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May 2, 2024 Joshua Beulke, Authorized Agent Inspire Services, LLC 32298 State Highway 13 Montgomery, MN 56069 License Number 1105997 CORRECTION ORDER Dear Joshua Beulke: On March 11 and 12, 2024, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 1031 Grace St., St. Peter, MN 56082. 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 indicate in their treatment services policy which services could be provided via telehealth. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4. 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 a treatment services policy that demonstrates compliance. 2. Violation: The license holder did not have a procedure for monitoring the available supply of naloxone on site, replenishing the naloxone supply when needed, and destroying naloxone as required. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the 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 meets all applicable requirements. 3. Violation: The license holder’s plan for transfer of clients and records upon closure was not reviewed and signed by a controlling individual in calendar years 2022 and 2023. Statute Violated: Minnesota Statutes, section 254A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. Personnel Files 4. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements. Orientation was not documented for the following: a. Policies and procedures (personnel files numbered 2 and 4); and b. Client needs (personnel files numbered 1, 2, and 4). Statute Violated: Minnesota Statutes, section 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. Within 30 days of receipt of this order, submit documentation that the above staff received the required orientation training. 5. Violation: One personnel file reviewed for requirements governing staff development (personnel file numbered 1) did not meet requirements. There was no documentation of the following: a. Every two-year training for calendar year 2023: 1) Client confidentiality rules and regulations; and 2) Client rights as specified in Minnesota Statutes, sections 148F.165 and 253B.03 Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b). 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. 6. Violation: One of three personnel file reviewed for requirements governing personnel file contents (personnel file numbered 1) did not meet requirements. 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 was not documented. Statute Violated: Minnesota Statutes, section 245G.13 subdivision 3.
Client Files 7. Violation: Three of three client files reviewed for requirements governing client orientation (client files numbered 1, 2, and 3) did not meet requirements. The license holder did not provide the commissioner approved tuberculosis (TB) written resource and screening information to each client as required per section 144.4804. Statute Violated: Minnesota Statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 8. Violation: Two of three client files reviewed for requirements governing initial service plan and vulnerable adult determination did not meet requirements as follows: a. The initial services plan and vulnerable adult determination was not completed within 24 hours of the day of service initiation (client file number 3); and b. The initial services plan and vulnerable adult determination was not documented as completed (client file number 2). Statue Violated: Minnesota Statutes section 245G.04, subdivisions 1 and 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that initial service plans and vulnerable adult determinations meet all applicable requirements. 9. Violation: Three of three 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 description of the circumstances on the day of service initiation (client file numbered 3); 2) A list of substance use history including the amount of substances used (client files numbered 1 and 3); 3) Current medical treatment needed or being received related to the diagnosis (client file numbered 1); 4) Whether or not the concerns need to be referred to an appropriate health care professional (client file numbered 1); 5) Mental health history, including symptoms and the effect on the client’s ability to function (client files numbered 1 and 2); 6) A description of how use affected the clients ability to function appropriately in a work and educational setting (client file numbered 1); 7) Ability to understand written treatment materials, including rules and client rights (client file numbered 1); and 8) Leisure time activities that have been associated with substance use (client file numbered 1); a. The client identified as having opioid use disorder or seeking treatment for opioid use disorder (client file numbered 1) and the program did not provide the following documentation: 1) Treatment options, including the use of a medication for opioid disorder; and 2) The risk of and recognizing opioid overdose. Statute Violated: Minnesota Statutes section 245G.05 subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that comprehensive assessments meet all applicable requirements. 10. Violation: Three of three 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 the treatment service (client file numbered 1); b. Resources to refer the client to when needs are to be addressed concurrently by another provider (client file numbered 2); and c. An individual treatment plan was not updated as recommended on December 20, 2023 per treatment plan review (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06 subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan that meets all applicable requirements. 11. Violation: One of three client files reviewed for requirements governing the documentation of treatment services (client file numbered 2) did not meet requirements. The treatment service on January 23, 2023, was not documented within seven days of providing the treatment service. 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. 12. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review was not entered according to the treatment services policy defined treatment week for the following: 1) November 29, December 8, December 15, and December 21, 2023 (client file numbered 1); 2) December 6, December 13, December 20, and December 27, 2023 (client files numbered 2 and 3); and b. The treatment plan review did not contain the following: 1) The span of time covered by the December 21, 2023, review (client file numbered 1); 2) The treatment plan did not address whether the methods were effective: 1. December 6, December 13, December 20, and December 27, 2023 (client file numbered 2); and 2. December 13, December 20, and December 27, 2023 (client file numbered 3); 3) Monitoring of any physical and mental health problems of on reviews dated December 6, December 13, December 20, and December 27, 2023 (client file numbered 3); and 4) Documentation of the participation of others on reviews dated December 6, December 13, December 20, and December 27, 2023 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.03, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan review that demonstrates compliance. 13. Violation: One client file reviewed for requirements governing service discharge summaries (client file numbered 3) did not meet requirements. The service discharge summary was not completed within five days of the client’s service termination. 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. 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: 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 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 have a telehealth policy outlining how services would be provided and how clients would be assessed for appropriateness. It is recommended that you develop a written policy and procedure necessary to provide telehealth services. 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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