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May 30, 2024 Dana Nelson, Authorized Agent AICDC Withdrawal Management 1800 Chicago Ave Minneapolis, MN 55404-2592 License Number 1100408 Withdrawal Management Program License Number 1016101 Detoxification Program CORRECTION ORDER Dear Dana Nelson: On February 28, 29, and March 1, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 1800 Chicago Ave, Minneapolis, MN 55404-2592. As a result of this visit, DHS determined that you are in violation of the withdrawal management statutes under Minnesota Statutes, chapter 245F and detoxication services under Minnesota Rules, parts 9530.6590 (Rule 32). As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Throughout the correction order, references to the statute or rule requirement will be identified as follows: · Withdrawal Management Program as (245F); and · Detoxification Program as (Rule 32) Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements governing policies and procedure manuals (245F and Rule 32). Through interviews with staff, it was identified that staff do not have immediate access to all policies and procedures, and that consumers of the services and other authorized parties do not have access to all policies and procedures. Rule and Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (c) and 245F.18 and Minnesota Rules, part 9530.6580. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that a policies and procedures manual meeting all applicable requirements is available to staff and clients. Within 30 days of receipt of this order, submit verification that you have a single policy manual and that other policies and procedures have been removed, deleted, or archived. 2. Violation: The license holder did not meet requirements governing grievance procedures (245F). The grievance procedure did not include addresses and phone numbers for the Board of Medical Practice or the Board of Nursing. Statute Violated: Minnesota Statutes, section 245F.10, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that meets all requirements. Personnel Files 3. Violation: One of four personnel files reviewed for requirements governing personnel files (personnel file numbered 2) did not meet requirements. The license holder had no documentation the technician demonstrated competency in the following areas: a. knowledge of and ability to perform basic health screening procedures with intoxicated clients that consists of: i. Interviewing to obtain relevant medical history and current health complaints; and ii. Knowledge of and ability to perform basic actives of daily living and person hygiene; b. a current first aid certificate from the American Red Cross, the American Heart Association, a community organization, or an equivalent organization within 30 days of hire. There was no documentation that this certificate had been obtained; and Rule and Statute Violated: Minnesota Statutes, section245F.15, subdivision 6, paragraph (2) and Minnesota Rules 9530.6565, subpart 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff meet all qualifications for their position. Within 30 days of receipt off this order, submit documentation that the staff mentioned above has met the requirements. 4. Violation: One of two personnel files reviewed for requirements governing staff orientation (personnel file numbered 5) did not meet requirements (245F and Rule 32). The personnel file did not include documentation of orientation to specific license holder and staff responsibilities for patient confidentiality completed within 72 hours of beginning employment. Rule and Statute Violated: Minnesota Statutes, section 245F.16, subdivision 2, paragraph (b) and Minnesota Rules 9530.6570, subpart 2, item A. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that staff orientation meets all applicable requirements. Within 30 days of receipt off this order, submit documentation that the staff mentioned above has completed the required training. 5. Violation: One personnel file was reviewed for requirements governing annual staff training (personnel file numbered 1) and did not meet requirements. There was no documentation of the following for calendar year 2024: a. Infection control procedures (245F and Rule 32); b. Program abuse prevention plan (245F and Rule 32); c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services, including specific training covering the facility’s policies for obtaining patient releases of information (245F and Rule 32); d. Mandatory reporting under Minnesota Statutes, chapter 260E (245F and Rule 32); e. HIV minimum standards (245F and Rule 32); and f. Motivational counseling techniques and identifying stages of change (245F). Rule and Statute Violated: Minnesota Rules 9530.6570, subpart 2, items D through F and Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245F.16, subdivision 2, paragraph (c). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual training meets all applicable requirements. Patient Files All patient files reviewed were for the 245F Withdrawal Management Program only. 6. Violation: Five of five patient files reviewed for requirements governing patient orientation (patient files numbered 1 through 5) did not meet requirements. Patients were not oriented to the following: a. A written statement of the rights in Minnesota Statutes, sections 144.651 and 148F.165 upon admission; and b. The program abuse prevention plan within 24 hours of admission. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (a) and 245F.10, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient orientation meets all applicable requirements. Within 30 days of receipt of this order, submit client rights statements, the program abuse prevention plan, and a client handbook that meets all requirements. 7. Violation: Five of five patient files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements as follows: a. The IAPP did not document the following: i. Individualized assessment of the person’s susceptibility to abuse by other individuals including other vulnerable adults and the person’s risk of abusing other vulnerable adults according to Minnesota Statutes, section 626.5572 (patient files numbered 1 through 5); ii. Referrals made when a vulnerable adult was susceptible to abuse out the scope or control of the licensed services (patient file numbered 4); and iii. That the vulnerable adult does not need specific risk reduction measures in addition to those identified in the program abuse prevention plan (patient file numbered 5); and b. The IAPP was not reviewed and evaluated as part of the service plan review (patient files numbered 1 through 5). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that individual abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of individual abuse prevention plans from two patient files that meet all requirements. 8. Violation: Four of five patient files reviewed for requirements governing medical services did not meet requirements in the following ways: a. A follow up screening was not conducted between 4 and 12 hours after service initiation (patient files numbered 2 and 3); and b. Hourly observations were missing as follows: i. One hour missing on February 6, 2024 (patient file numbered 5); ii. One hour missing on February 14 and 16, 2024 (patient file numbered 4); and iii. Two hours missing on January 18, 2024 (patient file numbered 3). Statute Violated: Minnesota Statutes, section 245F.12, subdivision 1. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services meet all applicable requirements. 9. Violation: Two of five patient files reviewed for requirements governing medications did not meet requirements. The procedures for acceptance, documentation, and implementation of prescriptions were not followed. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, and 245F.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that procedures regarding medications are followed. 10. Violation: One of two patient files reviewed for requirements governing comprehensive assessments (patient file numbered 3) did not meet requirements. It was not completed within 72 hours and it was not documented why it was not completed. Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Repeat Violation: The license holder was previously found in violation of the same statute in a correction order dated December 4, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 11. Violation: Five of five patient files reviewed for requirements governing individualized stabilization plans failed to meet requirements. The stabilization plan was not: a. Based on the patient’s initial health assessment (patient file numbered 4); b. Individualized for each patient accepted for stabilization services (patient files numbered 1 through 5); c. Updated based on new information gathered about the patient condition (patient file numbered 3); d. Did not specify the involvement of others in the development of the plan (patient files numbered 1 through 5); and e. Did not specify the involvement of the client in the development of the plan (patient file numbered 5). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 1. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of the stabilization plans from two patient files that meet all requirements. 12. Violation: One of five patient files reviewed for requirements governing progress notes (patient file numbered 3) did not meet requirements. A progress notes was not entered immediately following a significant event regarding a change in the legal status of the patient. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. 13. Violation: Five of five patient files reviewed for requirements governing discharge plans did not meet requirements. The discharge plans did not include the following: a. Referrals made to other services (patient file numbered 3); b. The patient’s plans for follow-up, aftercare, or post-stabilization services (patient files numbered 3 through 5); and c. A stabilization summary and final evaluation of the patients’ progress toward treatment objectives (patient files numbered 1 through 5). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of the discharge plans from two clients that meet all requirements. 14. Violation: Four of five patient files reviewed for requirements governing stabilization services did not meet requirements. There was no documentation of the following services provided: a. Peer recovery support services (patient file numbered 2); and b. Care coordination, including referral to mental health as identified by the comprehensive assessment (patient files numbered 3 through 5). Statute Violated: Minnesota Statutes, section 245F.08, subdivisions 1 and 2. Repeat Violation: The license holder was previously found in violation of the same statute in a correction order dated December 4, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure stabilization services meet all applicable requirements. 15. Violation: One of five patient files reviewed for requirements governing patient records (patient file numbered 5) did not meet requirements. The following patient records were not signed and dated by the staff member making the entry: a. Discharge summary; and b. Nursing education group note from February 22, 2024. Statute Violated: Minnesota Statutes, section 245F.19, subdivision 1. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient records meet all applicable requirements. 16. Violation: One of five patient files reviewed for requirements governing patient property management (patient file numbered 3) did not meet requirements. The license holder did not immediately document disbursement of the patient’s funds or other property at the time of disbursement, including the patient’s signature, or the signature of the conservator or payee. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c) and 245F.11. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure property management meets all applicable requirements. 17. Violation: Two of five patient files reviewed for requirements governing administration with medication administration did not meet requirements in the following ways: a. Medications were not given as ordered and guidelines for documenting problems with medication administration, including failure to administer, patient refusal of a medication, adverse reactions, or errors were not followed for the following: i. Daily Multivitamin on February 13, 14, 15, 18, and 19, 2024 (patient file numbered 4); and ii. Daily Multivitamin on February 15, 16, 18, 22, and 24, 2024 (patient file numbered 5). Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and 245F.13, subdivision 1. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction order dated December 4, 2023; and · Conditional order dated February 24, 2023. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication administration meets all applicable requirements. RECOMMENDATION The following recommendation is not a requirement 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. 1. Recommendation: Current stabilization plan does not properly specify the conditions in which certain medication prescriptions are implemented. Contact DHS for training on condition specific protocols. Statute: Minnesota Statutes, chapter 245F.13, subdivision 1. 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 withdrawal management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F and Minnesota Rules, parts 9530.6590 (Rule 32) · 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 Jennifer White, Licensor, at 651-431-6282. Sincerely, Jennifer White, Licensor Licensing Division Office of Inspector General
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