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September 24, 2024 William Lockett, Authorized Agent The Micah Halfway House 3047 5th St South Minneapolis, MN 55408 License Number: 1009414 Report Number: 202301337 and 202305080
Dear William Lockett: This matter arises from an Order of Conditional License, dated July 17, 2024, issued after a licensing review conducted on May 6, 7, 8, 13, and 14, 2024. On July 29, 2024, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration on behalf of the program of the Order of Conditional License. You requested reconsideration only of citation 1. You did not request reconsideration of the remaining citations, and those citations are therefore final and not included in the scope of this review. A. CONDITIONAL LICENSE DISPUTED, YOUR RECONSIDERATION REQUEST REGARDING STATUTORY CITATION AND LICENSING VIOLATIONS, AND DHS’ RESPONSE 1. Citation 1: Minnesota Statutes, sections 245C.04, subdivision 1, paragraph (g), 245C.13, subdivision d, and 245C.18. 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. Repeat Violation: In a Correction Order issued on March 19, 2021, you were found to be in violation of the same statute. Request for reconsideration: You indicate in the reconsideration request that the program completed background checks on all staff when hired, but background studies for staff hired during the pandemic needed to be resubmitted to complete fingerprints. You acknowledge that you did not resubmit the new background studies due to an oversight. DHS’ response: You did not provide any documentation to show that the background studies in the citation were submitted as required or that supervision was provided as required. You acknowledge in your reconsideration request that background studies were not resubmitted as required. The license holder is responsible for ensuring that expired background studies are corrected. As a result, there is sufficient evidence to support the citation, and it is affirmed. B. DISPOSITION Based on the foregoing, the Commissioner finds that the citations in the July 17, 2024, Order of Conditional License are supported by the record, and they are affirmed. Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program. In the request for reconsideration, you request that the Conditional License be removed and request that a fine be imposed instead. You also indicate the program has been providing services for 20 years and will work on areas that need improvement. You indicate the conditional license is not an accurate representation of the hard work that happens at the program. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and determined that a conditional license is warranted. The Conditional Order cites twenty-seven citations reflecting that the program has failed to comply with multiple requirements. The license holder challenged only one of the twenty-seven citations on reconsideration, and the citation was affirmed. The affirmed citation along with the remaining citations that were unchallenged support the need for a conditional license because they demonstrate a history of serious and chronic licensing violations that indicate a failure to follow procedure and practice requirements which affect the health, safety, and rights of clients. With regard to chronicity, the license holder failed to correct multiple prior violations cited on multiple occasions. Thirteen of the twenty-seven violations cited in the Conditional Order under review were previously cited in a Correction Order dated March 19, 2021. The failure to correct a large number of citations strongly supports the need for a conditional license, the terms of which are focused on ensuring that the license holder is taking meaningful steps toward achieving compliance and thereby protecting clients’ health, safety, and rights. Also on March 19, 2021, the program was advised of the recommendation to develop and implement specific measures, and the license holder failed to implement recommendations related to: technical assistance on the current NETStudy 2.0 system and Minnesota Statutes, section 245C requirements; and technical assistance on how to provide and document clinical treatment services. The nature of the cited violations is also a basis for the conditional license. The citations involved a failure to follow requirements which affected the health, safety, and rights of the persons served, including a failure to comply with background studies requirements and a failure to ensure staff were qualified. Background study requirements and requirements regarding staff qualifications are in place to ensure the safety of the residents served by the program. Other violations included a failure to ensure staff requirements for designating a responsible staff person and first aid certification were met and a failure to provide medical services as required. Requirements regarding staff designation and certification are in place to ensure a staff person is responsible for delivery of treatment service during all hours of operation and that staff persons have required first aid certification to protect the safety of clients. Also, clients rely on the provision of medical services to maintain their health and safety. Additionally, the license holder failed to meet requirements for receiving public funding reimbursement when it failed to meet requirements for billing for services. Rules and regulations are in place to ensure that public funds received by license holders are allocated properly and used for the benefit of the clients for which the funds are intended. Also, the license holder failed to meet requirements which resulted in violations that were severe in number and duration related to treatment documentation, including a failure to complete individual abuse prevention plans as required, the failure to comply with client service initiation and orientation requirements, the failure to meet requirements for record documentation, and two violations for a failure to complete comprehensive treatment plans and treatment plan reviews as required. Accurate documentation and determinations in client files are necessary to demonstrate that services are being provided, that the services being provided are relevant, how the client is responding to services, and whether the services are effective. Due to the need to monitor The Micah Halfway House for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on July 17, 2024. The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. C. TERMS OF THE CONDITIONAL LICENSE 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 decision, 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 decision. 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 decision, 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 decision, 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 decision. 3. Within 14 days of receipt of this decision, 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 decision, you must implement and submit to DHS Licensing a 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 245G. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the result 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 the month following the quarter, for two years from the effective date of the conditional license or otherwise determined by DHS Licensing. 5. Within 30 days from receipt of this decision, 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 licensor will monitor your compliance with all applicable laws and rules. Verification of compliance may include unannounced visits. Failure to comply with the requirements in Minnesota Statutes, chapter 245A (Human Services Licensing Act), Minnesota Statutes, chapter 245C (Human Services Background Study Act), Minnesota Statutes, chapter 245G (Chemical Dependency Based Treatment), Minnesota Statutes, section 626.557, and with the terms of your conditional license may result in further negative action, including revocation of your license. This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, please contact Maura McGarry, Unit Supervisor, at (651) 431-6671. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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