) HIV minimum standards was completed late; b. Client confidentiality was not completed in 2023 (personnel file numbered 5); c. Client ethical boundaries was not completed in 2023 (personnel file numbered 5) d. Emergency procedures including behavioral was not completed in 2023 (personnel files numbered 1, 2, and 5); e. Client rights as specified in 148G.165 was not completed in 2023 (personnel files numbered 1, 2, and 5); f. Twelve hours of training in co-occurring disorders within 6 months of employment was not completed or completed late (personnel files numbered 1, 2, 3, 5 and 7); and g. Administration of naloxone (personnel files numbered 1, 7, and 8). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.08, subdivision 5, and 245G.13, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure training components meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above staff received training that demonstrates compliance. 16. Violation: Six of seven personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. Employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel files numbered 1, 2, 5, 7 and 8); and b. A written annual review was not completed for the following: 1) In calendar year 2022 (personnel file numbered 1, 2, and 5); and 2) In calendar year 2023 (personnel file numbered 3 and 5). 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 personnel file contents meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above personnel file contents demonstrate compliance. You must correct the violations cited above. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email to: Charlene.M.Hanson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Char Hanson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. 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 the license holder did not follow their procedure for a staff member requested service termination (1105254). A client was discharged for problems with interpersonal relationships and behaviors in group which is not identified in policy as one of the reasons for a staff requested discharge. It is recommended that you update your discharge policy to reflect this being a criteria for service termination. Statute: Minnesota Statutes, sections 245G.14, subdivision 3, paragraph (2). 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 651-431-6617. Sincerely,
Char Hanson, Senior Licensor Licensing Division Office of Inspector General
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