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July 17, 2024 CERTIFIED MAIL William Lockett, Authorized Agent The Micah Halfway House 3047 5th St South Minneapolis, MN 55408 License Number: 1009414 Report Number: 202301337 and 202305080 ORDER OF CONDITIONAL LICENSE Dear William Lockett: The Department of Human Services (DHS) is placing your license to provide at Micah Halfway House, 3047 5th Ave S, Minneapolis, MN 55408, on conditional status for two years, beginning July 17, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Substance Use Disorder treatment licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On May 6, 7, 8, 13, and 14, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Micah Halfway House located at 3047 5th Ave S, Minneapolis, MN 55408. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed substance use disorder treatment programs, citing 27 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature and Severity: Your program filed to follow requirements that affected the health, safety, and rights of persons served: o The program failed to comply with background study requirements (violation numbered 1). o The program failed to ensure staff requirements for designating a responsible staff person and first aid certification were met (violation numbered 2). o The program failed to meet requirements for billing for services (violation numbered 3). o The program failed to ensure staff were qualified (violation numbered 4). o The program failed to provide medical services as required (violation numbered 5). o The program failed to complete individual abuse prevention plans as required (violation numbered 7) o The program failed to comply with client service initiation and orientation requirements (violation numbered 8). o The program failed to complete comprehensive assessments as required (violation numbered 10). o The program failed to complete treatment plans and treatment plan reviews as required (violation numbered 11 and 12). o The program failed to meet requirements for record documentation (violation numbered 14). · Chronicity: Your program failed to correct prior violations cited in a Correction Order that DHS issued on March 19, 2021. Of the 27 violations in this order, 13 are repeat violations. Furthermore, in a Correction Order that DHS issued on March 19, 2021, the program was recommended to develop and implement measures to strengthen its efforts. The license holder failed to implement recommendations related to: o Technical assistance on the current NETStudy 2.0 system and Minnesota Statutes, sections 245C requirements; and o Technical assistance on how to provide and document clinical treatment services. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder failed to comply with the following background study requirements: a. The license holder failed to request background studies on three staff persons (SP) (personnel files numbered 4, 14, and 20) before they began working in positions allowing direct contact with persons served. 1) SP (personnel numbered 4) was hired and began working in a position allowing direct contact with persons served by the program on February 12, 2024. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request for the SP. 2) SP (personnel numbered 14) was hired and began working in a position allowing direct contact with persons served by the program on April 2, 2015. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request for the SP. 3) SP (personnel numbered 20) was providing treatment services as a guest speaker up to two times weekly. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request for the SP. b. The license holder did not submit a background study request to DHS for an individual who previously had a cleared study that expired (personnel files numbered 1, 10, and 18). 1) SP (personnel numbered 1) was hired and began working in a position allowing direct contact with persons served by the program on April 28, 2020. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. 2) SP (personnel numbered 10) was hired and began working in a position allowing direct contact with persons served by the program on February 1, 2021. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. 3) SP (personnel numbered 18) was hired and began working in a position allowing direct contact with persons served by the program on August 4, 2021. At the time of the licensing review and investigation on May 6, 2024, the license holder had not submitted a background study request to the commissioner using the electronic system known as NetStudy 2.0 before the individual continued in a position allowing direct contact. c. Although the license holder initiated a background study on the individual before the individual began working in a position allowing direct contact with persons served by the program, the license holder failed to provide continuous, direct supervision of the BGS subject pending notice from the Commissioner (personnel file numbered 8). d. The license holder failed to remove a disqualified individual from direct contact or access (personnel file numbered 2). SP was disqualified on July 21, 2023, and did not get a set aside approved until August 25, 2023. The license holder admitted that the SP was allowed to work unsupervised during that time. Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 1, paragraph (g), 245C.13, subdivision d, and 245C.18. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 2. Violation: The license holder failed to meet staff requirements in the following ways: a. The treatment director failed to designate a responsible staff member who, when present at the facility, is responsible for the delivery of treatment service during all hours of operation; and b. The license holder failed to ensure that when clients were present at least one staff person on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate and at least one staff member on the premises who has a current American Red Cross community, American Heart Association, or equivalent CPR certificate. There was no documentation that staff were CPR and first aid certified. Statute Violated: Minnesota statutes, section 245G.10, subdivision 3 and 5. 3. Violation: The license holder failed to meet requirements for receiving public funding reimbursement from the commissioner for services provided. The license holder failed to provide the 30 hours of weekly clinical services required under Minnesota Statutes, section 245B.05, subdivision 5, paragraph (b) to clients receiving public funding reimbursement for high intensity residential treatment (client files numbered 2 and 6) for the following weeks: a. 4/22/24-4/28/24 19.5 hours (client file numbered 2); b. 4/29/24-5/5/24 19.0 hours (client file numbered 2); c. 2/26/24-3/3/24 18 hours (client file numbered 6); d. 3/18/24-3/24/24 19.25 hours (client file numbered 6); e. 4/1/24-4/7/24 15.25 hours (client file numbered 6); and f. 4/29/24-5/5/24 16.25 hours (client file numbered 6). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 4. Violation: One personnel file reviewed for staff qualifications for an individual providing treatment coordination (personnel file numbered 1) did not meet requirements in the following ways: a. A bachelor’s degree in one of the behavioral sciences or related fields or current certification as an alcohol and drug counselor; and b. One hour of treatment coordinator supervision was not documented monthly in April 2024. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 7. 5. Violation: One personnel file reviewed for staff qualifications for an individual with a temporary permit (personnel file numbered 1) did not meet requirements. There was no documentation of weekly supervision provided from March 2023 to March 2024. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 6. Violation: The license holder failed to ensure the treatment director knew and understood the implications of this chapter 245G. Per staff interview, the treatment director did not demonstrate competency and was not knowledgeable on all aspects of the program. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 3. 7. Violation: The license holder failed to provide medical services in the following ways: a. The license holder failed to provide and document monthly on-site supervision or more often if warranted by a client’s health needs by a registered nurse per 148.171, subdivision 23 from May 2022 through May 2024; and b. The license holder did not have a written procedure for assessing and monitoring a client’s health, including a standardized data collection tool for collecting health related information. Health assessments were not completed on each client. Statute Violated: Minnesota statutes, section 245G.08, subdivision 5 and 245G.21, subdivision 7. 8. Violation: Two of three client files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. Documentation was inconsistent about whether staff administer, or client self-administers medication (client files numbered 3 and 5); b. Client use of medication was not recorded (client file numbered 3): 1) 12/19/23-12/21/23 Buprenorphine 8 mg sublingual; 2) 2/16/24 MAR documents Methadone as having 2 bottles, no dosage amount listed; and 3) 3/1/24 MAR documents Methadone as having 2 bottles with no dosage amount and no documentation of the second bottle being administered on 3/4/24. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). 9. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. There was no documentation of the following: a. IAPP was not developed within 24 hours of the day of service initiation (client files numbered 1 and 3); b. An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults, and self-abuse (client files numbered 3 and 4); c. An assessment of the person’s risk of abusing other vulnerable adults (client files numbered 1 through 5); d. A statement of the specific measures that will be taken to minimize the risk of abuse to that person when the individual assessment indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan (client files numbered 3 and 4); e. If the facility knows that the vulnerable adult has committed a violent crime or an act of physical aggression towards others the individual abuse prevention plan must detail the measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility, if unsupervised per 626.557, subdivision 14 (client file numbered 3); f. and g. The person receiving services participating in the development of the IAPP to the full extent of the person's abilities (client file numbered 3). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 2, paragraph (b), and 245G.04, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 10. Violation: Five of five client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation to the following: a. The commissioner approved education on HIV minimum standards (client files numbered 1 through 5); b. The commissioner approved education on Tuberculosis (client files numbered 1 through 5); c. Consent to the disclosure of suspected maltreatment per 626.557 (client file numbered 3 and 5); and d. Client confidentiality was not protected against unauthorized disclosure: 1) Clients electronic file contained a comprehensive assessment for another client (client file numbered 3); 2) Releases of information signed by the client without entity listed (client files numbered 4 and 5); and 3) Client documentation was sent to their probation officer without a release of information (client file numbered 4). Statute Violated: Minnesota statutes, sections 245A.19 and 245G.09, subdivisions 1 and 3, paragraph (1). Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 11. Violation: Two out of five client files reviewed for requirements governing initial services plan (ISP) were not completed within 24 hours of the day of service initiation: a. ISP was completed 7 days late (client file numbered 1); and b. ISP was completed 2 days late (client file numbered 3). Statute Violated: Minnesota statutes, sections 245G.04, subdivision 1 and 245G.09, subdivision 3, paragraph (2). Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 12. Violation: Four of five client files reviewed for requirements governing comprehensive assessments did not meet requirements. There was no documentation of the following: a. The person-centered reason for the delay and the planned completion date (client files numbered 3, 4, and 5); and b. When the client file contained a comprehensive assessment that authorized the treatment service, the alcohol and drug counselor did not document a review of the comprehensive assessment within 5 calendar days from the day of service initiation and did not update the assessment as clinically necessary to ensure compliance (client files numbered 1, 3, 4, and 5). Statute Violated: Minnesota statutes, sections 245G.05, subdivision 1, paragraph (a), and 245G.09, subdivision 3, paragraph (3). Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 13. Violation: Two of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. The ITP was not completed within ten days from the day of service initiation for a residential program in the following ways: a. ITP was completed 17 days late (client file numbered 3); and b. ITP was completed 4 days late (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 14. Violation: Two of two client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following: a. TPRs were not entered in the clients file weekly or after each treatment service: a. 12/21/23-12/28/23; and b. 12/28/23-1/3/24 (client file numbered 3); b. No documentation of the following: 1) Monitoring of physical and mental health problems (client file numbered 3); 2) Participation of others (client file numbered 3); 3) Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 3); and 4) A review and evaluation of the individual abuse prevention plan (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 15. Violation: Two of three client files reviewed for requirements governing discharge summaries did not meet requirements. There was no documentation of the following: a. The client’s issues, strengths, and needs while participating in treatment, including services provided (client files numbered 3 and 5); b. The client’s progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 3); and c. A risk description according to section 245G.05 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 16. Violation: Four of four client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. No documentation of any treatment services being provided from 1/10/23-1/18/23 (client file numbered 5); b. Documentation did not record the date, type, and amount of each treatment service provided to the client and the client’s response to each treatment service within seven days of providing the treatment service: 1) Group note was completed late: i. 06/6/23 (client file numbered 1); and ii. 12/15/23, 12/18/23, 12/19/23, 3/27/24, 4/8/24, and 4/10/24 (client file numbered 3); 2) Group note was not signed by staff: i. 06/7/23 (client file numbered 1); ii. 04/17/24 and 4/22/24 (client file numbered 2); iii. 12/19/23 (client file numbered 3); and iv. 1/13/23 (client file numbered 5); 3) Group note did not document the type of service: i. 06/6/23 and 6/9/23 (client file numbered 1); ii. 04/23/24, 4/25/24, 4/26/24, and 5/3/24 (client file numbered 2); and iii. 12/19/23, 12/20/23, 12/23/23, 12/26/23, 1/3/24, 1/4/24, 1/8/24, 1/10/24, 1/11/24, 01/16/24, 1/17/24, 1/22/24, 1/24/24, and 1/29/24 (client file numbered 3); 4) No documentation of the client’s response: i. 4/29/24 and 4/30/24 (client file numbered 2); and ii. 1/31/24 (client file numbered 3); c. No documentation following a significant event at the program on the day the event occurred: 1) 6/10/23 (client file numbered 1); 2) 1/10/24 (client file numbered 3); and 3) 1/13/23 (client file numbered 5); d. The client record did not contain documentation of the following items on the day that each occurred: 1) Medical and other appointments the client attended (client files numbered 2 and 3); and 2) Concerns related to attendance for treatment services, including the reason for any client absence from the treatment service (client file numbered 5); e. Each entry in the client’s record was not accurate, legible, signed, dated, and included the job title of the staff person making the entry. No job title was listed: 1) 6/6/23, 6/9/23, 6/10/23 and 6/15/23 (client file numbered 1); 2) 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/29/24, 4/30/24, 5/1/24, 5/2/24, and 5/3/24 (client file numbered 2); and 3) 1/13/24 (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. 17. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of orientation to the following: a. The staff members specific job responsibilities (personnel file numbered 8); and b. Program abuse prevention plan (personnel files numbered 4 and 8). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 18. Violation: Six of six personnel files reviewed for requirements governing annual, biennial, and additional training did not meet requirements in the following ways: a. No documentation of annual training in calendar year 2022 and 2023 (personnel files numbered 1, 2, 3, and 8): 1) Policies for obtaining a release of client information; 2) Program abuse prevention plan; 3) Reporting of maltreatment of minors; and 4) Reporting of prenatal exposure to controlled substances; b. Vulnerable adult maltreatment reporting (personnel files numbered 1, 3, and 8); c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was late in 2023 (personnel files numbered 1 and 3); d. HIV minimum standards was not completed in 2023 and 2024 (personnel files numbered 1 and 3); e. Client ethical boundaries not completed in 2023 (personnel files numbered 1 and 2); f. Emergency procedures including behavioral and client rights specified in 144.651, 148F.165, and 253B.03 was not completed in 2023 (personnel file numbered 8); g. Medication administration training did not document the following: 1) Completion of formalized training program that is taught by a registered nurse and offered by the license holder including the process for administration of naloxone (personnel files numbered 2 and 8); and 2) Demonstration to a registered nurse competency to perform the delegated activity (personnel files 2 and 8); and h. Training in the specific mode of administration of emergency overdose treatment for naloxone (personnel files numbered 1, 2, 3, 4, 7 and 8). Statute Violated: Minnesota Statutes, sections 245A.65, 245G.08, subdivision 3 and 5, and 245G.13, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 19. Violation: Four of six personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. A completed application for employment signed by the staff member (personnel file numbered 4); b. Documentation related to the staff member’s background study data, according to chapter 245C (personnel file numbered 4); c. Employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel file numbered 4); d. A written annual review was not completed for the following: 1) In calendar year 2023 (personnel files numbered 2 and 8); and 2) Completed late in calendar year 2023 (personnel file numbered 1). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1 and 3. Repeat Violation: In a Correction Order that DHS issued on March 19, 2021, you were previously found in violation of this same statute. 20. Violation: The license holder failed to ensure the grievance procedure and program abuse prevention plan was posted in a prominent location and was visible and available upon request to mandated reporters, persons receiving services, and legal representatives. Violation corrected on site. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), 245G.15, subdivision 2, and 245G.21, subdivision 5. 21. Violation: The license holder failed to set and post a notice of visiting rules and hours including both day and evening times. Posted visiting hours and policy were inconsistent. Violation corrected on site. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. 22. Violation: The license holder’s grievance procedure did not contain the current address and telephone number for the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, paragraph (2) and (3). 23. Violation: Four of four client files reviewed for requirements governing client property management (client files numbered 1, 2, 3, and 5) did not meet requirements. The license holder failed to document receipt and disbursement, including the persons signature when safekeeping funds or other property, including cell phones. Through documentation, observation and staff interview, the license holder did not follow their policy. Statute Violated: Minnesota statutes, section 245A.04, subdivision 13. 24. Violation: The license holder failed to ensure treatment services and provider policy and procedures were implemented in the following ways: a. The license holder failed to describe how the required amount of clinical services is provided per week for each intensity level in their treatment services description; and b. The license holder failed to ensure guest speakers obtained the training required when the presentation of information constitutes a direct contact service as defined in section 245C.02, subdivision 11. Additionally, the program did not have a policy and procedure on utilizing guest speakers nor was it specified as to which groups they would do so in the treatment services description. Statute Violated: Minnesota statutes, sections 245G.07, subdivision 3a, paragraph (c) and (c) and 245G.12, paragraph (10). 25. Violation: The license holder’s procedure for monitoring the available supply of naloxone on site did not include a procedure for destroying naloxone. Statute Violated: Minnesota statutes, section 245G.08, subdivision 6, paragraph (7). 26. Violation: The license holder’s program abuse prevention plan was not reviewed in calendar year 2022 and 2023 by the governing body or delegated representative. Statute Violated: Minnesota statutes, section 245A.65, subdivision 2, paragraph (c). 27. Violation: The license holder’s transfer of clients and records upon closure policy was not reviewed in calendar year 2022 and 2023 by a controlling individual. Statute Violated: Minnesota statutes, section 245A.04, subdivision 15a, paragraph (a). Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with Substance Use Disorder treatment requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Submit documentation to your licensor as outlined in the Conditional License terms below: 1. By secure email to: Jennifer.White@state.mn.us; or 2. By Mail to: Commissioner, Department of Human Services ATTN: Jennifer White Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Additionally, DHS will not approve a request to open a new licensed program from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the Substance Use Disorder treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this order, you must notify current clients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by your DHS Licensor prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving services. The notification to new clients must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file. Within 30 days of receipt of this order, you must submit to your DHS Licensor, a copy of the notice and a list of all referral sources that received the notice. 2. Within 14 days of receipt of this order, you must contact Maura McGarry, DHS Licensing Substance Use Disorder Unit Supervisor, to schedule a training on requirements for Substance Use Disorder residential treatment programs under Minnesota Statutes, Chapter 245G. Individuals required to attend are the Treatment Director, ADC Supervisor, Compliance Officer, Registered Nurse, Authorized Agent and Human Resource designee. Training must be completed within 45 days of receipt of this order. 3. Within 14 days of receipt of this order, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Treatment Director or ADC Supervisor. If providing treatment services, the Compliance Officer may only allocate 50 percent of their working hours to treatment services. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. 2 years of professional experience in the following: 1) A regulatory or compliance position, and 2) Involved in direct care as a substance use counselor, or 3) The development and implementation of mental health or substance use disorder treatment planning in a DHS licensed 245G Substance Use Disorder program. b. Working knowledge of Minnesota Statutes, Chapter 245A (Human Services Licensing) and Chapter 245G (Substance Use Disorder). c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology, or a related field. 4. Within 30 days of the receipt of this order, you must implement DHS Licensing self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapters 245A and Chapter 245G. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the conditional license or otherwise determined by DHS licensing. 4. Within 30 days from receipt of this order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the program’s DHS Licensor and must include: a. Identification of the specific individual designated for Human Resources (HR) duties and responsibilities. The person must not be the treatment director, LADC supervisor, or clinical staff person who is involved with the day-to-day treatment services; b. A description of how the program will ensure that background study requirements are met on an ongoing basis, including identifying who will be responsible for managing staff background studies, and documentation that the responsible person has received training on these duties; c. A description of how the program will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; and d. A description of how the program will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation that the responsible person has received training on these duties. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 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 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Substance Use Disorder treatment laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Substance Use Disorder treatment programs are required to follow Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Maura McGarry, SUD unit supervisor Licensing Division Office of Inspector General
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