November 19, 2024                      

Kristine Swanson, Authorized Agent

Center for Alcohol and Drug Tx 400 Torrey Building

314 W Superior St Ste 400

Duluth, MN 55802

License Number: 804017 (CADT Residential Treatment Facility & Clear Path Clinic (OTP))

License Number: 804177 (CADT Outpatient Treatment Facility)

Report Number: 202205065

Report Number: 202303958

CORRECTION ORDER

Dear Kristine Swanson:

On August 19, 20, 21, 22, and 23, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigations at your facilities located at the following:

· CADT Residential Treatment Facility & Clear Path Clinic (OTP), 1402 E Superior St, Duluth, MN 55805, license number 804017

· CADT Outpatient Treatment Facility, 304 W Superior St Ste 400, Duluth, MN 55802, license number 804177

This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment 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’s treatment service description (804017) did not meet requirements in the following ways:

a. The description of treatment services included services that were not being offered for the following:

i. Group counseling;

ii. Peer recovery support services; and

iii. Room and board.

Statute Violated: Minnesota Statutes, section 245G.12.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that demonstrates compliance.

Client Files

2. Violation: Two of five client files reviewed for requirements governing criteria for unsupervised use did not meet requirements. The criteria reviews completed on April 1, 2024 (client file numbered 1) and May 25, 2022 (client file numbered 2) indicated that there was absence of recent abuse of drugs; however, the client had a positive urinalysis screen.

Statute Violated: Minnesota Statutes, section 245G.22, subdivision 6, paragraph (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure criteria for unsupervised use meet all applicable requirements.

3. Violation: Three of nine client files reviewed for requirements governing initial services plans (client files numbered 6, 7, and 9) did not meet requirements. The initial services plan was not person-centered and client-specific.

Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements.

4. Violation: Nine of nine client files reviewed for requirements governing comprehensive assessments did not meet requirements. The assessment did not include the following:

a. The client’s perceptions of the client’s condition (client file numbered 3);

b. Reason for the client’s referral (client file numbered 8);

c. History of mental health and substance use disorder treatment (client files numbered 3, 4, and 5);

d. Substance use history, including amounts, frequency and duration (client file numbered 5);

e. The client’s relationship with family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client file numbered 10);

f. The client’s resources (client files numbered 1, 3, 4, 5, 6, 7, 8, 9, and 10);

g. Important developmental incidents in the client’s life (client files numbered 3 and 5);

h. Maltreatment that the client has suffered (client file numbered 1);

i. Potential brain injuries the client has suffered (client file numbered 10);

j. Exposure to alcohol and drug usage (client files numbered 1, 3, 4, and 5); and

k. The client’s family health history (client files numbered 1 and 10).

Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit two client comprehensive assessments that meet all applicable requirements.

5. Violation: Four of eleven client files reviewed for requirements governing individual treatment plans did not meet requirements in following ways:

a. Not completed by the end of the tenth day on which a treatment session has been provided from the day of service initiation (client files numbered 6 and 10);

b. Not signed by the client (client file numbered 6);

c. Not updated based on new information gathered about the client’s condition and on whether methods identified had the intended effect (client file numbered 6); and

d. No documentation of resources to refer the client to when the client's needs will be addressed concurrently by another provider (client files numbered 3, 5, and 6).

Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements.

6. Violation: Seven of ten client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways:

a. The review was completed on August 2, 2024, prior to the span of time indicated on the review, July 29 through August 4, 2024 (client file numbered 7);

b. The review for the treatment week of February 5 through 11, 2024, was not completed (client file numbered 4); and

c. No continuing documentation of collaboration with continuing care mental health providers (client files numbered 1, 3, 4, 5, 6, 7, and 8).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 3 and 3a and 245G.20.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit two treatment plan reviews that demonstrate compliance.

7. Violation: One of twelve client files reviewed for requirements governing client record documentation (client file numbered 7) did not meet requirements. The license holder did not document in the client record a significant event that occurred at the program within 24 hours of the event.

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements.

8. Violation: Two of four client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways:

a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 12); and

b. The discharge summary did not identify the client’s issues and needs while participating in treatment (client file numbered 6).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements.

Personnel Files

9. Violation: One of six personnel files reviewed for requirements governing staff orientation (personnel file numbered 4) did not meet requirements. Orientation was not provided within 24 hours on the following:

a. The staff member’s specific job responsibilities; and

b. Policies and procedures.

Statute Violated: Minnesota Statutes, section 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.

10. Violation: One personnel file reviewed for requirements governing treatment director qualifications (personnel file numbered 9) did not meet requirements. There was no documentation that the treatment director knew and understood the implications of chapter 245G and 260E.

Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 3 and 245G.13, subdivision 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment director meets all applicable requirements.

11. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit from the Board of Behavioral Health and Therapy to provide substance use disorder treatment services (personnel file numbered 11) did not meet requirements. The supervising licensed alcohol and drug counselor did not document the amount and type of supervision provided on May 1, 8, 15, 22, June 5, 12, 20, July 3, 10, 16, 24, 31, August 7, 14, 2024.

Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements.

12. Violation: Four of nine personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways:

a. No documentation of employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel file numbered 4); and

b. No documentation of a written annual review of the staff member’s job performance for calendar years 2022 (personnel file numbered 3), 2023 (personnel files numbered 1 and 3), and 2024 (personnel file numbered 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 personnel file contents 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 Kayla.Northrop@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Kayla Northrop

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 651-431-5843 or at Kayla.Northrop@state.mn.us.

Sincerely,

Kayla Northrop, Licensor II

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/