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August 19,2024 Emily Vilhauer, Authorized Agent The Refuge A Religious Association 921 8th St SE Detroit Lakes, MN 56501 License Number 1106677 CORRECTION ORDER Dear Emily Vilhauer: On May 20 through 22, 2024, Department of Human Services (DHS) licensors conducted a licensing review at Daystar Recovery Center located at 921 8th Street SE, Detroit Lakes, MN, 56501. As a result of this visit, DHS determined that you are in violation of the Substance Use Disorder Treatment Services statutes under Minnesota Statutes, chapter 245G. 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. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. The program did not offer medical services delivered by an appropriately credential health care staff in an amount equal to two hours per client for the following weeks starting on: a. December 28, 2023 through January 3, 2024 (client file numbered 3); b. February 26, 2024 through May 1, 2024 (client file numbered 2); c. April 10 through May 1, 2024 (client files numbered 1). Statute Violated: Minnesota Statute, section 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure 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 services; 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 the plan for transfer of clients and records upon closure. There was no documentation that the plan was reviewed and signed by a controlling individual for calendar year 2022. Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing the maltreatment of vulnerable adults. There was no documentation that an internal review was completed within 30 calendar days when the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made on August 11, 2022. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adults reporting requirements meet all applicable statutes. 4. Violation: The license holder did not meet requirements governing the control of drugs. The license holder’s policies and procedures did not include a system which accounts for all scheduled drugs each shift. Statute Violated: Minnesota Statute, section 245G.08, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policies regarding the control of drugs meet all applicable requirements. Within 30 days of receipt of this order, submit a control of drugs policy that meets all applicable requirements. Personnel Files 5. Violation: One personnel file reviewed for requirements governing the program’s drug and alcohol policy (personnel file numbered 5) did not meet requirements. There was no documentation that the employee had been trained to the policy. Statute Violated: Minnesota Statute, section 245A.04, subdivision 1, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all employees are trained on the program’s drug and alcohol policy. Within 30 days of receipt of this order, submit documentation that the staff mentioned above has received this training. 6. Violation: Three of four personnel files reviewed for requirements governing the orientation of mandated reporters (personnel files numbered 2, 4, and 5) did not meet requirements. There was no documentation that orientation was provided within 72 hours on the following: a. The reporting requirements and definitions in 626.557, 626.5572, and 245A.65; b. the license holder’s program abuse prevention plan; and c. all internal policies and procedures related to the reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statute, section 245A.65, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 7. Violation: One of five personnel files reviewed for requirements governing written annual reviews (personnel file numbered 3) did not meet requirements. There was no documentation of a written annual review for calendar year 2022. Statute Violated: Minnesota Statute, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that written annual reviews meet all applicable requirements. 8. Violation: Two of five personnel files reviewed for requirements governing staff orientation did not meet requirements. a. Orientation was not provided within 24 working hours for the following: i. Staff member’s specific job responsibilities (personnel file numbered 5); ii. Policies and procedures (personnel file numbered 5); iii. Client confidentiality (personnel file numbered 5); and iv. Client needs (personnel file numbered 4 and 5); and b. Orientation was not provided within 72 working hours for HIV minimum standards (personnel files numbered 4 and 5). Statute Violated: Minnesota Statute, sections 245A.19 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. 9. Violation: Two of five personnel files reviewed for requirements governing annual staff development did not meet requirements. Annual training for calendar year 2023 was not documented (personnel files numbered 2 and 3) on the following topics: a. Mandatory training as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific policies for obtaining a release of client information; b. Program abuse prevention plan; c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. HIV minimum standards. Statute Violated: Minnesota Statute, sections 245A.19 and 245G.13, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual training meets all applicable requirements. 10. Violation: One personnel file (personnel file numbered 1) reviewed for requirements governing personnel file contents did not meet requirements. The file did not include employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client. Statute Violated: Minnesota Statute, 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 11. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 through 3) did not meet requirements. The IAPP did not document an individualized assessment of the person’s risk of abusing other vulnerable adults. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit individual abuse prevention plans from two client files that meet all requirements. 12. Violation: Three of three client files reviewed did not meet requirements for comprehensive assessments in the following ways: a. The comprehensive assessment was not completed within three calendar days from the day of service initiation and the person-centered reason for the delay was not documented (client file numbered 1); b. The comprehensive assessment did not include the following information: i. Physical and medical concerns or diagnoses (client files numbered 2 and 3); ii. Arrests and legal interventions related to use (client file numbered 3); and iii. A description of how the client’s use affected the client’s ability to function in work and educational settings (client file numbered 3) c. The client was identified as having an opioid use disorder and did not receive the following education within 24 hours of service initiation (client file numbered 1): i. Risks for opioid use and dependence; ii. Treatment options, including the use of a medication for opioid use disorder; iii. The risk and recognition of opioid overdose; and iv. The use, availability, and administration of an opiate antagonist to respond to opioid overdose. Statute Violated: Minnesota Statute, section 245G.05, subdivisions 1 and 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 13. Violation: One of three client files reviewed for requirements governing individual treatment plans (client file numbered 2) did not meet requirements. The individual treatment plan was not updated based on new information gathered about the client’s condition, the client’s level of participation, and on whether methods have the intended effect. There was no documentation that a change in the plan was made when the client transitioned from high to medium intensity treatment services. Statute Violated: Minnesota Statute, section 245G.06, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 14. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan reviews indicated changes to the treatment plan were determined to be necessary, however there was no documentation of the staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change for the treatment weeks starting on: a. December 22, December 29, 2023, and January 5, 2024 (client file numbered 3); b. April 5 and April 19, 2024 (client file numbered 2); c. May 3 and May 17, 2024 (client files numbered 1 and 2); and d. May 10, 2024 (client file numbered 1); Statute Violated: Minnesota Statute, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit treatment plan reviews from two client files that meet all applicable requirements. 15. Violation: One of three client files reviewed for requirements governing medication administration procedures (client file numbered 3) did not meet requirements. On December 16, 2023, gabapentin was 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. Statute Violated: Minnesota Statute, section 245G.08, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration procedures meet all applicable requirements. 16. Violation: One of three client files reviewed for requirements governing client records (client file numbered 1) did not meet requirements. The record contained a group attendance note that did not include the date that the staff member made the entry. Statute Violated: Minnesota Statute, section 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client records 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.white@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer White 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 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 me at (651) 431-6282 or at Jennifer.white@state.mn.us Sincerely, Jennifer White, Licensor II Licensing Division Office of Inspector General
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