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June 27, 2024 Jeremy Gerres, Authorized Agent Spirits at Rest 202 1st Street South Montgomery, MN 56069 License Number 1103887 CORRECTION ORDER Dear Jeremy Gerres: On March 25, 26, 27, and 28, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 202 1st Street South, Montgomery, MN 55069. 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 for receiving public funding reimbursement from the commissioner for peer recovery services provided as follows: a. Peer recovery support services were not provided one-to-one on the following dates: 1) June 8, 2023 (client files numbered 3 and 17); 2) June 15, 2023 (client files numbered 3 and 11); 3) June 22, 2023 (client files numbered 3 and 18); 4) June 29, 2023 (client files numbered 3, 11, and 18); 5) July 6, 2023 (client files numbered 3, 6, 11, and 12); 6) September 29, 2023 (client files numbered 5 and 6; client files numbered 7 and 8; client files numbered 9 and 10; and client files numbered 11 and 12); 7) November 16, 2023 (client files numbered 5, 6, 12, 13, 14, and 15); 8) December 7, 2023 (client files numbered 2, 13, 14, and 15); and 9) December 21, 2023 (client files numbered 2 and 16); b. Peer recovery support services were billed for on February 2, 2024, after the client was discharged (client file numbered 2). 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. 2. Violation: The license holder did not meet requirements governing client records. Client records were not protected against loss, tampering, or unauthorized disclosure in the following ways: a. Paper client records were observed to be stored in a room that was unlocked and accessible by the public; and b. The license holder lost access to electronic health records that were taken by a former staff member. 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. Corrected on-site. 3. Violation: The license holder did not meet requirements governing provider personnel policies and procedures. The organizational chart did not describe the current structure and accurately indicate the lines of authority. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the chart or description of the organizational structure accurately indicates lines of authority and responsibilities. Within 60 days of receipt of this order, submit a revised organizational chart that meets all applicable requirements. 4. Violation: The license holder did not meet the requirements governing policies and procedures. The license holder did not monitor the implementation of policies and procedures as the licensor observed the program had multiple variations of policies and/or procedures or policies that had outdated statute references for the following: a. Service initiation policy; b. Service termination policy; c. Program abuse prevention plan; d. Grievance procedure; and e. Reporting of maltreatment of minors. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), 245G.12, 245G.14, subdivision 1, and 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all policies and procedures meet requirements. Within 60 days of receipt of this order, submit updated policies for items (a) through (d) above that meet all applicable requirements. 5. Violation: The license holder did not meet requirements governing program abuse prevention plans. The plan in the policies and procedures manual was not reviewed at least annually by the license holder's governing body or the governing body’s delegate using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all program abuse prevention plans are consistent and meet all applicable requirements. 6. Violation: The policies and procedures for reporting the maltreatment of vulnerable adults did not meet requirements. The policy did not require that a mandated reporter who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information to the common entry point. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure policies and procedures for reporting the maltreatment of vulnerable adults meet all applicable requirements. Within 60 days of receipt of this order, submit revised policies and procedures for reporting the maltreatment of vulnerable adults that meets all applicable requirements. 7. Violation: The license holder provided treatment services off site from the licensed site and did not include a policy and procedure detailing telehealth as a part of the treatment service description. 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 location of service provision meets all applicable requirements. Within 60 days of receipt of this order, submit a policy and procedure detailing the off-site location as a part of the treatment service description and the program abuse prevention plan. 8. Violation: The license holder did not meet requirements governing medical services in the following ways: a. The license holder did not maintain a complete description of the health care services to include the administration of an opioid antagonist; b. The license holder did not develop a procedure for monitoring the available supply of naloxone on site, replenishing the naloxone supply when needed, and destroying naloxone; and c. The license holder did not document the availability of a licensed mental health professional to provide diagnostic assessment and treatment planning assistance.sss Statute Violated: Minnesota Statutes, sections, 245A.242, subdivision 2, and 245G.08, subdivisions 1, 4 and 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services policies and procedures meet all applicable requirements. Within 60 days of receipt of this order, submit a revised medical services policy that meets all applicable requirements. 9. Violation: The license holder did not meet requirements governing responsible staff members. The policy allowed for multiple staff members to be designated as the responsible staff members concurrently. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policies governing responsible staff members and knowledge and understanding of responsible staff members meet all applicable requirements. 10. Violation: A controlling individual of the program did not review and sign the plan for transfer of clients and records upon closure for the 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 a controlling individual of the program annually review and sign the plan for transfer of clients and records upon closure and that the plan meets all applicable requirements. Personnel Files 11. Violation: One personnel file reviewed for requirements governing treatment director qualifications (personnel file numbered 1) did not meet requirements. No documentation that the treatment director knew and understood the implications of chapter 245G. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment director meets all applicable requirements. 12. Violation: One personnel file reviewed for requirements governing personnel files (personnel file numbered 2) did not contain documentation to demonstrate that the staff member met the qualifications of an alcohol and drug counselor (ADC). Personnel record did not contain a current ADC license. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the alcohol and drug counselor meets all applicable requirements. 13. Violation: One personnel file reviewed for requirements governing recovery peer qualification did not meet requirements. No documentation of the following: a. A minimum of one year in recovery from substance use disorder; b. a current credential from the Minnesota Certification Board, the Upper Midwest Indian Council on Addictive Disorders, or the National Association for Alcoholism and Drug Abuse Counselors; and c. Supervision under an alcohol and drug counselor. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure recovery peers meet all applicable requirements. Within 60 days of receipt of this order, submit documentation for the items identified above. 14. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements. No documentation that orientation was provided for the following: a. Within 24 working hours: 1) The staff member’s specific job responsibilities (personnel file numbered 3); 2) Policies and procedures (personnel file numbered 3); 3) Client confidentiality (personnel file numbered 3); 4) Client needs (personnel file numbered 3); 5) HIV minimum standards (personnel file numbered 3); and 6) Drug and alcohol policy (personnel files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c) and 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. 15. Violation: Three of three 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 years: 1) 2022 and 2023 (personnel files numbered 1 and 2); and 2) 2024 (personnel file numbered 3); b. The program abuse prevention plan for calendar years: 1) 2022 and 2023 (personnel files numbered 1 and 2); and 2) 2024 (personnel file numbered 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 years: 1) 2022 and 2023 (personnel files numbered 1 and 2); and 2) 2024 (personnel file numbered 3); d. Mandatory reporting as specified in Minnesota Statutes, chapter 260E for calendar years: 1) 2022 and 2023 (personnel files numbered 1 and 2); and 2) 2024 (personnel file numbered 3); e. HIV minimum standards for calendar years 2022 and 2023 (personnel files numbered 1 and 2). 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 60 days of receipt of this order, submit documentation that the staff mentioned above have completed the trainings identified above. 16. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. The completed application for employment signed by the staff member and containing the staff member's qualifications for employment was signed after the staff member’s date of hire (personnel file numbered 3); b. No written annual review of the staff member’s job performance for calendar years: 1) 2023 (personnel files numbered 1 and 2); and 2) 2024 (personnel file numbered 3). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files 17. Violation: One client file reviewed for requirements governing individual treatment plans (client file numbered 2) did not meet requirements. The client received peer recovery support services and the individual treatment plan was not updated based on new information about the client’s condition. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that peer recovery support services meet all applicable requirements. 18. Violation: Four of four client files reviewed for requirements governing client orientation (client file numbered 3) did not meet requirements in the following ways: a. No documentation that orientation was provided for the license holder’s policy on photographs of clients (client file numbered 3); and b. No documentation that orientation was provided on HIV minimum standards (client files numbered 1, 2, 3, and 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245G.09, subdivision 3, and 245G.15, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedure meets all applicable requirements. 19. Violation: Four of four client files reviewed for requirements governing initial services plans did not meet requirements in the following ways: a. The initial services plan was not completed (client file numbered 3); b. The initial services plan was not completed within 24 hours of the day of service initiation (client files numbered 1and 4); and c. The initial services plan was not person-centered and client-specific (client files 1, 2, and 4). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. 20. Violation: Two of four client files reviewed for requirements governing determination of vulnerable adult status (client files numbered 3 and 4) did not document a vulnerable adult determination. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, 245G.04, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the determination of vulnerable adult status meets all applicable requirements. 21. Violation: Four of four client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment and comprehensive assessment summary did not meet the following requirements: a. The comprehensive assessment and comprehensive assessment summary were not completed within 3 calendar days on which a treatment service has been provided of the day of service initiation of a client (client files numbered 2 and 3); b. The person-centered reason for the delay and the planned completion date for the assessment was not documented (client files numbered 2 and 3); c. The client received a comprehensive assessment that authorized the treatment service. No documentation that the alcohol and drug counselor reviewed the comprehensive assessment and updated the comprehensive assessment as clinically necessary (client files numbered 1 and 4); d. The assessment did not include the client’s cultural background (client files numbered 1, 2, and 3); e. The assessment did not include the client’s level of education, and status of basic needs (client file numbered 2); f. For each substance used within the previous 30 days, the presence or absence of previous withdrawal symptoms was not included (client files numbered 1 and 2); g. The assessment did not include mental health symptoms and the effect on the client’s ability to function (client files numbered 1, 2, and 3); h. The assessment did not utilize screening tools approved by the commissioner pursuant to section 245.4863 to identify whether the client screens positive for co-occurring disorders (client file numbered 2); i. The assessment did not include the client’s ability to understand written treatment materials, including rules and the client's rights (client file numbered 2); j. The assessment did not include the client’s social network in relation to expected support for recovery (client file numbered 2); k. The assessment did not include leisure time activities that are associated with substance use (client files numbered 1 and 2); l. The assessment did not include whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client file numbered 2); m. The comprehensive assessment summary did not include a summary to support the risk ratings within each of the dimensions listed in section 254B.04, subdivision 4 (client file numbered 1); and n. Withdrawal symptoms were not included (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1, 2 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 60 days of receipt of this order, submit two client comprehensive assessments that meets all applicable requirements. 22. Violation: Two of three client files reviewed for requirements governing individual treatment plans and treatment plan reviews did not meet requirements for in the following ways: a. The individual treatment plan was not completed within five calendar days on which a treatment session has been provided from the day of service initiation (client files numbered 1 and 2); b. The individual treatment plan did not identify resources to refer the client to when the client's needs will be addressed concurrently by another provider (client file numbered 2); c. The individual treatment plan did not include goals the client must reach to complete treatment and have services terminated (client file numbered 2); d. The treatment plan review was not entered in the client file the for the treatment weeks ending: 1) December 30, 2023, and January 6, 2024 (client file numbered 2); and 2) September 2, 2023, September 30, 2023, and December 30, 2023 (client file numbered 3); e. The treatment plan review was not entered in a client's file within seven days of providing the treatment service for treatment weeks ending: 1) November 18, 2023, November 25, 2023, December 2, 2023, December 16, 2023, and January 6, 2024 (client file numbered 1); and 2) June 24, 2023 and October 21, 2023; f. The treatment plan review documented events that occurred after the span of time covered by the review (client file numbered 1); g. The treatment plan review for the period ending December 7, 2023, did not address each goal in the treatment plan and whether the methods to address the goals are effective (client file numbered 2); and h. The treatment plan review for the period ending December 7, 2023 (client file numbered 2) and all periods (client file numbered 3) did not include monitoring of any physical and mental health problems. Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1, 2, 2a, and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans and treatment plan reviews meet all applicable requirements. Within 60 days of receipt of this order, submit two client individual treatment plans and two treatment plan reviews that meets all applicable requirements. 23. Violation: Three of three client files reviewed for requirements governing client record documentation requirements (client files numbered 1, 2, and 3) did not include the job title or position of the staff person that made the entry. After staff signature, title was signed “counselor,” however; not all staff were qualified as a counselor. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation requirements meet all applicable requirements. WRITTEN RESPONSE REQUIRED If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at Kayla.Northrop@state.mn.us or by mail: 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 Maura McGarry, Supervisor, at 651-431-6671. Sincerely, Kayla Northrop Licensing Division Office of Inspector General
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