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July 22, 2024 Marlin Martin, Authorized Agent Valhalla Place Woodbury dba BHG Woodbury Treatment Center 5001 Spring Valley Road STE 600E Dallas, TX 75244-8217 License Number 1108978 (245G) CORRECTION ORDER Dear Marlin Martin, On March 25, 26, 27 and 28, 2024 Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 6043 Hudson Road, Suite 220, Woodbury MN 55125. As a result of this visit, DHS determined that you are in violation of the substance use disorder treatment statutes under Minnesota Statute, chapter 245G. 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. Policies, Practices, and Procedures 1. Violation: The license holder did not develop written policies and procedures necessary to maintain compliance with licensing requirements. The program policy titled MN Patient Rights did not meet requirements, as follows: a. Did not require that a written statement of the client’s rights and responsibilities be provided to each client on the day of service initiation; and b. Included incorrect client rights. Statute Violated: Minnesota Statutes, section 245G.12. 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 a revised client rights policy that meets all applicable requirements. 2. Violation: The license holder did not meet requirements governing grievance procedures. One of four grievances reviewed did not document a response to a client’s grievance within three days of a staff member’s receipt of the grievance. A grievance was received by the program on October 20, 2023, and a response was not documented until October 24, 2023. 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. 3. Violation: The license holder did not meet requirements governing quality improvement plans. There was no goal concerning community outreach, including but not limited to communications with local law enforcement and county human services agencies, to increase coordination of services and identification of areas of concern to be addressed in the plan for the calendar year 2023. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 18. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that quality improvement plans meet all applicable requirements. Within 60 days of receipt of this order, submit a quality improvement plan that meets all applicable requirements. 4. Violation: The license holder did not meet record retention requirements for personnel records. During the review, it was identified through personnel file review and staff interviews, that the training transcript only lists the most recently completed training and does not provide historical information. Statute Violated: Minnesota Statutes, section 245A.041, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that record retention meets all applicable requirements. Within 60 days of receipt of this order, submit a plan outlining how the program will ensure that historical records are being maintained and are accessible. Personnel Files 5. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation being completed: a. Within 24 working hours of starting: 1) Staff members specific job responsibilities (personnel file numbered 1, 5, and 6); 2) Policies and procedures (personnel files numbered 5 and 6); 3) Client confidentiality (personnel files numbered 5 and 6); and 4) Client needs (personnel files numbered 5 and 6); b. Within 72 hours of employment (personnel files numbered 5 and 6): 1) HIV minimum standards; 2) Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E; 3) Program abuse prevention plan; and 4) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and c. Drug and alcohol policy (personnel files numbered 5 and 6). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, 245A.65, subdivision 3, 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. Within 60 days of receipt of this order, submit documentation that the identified staff have received orientation to the program’s drug and alcohol policy. 6. Violation: Six of six personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following annual trainings being completed: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E: 1) For calendar year 2022 (personnel files numbered 1 through 4); and 2) For calendar year 2023 (personnel files numbered 3); b. Program abuse prevention plan: 1) For calendar year 2022 (personnel files numbered 1, 3, and 4); 2) For calendar year 2023 (personnel files numbered 1 through 5); and 3) For calendar year 2024 (personnel file numbered 6); c. All 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 client releases of information as required by Minnesota Statutes, section 626.557, subdivision 3a, paragraph (a): 1) For calendar year 2022 (personnel files numbered 1 through 4); and 2) For calendar year 2023 (personnel files numbered 2 and 3); and d. HIV minimum standards: 1) For calendar year 2022 (personnel files numbered 1 through 4); 2) For calendar year 2023 (personnel file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) through (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual staff training meets all applicable requirements. 7. Violation: Four of four personnel files reviewed for requirements governing every two year trainings did not meet requirements. There was no documentation of the following every two year training for calendar year 2023 being completed for the following: a. Client confidentiality (personnel files numbered 1 through 4); b. Client ethical boundaries (personnel files numbered 1, 2 and 4); c. Emergency procedures (personnel files numbered 1 through 4); and d. Client rights as specified in Minnesota Statutes, sections 148F.165 and 253B.03 (personnel files numbered 1, 2, and 4). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff every two year training meets all applicable requirements. 8. Violation: Five of six personnel files reviewed for requirements governing personnel contents did not meet requirements. Personnel files did not contain the following: a. A completed application for employment (personnel files numbered 5 and 6); b. Documentation of an inquiry required in by Minnesota Statutes, sections 604.20 to 602.205 made to a staff member’s former employer regarding substantiated sexual contact with a client (personnel file numbered 5); c. Documentation of the staff member’s current professional license (personnel files numbered 2 through 6); and d. A written annual review: 1) For calendar year 2022 (personnel file number 3); and 2) For calendar 2023 (personnel files 4 through 6). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel file contents meet all applicable requirements. Within 60 days of receipt of this order, submit current licensure verification for above identified staff persons. Client Files 9. Violation: Six of six client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation to orientation of the following (client files numbered 1 through 6): a. Grievance procedure on the day of service initiation; b. Within 72 hours of admission to the program: 1) HIV minimum standards; and 2) The internal and external maltreatment of vulnerable adults reporting policies; c. The policy regarding the use of any personal electronic device and the client’s right to refuse being photographed or recorded; and d. Information on tuberculosis education on a form approved by the commissioner. Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c), 245G.07, subdivision 1, 245G.09, subdivision 3, and 245G.15. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 60 days of receipt of this order, submit client chart orientation documentation from two recently admitted clients that meets all applicable requirements. 10. Violation: One of six client files reviewed for requirements governing initial services plans (client file numbered 5) did not meet requirements. The initial services plan: a. Was not completed withing 24 hours of the day of service initiation; and b. Did not identify treatment needs to be addressed between the day of service initiation and development of the individual treatment plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans meet all applicable requirements. 11. Violation: One of six client files reviewed for requirements governing vulnerable adult determinations (client file numbered 5) did not meet requirements. A determination of whether a client was vulnerable adult was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult determinations meet all applicable requirements. 12. Violation: Six of six client files reviewed for requirements governing comprehensive assessments did not meet requirements as follows: a. The comprehensive assessment was not completed within 21 days from the day of service initiation and there was no person-centered reason for the delay (client file numbered 1); and b. The comprehensive assessment did not contain the following information: 1) List of previous attempts at substance use disorder treatment (client file numbered 4); 2) List of previous attempts for compulsive gambling (client files numbered 2 and 5); 3) A substance use history including amounts and types of substances used (client file numbered 2); 4) Frequency and duration of substance use (client file numbered 2); 5) Circumstances of relapse (client files numbered 1 and 5); 6) For each substance used within the previous 30 days, the absence or presence of previous withdrawal symptoms (client files numbered 2 through 6); 7) Specific problem behaviors exhibited by the client when under the influence of substances (client files numbered 1 through 4, and 6); 8) The clients desire for family involvement in the treatment program (client files numbered 1 through 6); 9) Family history of substance use and misuse (client file numbered 5); 10) History or presence of physical or sexual abuse (client file numbered 5); 11) Level of family support (client file numbered 5); 12) Whether medical concerns need to be referred to an appropriate health care professional (client file numbered 2); 13) Mental health history, including symptoms and effect on client’s ability to function (client files numbered 4 and 6); 14) Psychotropic medications needed to maintain stability (client files number 1 and 5); 15) Screening tools approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 to identify whether the client screens positive for co-occurring disorders (client file numbered 5); 16) Arrests and legal interventions related to substance use (client file numbered 5); 17) Description of how use affected client’s ability to function appropriately in a work or education setting (client files numbered 1 through 3, 5, and 6); 18) Ability to understand written treatment materials, including rules and client rights (client files numbered 1 through 6); 19) Description of any risk-taking behavior, including behavior that puts the client at risk of exposure to blood-borne or sexually transmitted diseases (client files numbered 1 through 6); 20) Social network in relation to expected support for recovery (client files numbered 1 and 5); 21) Leisure time activities that have been associated with substance use (client files numbered 1 through 6); 22) Whether the client is pregnant and if so, the health of the unborn child and current involvement in prenatal care (client files numbered 2 and 5); and 23) Whether the client recognizes needs related to substance use and is willing to follow treatment recommendations (client files numbered 1, 3, and 4). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 13. Violation: Three of six client files reviewed for requirements governing comprehensive assessment summaries did not meet requirements as follows: a. Was not completed within 21 days from the day of service initiation (client files numbered 1 and 3); and b. The following information was not included in the comprehensive assessment summary: 1) A risk description according to Minnesota Statutes, section 245G.05, paragraph (c) for each dimension listed (client file numbered 3); 2) A narrative summary supporting the risk descriptions (client files numbered 3 and 4); and 3) Information relevant to treatment service planning and recorded in the dimensions (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.05 subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 14. Violation: Seven of ten client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. There was no ITP contained in the client file (client files numbered 4, 5, 6 and 8); b. The ITP was not completed within 21 days from the day of service initiation (client files numbered 2 and 3); c. The ITP did not address each issue identified in the assessment summary (client file numbered 1); and d. The ITP did not include the following: 1) Specific goals and methods to address each identified need in the comprehensive assessment summary, including frequency of treatment services (client file numbered 1); and 2) Resources to refer the client to when the needs are to be addressed concurrently by another provider (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06 subdivisions 1 and 2 and 245G.09 subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order, submit an ITP from two recently admitted clients that meet all applicable requirements. 15. Violation: Three of six client files reviewed for requirements governing documentation of treatment services did not meet requirements. Documentation of the following treatment services were not completed within seven days: a. Individual counseling provided on November 09, 2023 (client file numbered 4); and b. Individual counseling provided on November 20, 2023 (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.06 subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (client files numbered 1 through 3) did not meet requirements. Treatment plan reviews did not document the participation of others. Statute Violated: Minnesota Statutes, section 245G.06 Subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing treatment plan reviews meet all applicable requirements. 17. Violation: Four of four client files reviewed for requirements governing service discharge summaries did not meet requirements as follows: a. The service discharge summary was not completed within five days of the client’s service termination (client file numbered 3); b. The service discharge summary did not include documentation of the following: 1) Client issues, strengths and needs while participating in treatment including services provided (client files numbered 3 through 5); 2) The client’s progress towards achieving each goal identified in the individual treatment plan (client files numbered 3 through 5); 3) A risk description according to Minnesota Statutes, section 245G.05 (client files numbered 3 and 5); 4) Continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health, as needed (client file numbered 6); and 5) A service termination diagnosis (client files numbered 3, 5, and 6). Statute Violated: Minnesota Statutes, section 245G.06 subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing service discharge summaries meet all applicable requirements. 18. Violation: Three of six client files reviewed for requirements governing central registry requirements did not meet requirements. The information submitted to the state central registry did not include the following: a. Date of admission (client files numbered 1 through 3); b. Current or previous enrollment status in another opioid treatment program (client file numbered 1); and c. Government-issued photo identification card number (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure central registry meets all applicable requirements. 19. Violation: One of six client files reviewed for requirements governing nonmedication treatment services (client file numbered 6) did not meet requirements. There was no documentation of individual or group therapy treatment provided for the first ten weeks following the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 15, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all required nonmedication treatment services 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 Jennifer.Eppel@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jen Eppel Licensing Division PO Box 64242 St. Paul, MN 55164-0242 RECOMMENDATION The following recommendation(s) are not requirements 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. Recommendation: During the review, it was identified that there is not a single document that contains all the required elements of the comprehensive assessment. Through chart reviews and conversation with program staff, it was identified that this information is contained across three documents (the admission assessment, the comprehensive assessment, and nursing assessment), completed at different timeframes by varying staff members. It was identified that this process resulted in citations identified above. It is recommended that the comprehensive assessment be one standalone document. Statute: Minnesota Statutes, section 245G.05. 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 · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below 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: 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 - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. 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 your licensor at 651-431-6698 or at Jennifer.Eppel@state.mn.us Sincerely,
Maura McGarry, SUD Licensing Supervisor Licensing Division Office of Inspector General
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