May 31, 2024                      

Allison Updike, Authorized Agent

Pride Institute, Inc.

14400 Martin Drive

Eden Prairie, MN 55344

License Number 1030116

CORRECTION ORDER

Dear Allison Updike:

On February 20, 21, and 22, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 2101 Hennepin Avenue Suite 202, Minneapolis, MN 55408. As a result of this visit, DHS determined that you are in violation of the substance use disorder treatment rules and statutes. 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.

Practices, Policies, and Procedures

1. Violation: The license holder did not meet requirements governing grievance procedures. One grievance was reviewed, dated January 23, 2024, and did not include a response within three days of a staff member's receipt.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements.

2. Violation: The license holder did not meet requirements for the plan for transfer of clients and records upon closure. There was no documentation that a controlling individual of the program reviewed and signed the plan for calendar year 2023.

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

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.

3. Violation: The license holder did not meet requirements governing client records. Client records were not protected against loss, tampering, or unauthorized disclosure. Paper client records were observed to be stored in a room that was unlocked and accessible by the public.

Statute Violated: Minnesota statutes, section 245G.09, subdivision 1, paragraph (a).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client records are protected against loss, tampering, or unauthorized disclosure. Within 30 days of receipt of this order, submit a plan to protect client records against loss, tampering, and unauthorized disclosure.

Personnel Files

4. Violation: As the result of a licensing review on February 21, 2024, a DHS licensor determined that the license holder did not verify that the information collected about a staff person (personnel file numbered 1) was correct before the background study request for the staff person was submitted to DHS.

Statute Violated: Minnesota Statutes, sections 245C.05, subdivision 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements.

5. Violation: One of three personnel files reviewed for requirements governing personnel file contents (personnel file numbered 3) did not meet requirements. There was no documentation of the following:

a. A completed application for employment signed by the staff member and containing the staff member’s qualifications for employment; and

b. A written annual review of the staff member’s job performance for calendar year 2024.

Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3.

Repeat Violation: In a Correction Order that DHS issued on October 16, 2023, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements.

6. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit from the Board of Behavioral Health and Therapy to provide substance use disorder treatment service (personnel file numbered 1) did not meet requirements. Supervision provided by a licensed alcohol and drug counselor was not documented for the weeks of December 23, 2023, December 30, 2023, January 6, 2024, January 13, 2024, January 20, 2024, January 27, 2024, and February 17, 2024.

Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on October 16, 2023, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements.

7. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements as follows:

a. Within 24 working hours, no orientation documentation provided on the following:

1) The staff member’s specific job responsibilities (personnel file numbered 1);

2) Client confidentiality (personnel file numbered 3); and

3) Client needs (personnel files numbered 1 and 3); and

b. Within 72 hours of first providing direct contact services to a vulnerable adult (personnel file numbered 1), no orientation documentation provided on the following:

1) Vulnerable adults maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; and

2) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 1.

Repeat Violation: You were previously found in violation of this same statute in:

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 staff mentioned above have completed the trainings identified above.

8. Violation: Two of two personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation for the following:

a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 for calendar year 2024 (personnel file numbered 3);

b. The program abuse prevention plan for calendar year 2024 (personnel files numbered 2 and 3);

c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services, including specific training covering the license holder’s responsibility for obtaining a release of client information for calendar year:

1) 2023 (personnel file numbered 2); and

2) 2024 (personnel files numbered 2 and 3);

d. Mandatory reporting as specified in Minnesota Statutes, chapter 260E for calendar year 2024 (personnel files numbered 2 and 3); and

e. HIV minimum standards for calendar year 2024 (personnel files numbered 2 and 3).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that annual trainings are provided. Within 30 days of receipt of this order, submit documentation that the staff mentioned above have completed the trainings identified above.

9. Violation: One personnel file reviewed for requirements governing every two year trainings (personnel file numbered 2) did not meet requirements. There was no documentation of training on client ethical boundaries for calendar year 2023.

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 and document that biennial trainings are provided. Within 30 days of receipt of this order, submit documentation that the staff mentioned above have completed the training identified above.

10. Violation: One of three personnel files reviewed for additional trainings (personnel file numbered 1) did not meet requirements. The license holder did not require staff to undergo training in the specific mode of administration used at the program for emergency treatment of opioid overdose.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff mentioned above has completed the training identified above.

Client Files

11. Violation: Three of three client files reviewed for requirements governing client orientation (client files numbered 1, 2, and 4) did not meet requirements. The license holder did not provide an orientation to the internal and external reporting procedures for the maltreatment of vulnerable adults.

Statute Violated: Minnesota statutes, section 245A.65, subdivision 1, paragraph (a).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 30 days of receipt of this order, submit a client handbook that demonstrates compliance with the requirements for the internal and external reporting procedures for the maltreatment of vulnerable adults.

12. Violation: Four of four client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not contain the following information:

a. Amount of substances used (client files numbered 1 and 4);

b. Duration of use (client file numbered 4);

c. For each substance used within the previous 30 days, the presence or absence of previous withdrawal symptoms (client files numbered 1, 2, and 4);

d. Physical and medical concerns or diagnoses (client file numbered 3);

e. Mental health history, including the effect on the client’s ability to function (client files numbered 2 and 3);

f. Social network in relation to expected support for recovery (client file numbered 3); and

g. Leisure time activities that have been associated with substance use (client file numbered 3).

Statute Violated: Minnesota statutes, section 245G.05, subdivision 1, paragraph (a).

Repeat Violation: You were previously found in violation of this same statute in:

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure comprehensive assessment requirements are met.

13. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways:

a. The ITP was not completed within five calendar days on which a treatment session had been provided from the day of service initiation (client files numbered 2 and 4);

b. The ITP was not signed by the client (client file numbered 4);

c. The ITP was not signed by an alcohol and drug counselor (client file numbered 4);

d. The ITP did not contain the following information:

1) Documentation of the client’s involvement in the development of the plan (client file numbered 4);

2) How the family or others will be involved in the client’s treatment (client file numbered 2);

3) Resources to refer the client to when needs are to be addressed concurrently by another provider (client files numbered 1 through 4); and

4) Goals the client must reach to complete treatment and terminate services (client file numbered 2); and

e. The ITP was not updated based on new information gathered about the client’s condition and on whether methods identified had the intended effect (client file numbered 1).

Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 2.

Repeat Violation: You were previously found in violation of this same statute in:

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements.

14. Violation: Three of five client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways:

a. A treatment plan review was not entered in the client file for treatment weeks ending:

1) December 24, 2023 (client file numbered 1 and 5); and

2) December 16, 2023 and January 31, 2024 (client file numbered 5);

b. A treatment plan review did not indicate the span of time covered by the review for the treatment weeks ending December 3, 2023, December 10, 2023, and December 17, 2023 (client file numbered 3); and

c. The treatment plan review did not address whether the methods to address the goals are effective (client file numbered 5).

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

Repeat Violation: In a Correction Order that DHS issued on October 16, 2023, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meets all applicable requirements.

15. Violation: Two of two client files reviewed for requirements governing service discharge summaries did not meet requirements. The service discharge summary did not include:

a. The client’s strength and needs while participating in treatment (client file numbered 3);

b. The client's progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 4); and

c. A risk description according to Minnesota Statutes, section245G.05 (client file numbered 4).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b).

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.

Corrective action required

You must correct the violations cited above. Submit 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:

1. By secure email to: Kayla.Northrop@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Kayla Northrop

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 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 Kayla.Northrop@state.mn.us or at 651-431-5843.

Sincerely,

Kayla Northrop, Licensor

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/