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May 17, 2024 Christopher McCalla, Authorized Agent Partners in Recovery, LLC 1611 County Road B W Ste 102 Roseville, MN 55113 License Number: 1104202 Licensing Investigation Number: 202304424
Dear Christopher McCalla: On January 4, 2024, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of the citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on December 13, 2023.
Citation 1: Violation: The license holder did not monitor the implementation and procedures of their service termination policy. C1 was discharged at staff request for a reason not written in the service termination policy. C1 was discharged as a result of a physical altercation with a client in the sober living home, unrelated to services at Partners Behavioral Healthcare. Request for Reconsideration. You submitted a letter requesting reconsideration in which you indicate you believe the program was in compliance with the applicable law at the time the citation was issued. You provided photographs of program policies and the client’s discharge summary.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.14, subdivision 3, a license holder must have a written policy specifying the conditions when a client must be terminated from service. Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) requires the license holder to monitor implementation of policies and procedures by program staff. You indicate in your reconsideration request that the program acted according to policy in discharging a client who had been involved in a physical altercation with their roommate at a sober living facility that was separate from the program. You indicate the policy allowed for discharge at staff request in situations involving a client “physically striking another person” or having “severely violent and abusive behavior.” You indicate there is no requirement that the situation occur at the program rather than another location and that a physical altercation impacts the safety of the client other clients and the community regardless of where it occurs. However, the program’s Service Termination Policies also contains a section that lists procedures for discharging a client at staff request, and that section specifies that the treatment team will meet following the behavior exhibited to determine if 1) the behavior was isolated in nature and if unlikely to be repeated or 2) if the client will continue to be a threat to self or others. If safety of others is determined to be at continued risk, client will be informed of his/her discharge and effort will be made to contact referral source and make alternative plan for client care. Also, in an interview on December 1, 2023, during the investigation, you indicated that a client being discharged from housing does not necessarily mean they are discharged from programming, but an altercation between current clients would be taken into consideration. The individual involved in the assault with the client was not a client of the program but was the client’s roommate in a different setting. There was no documentation of how the client’s behavior would pose a risk within the program, and there was no documentation to indicate the client was aggressive within the program. The applicable law requires the program to have a written policy specifying conditions when a client must be terminated from service, and it requires the program to monitor implementation of polices by program staff. Because there is sufficient evidence to indicate the program did not monitor implementation of its Service Termination Policies, there is therefore sufficient evidence to support the violation and it is affirmed. Citation 2: Violation: One client file was reviewed for requirements governing the service discharge summary (C1) and did not meet requirements. The discharge summary did not include referrals. Request for Reconsideration. You submitted a letter requesting reconsideration in which you indicate the belief that the program was in compliance with applicable law at the time the citation was issued. You provided photographs of your policies and the client’s discharge summary.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b), the service discharge summary must include specified information, including continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health, as needed. The information submitted with the reconsideration request shows the license holder was in compliance with requirements. As a result, it is appropriate to rescind the citation. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the citation 1, and it is affirmed. The Commissioner finds there it is appropriate to rescind citation 2. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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