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October 8, 2024 Lewis Zeidner, Authorized Agent Tomorrow LLC dba Anchorage 550 Main St STE 230 New Brighton MN 55112-3274 License Number 1044799 (245G)
CORRECTION ORDER Dear Lewis: On June 24, 25, and 26, 2024, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Tomorrow LLC dba Anchorage, located at 3027 South Frontage Road, Moorhead, MN 56560. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder Treatment Services 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. Client files 1. Violation: One of four client files reviewed for requirements governing client orientation (client file numbered 2) did not meet requirements. An individual assessed for opioid use disorder did not receive educational material within 24 hours of service initiation on: a. Risks for opioid use disorder and dependence; b. Treatment options, including the use of a medication for opioid use disorder; c. The risk and recognition of opioid overdose; and d. The use, availability, and administration of an opiate antagonist to respond to opioid overdose. Statute Violated: Minnesota Statute, section 245G.05, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 2. Violation: Two of four client files reviewed for requirements governing individual abuse prevention plans did not meet requirements. There was no documentation of the following: a. An assessment of the person’s risk of abuse others (client file numbered 1); b. Specific actions the program will take to minimize the risk of abuse within the scope of the licensed services (client files numbered 1 and 3); and c. Identify referrals made when the vulnerable adult is susceptible to abuse outside the scope or control of the licensed services (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b) and 245G.04, 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 an individual abuse prevention plan from one recently admitted client which meets all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023; and · Order of Conditional License dated December 14, 2022 3. Violation: Four of four clients files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed within five calendar days of service initiation and there was no documentation of the person-centered reason for the delay (client file numbered 2); and b. The comprehensive assessment did not contain documentation of the following: i. The status of the client’s basic needs (client files numbered 1 through 4); ii. Any immediate risks to the client’s health and safety, including withdrawal symptoms, medical conditions and behavioral and emotional symptoms (client files numbered 1 through 4); iii. The client’s perception of the client’s condition (client files numbered 1 through 4); iv. The client’s description of the client’s symptoms, including the reason for the client’s referral (client files numbered 1 through 4); v. Frequency and duration of substances used (client file numbered 3); vi. The impact to functioning when under the influence of substances, including legal interventions (client files numbered 1 through 4); vii. The client’s relationship with family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client files numbered 1 through 4); viii. Important developmental incidents in the client’s life (client files numbered 1, 2 and 4); ix. Maltreatment, trauma, potential brain injuries and abuse that the client has suffered (client file numbered 2); x. The client’s history of or exposure to alcohol and drug usage and treatment (client files numbered 1 through 4) and; xi. The client’s health history and the client’s family health history, including the client’s physical, chemical, and mental health history (client files numbered 1 through 4). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1 and 3, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 of receipt of this order, submit a comprehensive assessment from one recently admitted client which meets all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023 · Order of Conditional License dated December 14, 2022 4. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed within ten days from the day of service initiation (client files numbered 1 through 3); b. The ITP was not updated based on new information gathered about the client's condition, the client’s level of participation, and on whether methods identified have the intended effect (client files numbered 1 and 4); c. The ITP did not contain documentation of the following: i. How the family or others will be involved in the client’s treatment and the reason that the license holder did not involve the client’s family or other natural supports in the client’s treatment planning (client file numbered 3); ii. A treatment strategy (client files numbered 1 through 4); iii. The ASAM level of care under which the client is receiving services (client files numbered 1 through 4); iv. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client files numbered 1 through 3) and; v. Active interventions to stabilize mental health symptoms (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 2 and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan for one recently admitted client which meets all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023 · Order of Conditional License dated December 14, 2022 5. Violation: Four of four client files reviewed for requirements governing documentation of treatment services did not meet requirements in the following ways: a. Treatment services were not documented within seven days of providing the treatment service on the following dates: i. May 29, 2024 (client file numbered 3); and ii. June 03, June 05, and June 06, 2024 (client files numbered 1 through 4) and; b. Documentation of treatment services did not identify the type of each treatment service provided on the following dates: i. April 19, 2024 (client file numbered 1); ii. May 1, 2024 (client file numbered 3); iii. June 4, 2024 (client files numbered 1 and 4); and iv. June 11, 2024 (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation of treatment services meets all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023 · Order of Conditional License dated December 14, 2022 6. Violation: Four of four client files reviewed for requirements governing client record documentation did not meet requirements. Entries in a client’s record did not include the job title or position of the staff person that made the entry as follows: a. April 19, May 29, June 5, and June 7, 2024 (client file numbered 1); b. June 11, and June 14, 2024 (client file numbered 2); c. May 3, and June 11, 2024 (client file numbered 3); and d. June 3, June 17, and June 19, 2024 (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation of significant events meets all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023 · Order of Conditional License dated December 14, 2022 7. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements. Treatment plan reviews did not document the following: a. Client goals addressed since the last treatment plan review and whether they identified methods continue to be effective for the following 14 day span of times starting on: i. April 15, 2024 (client file numbered 1); and ii. June 3, 2024 (client file numbered 4); and b. Any referrals made since the previous treatment plan review for the 14 day span of time starting on June 3, 2024 (client file numbered 3). Statute Violated: Minnesota Statutes, 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. 8. Violation: One of one client file reviewed for requirements governing service discharge summaries (client file numbered 1) did not meet requirements. There was no documentation of the following: a. The clients progress toward achieving each of the goals identified in the individual treatment; b. A risk rating and description for each of the ASAM six dimensions; and c. Continuing care recommendations, including transitions between more or less intensive services or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health, as needed. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service termination summaries meet all applicable requirements. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated October 30, 2023 · Order of Conditional License dated December 14, 2022 Corrective action required You must correct the violations cited above. If you fail to correct the violations 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 a corrective action ordered must be sent to your Licensor at: 1. By secure email to: Jennifer.eppel@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Jen Eppel 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: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Substance Use Disorder Program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at Jennifer.eppel@state.mn.us or at 651-431-6698. Sincerely, Jennifer Eppel, Licensor II Licensing Division Office of Inspector General
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