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October 22, 2024 Lewis Zeidner, Authorized Agent Tapestry LLC 550 Main St Ste 230 New Brighton, MN 55112-3274 License Number 830536 CORRECTION ORDER Dear Lewis Zeidner: On June 3 through 7, 2024, Department of Human Services (DHS) licensors conducted a licensing review at Tapestry located at 135 E Colorado St, St. Paul, MN 55107. 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 in Minnesota Statute 254B.05, subdivision 5, paragraph (c) to be eligible for higher rates that meet additional requirements. A counseling staff (personnel file numbered 8) did not complete eight hours of co-occurring disorder training for calendar year 2022. Statute Violated: Minnesota Statute, sections 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document 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 service; 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 program abuse prevention plans. There was no documentation that the governing body or the governing body’s delegated representative reviewed the plan for calendar years 2022 and 2023. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program abuse prevention plans meet all applicable requirements. Personnel Files 3. Violation: Nine of nine personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual training on: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E for calendar year: a. 2022 (personnel files 2, 4, 8, and 10); b. 2023 (personnel files numbered 2, 3, 4, 5, 7, 8, and 10); and c. 2024 (personnel files numbered 2 through 10). ii. Program abuse prevention plan for calendar year 2023 (personnel file numbered 3). iii. Training on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: a. 2022 (personnel files numbered 2, 4, 8, and 10); b. 2023 (personnel files numbered 2, 3, 4, 5, 7, 8, and 10); and c. 2024 (personnel files numbered 2 through 10). iv. HIV Minimum standards for calendar year 2024 (personnel files numbered 2 and 3); and b. Every two year training for the calendar year 2024 (client personnel file numbered 3) in: i. Client confidentiality; and ii. Client ethical boundaries. Repeat Violation: The license holder was found in violation of the same statute in a correction order dated November 17, 2021. Statute Violated: Minnesota Statute, sections 245A.19, 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (b) through (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all annual and every two year training requirements. Within 30 days of receipt of this order, submit documentation that the above staff completed training that meets requirements. 4. Violation: The license holder did not meet requirements governing background studies. The license holder did not document that there was sufficient information to ensure an accurate study (personnel files numbered 3, 4, and 5). The license holder did not have a copy of staff identification in the personnel file. Statute Violated: Minnesota Statute, section 245C.05, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all background study requirements in Minnesota Statutes, chapter 245C. 5. Violation: One personnel file reviewed (personnel file numbered 1) for requirements governing staff development did not meet requirements. There was no documentation of training on maltreatment of minors reporting requirements before the staff member had direct contact with persons served. Statute Violated: Minnesota Statute, section 245G.13, subdivision 2, paragraph (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all staff development requirements. Within 30 days of receipt of this order, submit documentation that the above staff completed training that meets requirements. 6. Violation: One of three personnel files reviewed (personnel files numbered 6) for requirements governing staff development did not meet requirements. There was no documentation of training on twelve hours of co-occurring disorders within six months of hire. Statute Violated: Minnesota Statute, section 245G.13, subdivision 2, paragraph (f). Repeat Violation: The license holder was found in violation of the same statute in a correction order dated November 17, 2021. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all staff development requirements. Within 30 days of receipt of this order, submit documentation that the above staff completed training that meets requirements. 7. Violation: Six of ten personnel files reviewed for requirements governing personnel files did not meet requirements as follows: a. There was no completed application for employment signed by the staff member (personnel files numbered 1, 2, and 5); and b. No job performance evaluation was completed for calendar year: i. 2022 (personnel file numbered 4); and ii. 2023 (personnel files numbered 3 and 10). Statute Violated: Minnesota Statute, section 245G.13. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all staff development requirements. Client Files 8. Violation: Four of five client files reviewed for requirements governing client orientation did not meet requirements as follows: a. Clients were not oriented to HIV minimum standards within 72 hours of admission to the program (client files numbered 1 and 2); and b. Clients were not provided educational information concerning (client files numbered 2 through 4): i. risks for opioid use and dependence; ii. treatment options, including the use of a medication, for opioid use disorder; iii. the risk of an recognizing opioid overdose; and iv. the use, availability of, and administration of naloxone to respond to an opioid overdose. Statute Violated: Minnesota Statutes, sections 245A.19 and 245G.09, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 9. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans did not meet requirements. The individual abuse prevention plans did not contain the following: a. The person’s susceptibility to abuse by other individuals, including other vulnerable adults (client files numbered 1 through 5); and b. The person’s risk of abusing other vulnerable adults (client files numbered 1 through 5). Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (b). Repeat Violation: The license holder was found in violation of the same statute in a correction order dated November 17, 2021. 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. 10. Violation: Five of five client files reviewed did not meet requirements for comprehensive assessments. Comprehensive assessments did not include information about: a. A list of substance use history including duration of use (client files numbered 3 through 5); b. a determination or whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner (client file numbered 2); c. A description of how the client’s use affected the client’s ability to function appropriately in work and educational settings (client file 3); d. A risk description according to section 245G.05 for each dimension (client file numbered 2); and e. A diagnosis of substance use disorder or a finding that the client does not meet the criteria for a substance use disorder (client file numbered 1). Statute Violated: Minnesota Statute, section 245G.05, subdivision 3. Repeat Violation: The license holder was found in violation of the same statute in a correction order dated November 17, 2021. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit two comprehensive assessments that meet requirements. 11. Violation: Four of five client files reviewed for requirements governing individual treatment plans did not meet requirements. a. The individual treatment plan did not include: i. Specific goals and methods to address each identified need in the assessment summary, including amount, frequency, and anticipated duration of treatment (client files numbered 1 through 3 and 5); and ii. Active interventions to stabilize mental health symptoms (client files numbered 2 and 3). b. The individual treatment plan was not updated based on new information about the client’s condition (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1a and 2 and 245G.20. Repeat Violation: The license holder was found in violation of the same statute in a correction order dated November 17, 2021. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit two individual treatment plans that meet requirements. 12. Violation: Five of five client files reviewed (client files numbered 1 through 5) for requirements governing documentation of treatment services did not meet requirements. Client documentation did not record: a. The signature of the staff member who provided the treatment service on November 2, 2023 (client file numbered 4); b. Type of treatment service provided for the following timeframe: i. April 11 through May 15, 2023 (client file numbered 5); ii. October 16 through November 15, 2023 (client file numbered 4); iii. December 8 through December 16, 2023 (client file numbered 3); iv. February 19 through March 3, 2024 (client file numbered 2); v. May 8 through June 3, 2024 (client file numbered 1); The treatment service note only indicated “group session” and not the specific treatment service provided. c. Client response for the following dates: i. Two services provided on May 20, 2024 (client file numbered 1); and ii. February 26, 2023 (client file numbered 2); Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 2a. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that documentation of treatment services meet all applicable requirements. 13. Violation: Four of five client files reviewed for requirements governing client record documentation did not meet requirements. a. The following items were not documented on the day that each occurred: i. Medical and other appointments the client attended on May 9, 13, and 20, 2024 (client file numbered 1); ii. Hospitalization that occurred from March 1 through 3, 2024 (client file numbered 2); iii. Reasons for client absences from groups (client files numbered 1 and 2); and b. Entries were not accurate for: i. October 20, 2023 (client file numbered 4); and ii. February 28, 2024 (client file numbered 2); and c. Entries did not include job title or position of the staff person that made the entry for April 24, 26, 28, and 29, 2023 (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 2b, paragraphs (b) and (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that documentation of treatment services meet all applicable requirements. 14. Violation: Three of five client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan reviews did not: a. Document monitoring of any physical and mental health problems from May 15 through May 28, 2024 (client file numbered 1); b. Document the participation of others involved in the individual’s treatment planning for the following dates: i. May 15 through May 28, 2024 (client file numbered 1); ii. October 16 through November 15, 2023 (client files numbered 4); c. Document collaboration with continuing care mental health providers, and involvement of providers in treatment planning meetings for the following dates: i. May 15 through May 28, 2024 (client file numbered 1); and ii. December 6 through December 26, 2023 (client file numbered 3); and d. Include a review of the individual abuse prevention plan. The Individual Abuse Prevention Plan was updated on November 8, 2023 (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 3 and 245G.20. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that documentation of treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit two treatment plan reviews that meet requirements. 15. Violation: Two of four client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of service termination (client file numbered 3); and b. The discharge summary did not include the following information: i. A risk rating and description for each of the ASAM six dimensions (client files numbered 2 and 3); ii. The reason for discharge and the procedure followed for the decision to discharge in compliance with section 245G.14 (client fille numbered 2); iii. Continuing care recommendations (client file numbered 2); and iv. Service termination diagnosis (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 4. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries 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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