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November 22, 2024 Halimo Husein, Authorized Agent Gateway Health Services, Inc. 13754 Frontier Court, Suite 108 Burnsville, MN 55337-6733 License Number: 1119232 (IRTS/RCS) Program Location: 16005 Joplin Avenue, Lakeville, MN 55044-9483
Dear Halimo Husein: On September 11, 2024, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations 1, 4, 22, 24 as to violation d, and 25 in the Correction Order (Attachment A) issued to you by the Department of Human Services on August 16, 2024. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 1: Violation: The license holder’s facility did not meet requirements when the license holder was not licensed or certified as a board and lodging facility, supervised living facility, or boarding care home by the Department of Health. Request for Reconsideration. You indicated the program received its initial license on November 13, 2023, and the license from the Department of Health was obtained on November 14, 2023. You indicate the program only operates when both licenses are in place and that the program did not provide services to clients until January 8, 2024. You indicate that while the correction order indicates the violation was corrected on-site, you believe the violation was a procedural oversight rather than an error attributable to the program. You provide a copy of your supervised living facility license, which you indicate shows an effective date of November 14, 2023.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245I.23, subdivision 19, paragraph (a), intensive residential treatment services is a community-based medically monitored level of care for an adult client that uses established rehabilitative principles to promote a client’s recovery and to develop and achieve psychiatric stability, personal and emotional adjustment, self-sufficiency, and other skills that help a client transition to a more independent setting. After further review, the Commissioner has determined it is appropriate to rescind the citation. Citation 4: Violation: Emergency overdose treatment requirements were not met in the following ways: a. The license holder did not maintain a supply of opiate antagonists, available for emergency treatment of opioid overdose; b. The license holder did not have a written standing order protocol by a physician, APRN, or physician assistant that permits the license holder to maintain a supply of opiate antagonists on site; and c. The license holder did not require staff to undergo training in the specific mode of administration used at the program, which may include intranasal administration, intramuscular injection, or both. Request for Reconsideration. You do not dispute the citation, but rather you indicate you made a good faith effort to comply with all licensing requirements. You indicate the program was not made aware of the requirement that resulted in the citation, and the program’s license was granted. You provide a copy of the program’s emergency overdose treatment policy.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245A.242, subdivision 2, a license holder must maintain a supply of opiate antagonists as defined in section 609A.04, subdivision 1, available for emergency treatment of opioid overdose and must have a written standing order protocol by a physician who is licensed under chapter 147, advanced practice nurse who is licensed under chapter 148, or physician assistant who is licensed under chapter 147A, that permits the license holder to maintain a supply of opiate antagonists on site. A license holder must require staff to undergo training in the specific mode of administration used at the program, which may include intranasal administration, intramuscular injection or both. The requirements regarding emergency overdose treatment took effect on July 1, 2023, and the program was licensed on November 14, 2023. The program is responsible for ensuring compliance with all applicable laws and rules. Also, DHS records show an email was sent on February 7, 2024, advising programs of the requirements. There is therefore sufficient evidence to support the citation, and it is affirmed. Citation 22: Violation: 1 of 1 personnel files reviewed for requirements governing the direct observation of a mental health rehabilitation worker did not meet requirements in the following ways: a. Direct observation of the staff person was not conducted at least twice per month for the first six months of employment (SP2). Request for Reconsideration. You indicate you disagree with the citation because SP2 was employed on March 11, 2024, and had first contact with clients on March 19, 2024. You disagree that SP2 had been employed for six months, and you indicate SP2 received observation as indicated on the clinical supervision plan, which was conducted twice per month. You provided a copy of SP2’s clinical supervision with observation dates.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245I.06, subdivision 3, paragraph (a), a mental health behavioral aide or a mental health rehabilitation worker must receive direct observation from a mental health professional, clinical trainee, certified rehabilitation specialist, or mental health practitioner while the mental health behavioral aide or mental health rehabilitation worker provides treatment services to clients, no less than twice per month for the first six months of employment and once per month thereafter. The staff person performing the direct observation must approve of the progress note for the observed treatment service. Because SP2 began work on March 11, 2024, and had a date of first contact on March 19, 2024, s/he would have required direct observation in April and May because s/he was still within the first six months of employment during that time. Although SP2’s treatment supervision plan indicated that direct observations would take place, the licensor requested during the licensing review that you provide documentation to demonstrate direct observation had actually occurred. You did not provide the requested documentation during the licensing review or within 24 hours after the review. There is therefore sufficient evidence to support the citation, and it is affirmed. Citation 24: Violation: 4 of 4 personnel files reviewed for requirements governing initial training did not meet requirements in the following ways: a. For staff identified as needing additional trainings before providing direct contact services, documentation did not demonstrate the staff person received 30 hours of training about: 1. Mental illnesses (SP3); 2. Client recovery and resiliency (SP3); 3. Mental health de-escalation techniques (SP3); and 4. Co-occurring mental illness and substance use disorders (SP3). Request for Reconsideration. You only submitted information regarding a challenge to violation d of the violation as stated above. You indicate you disagree with the violation because SP3 served as the program’s lead registered nurse and also qualifies as a mental health practitioner based on education and work experience. You indicate SP3 was exempt from the requirement to complete the additional 30 hours of training due to his/her qualifications. You provide copies of SP3’s training record, resume, and qualifications.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245I.05, subdivision 3, paragraph (c), before providing direct contact services to a client, a mental health rehabilitation worker, mental health behavioral aide, or mental health practitioner required to receive the training according to section 245I.04, subdivision 4, must receive 30 hours of training about: mental illness; client recovery and resiliency; mental health de-escalation techniques; co-occurring mental illness and substance use disorders; and psychotropic medications and medication side effects. After further review, the Commissioner has determined it is appropriate to rescind violation d of the citation. Citation 25: Violation: 3 of 3 personnel files reviewed for requirements governing medication administration training did not meet requirements in the following way: a. The formalized training program did not include direct observation of the staff person to determine their areas of competency (SP1, SP2 and SP4). Request for Reconsideration. You indicate the program’s training plan involves staff completing reading materials on psychotropic medications, a PowerPoint presentation on medication education, and an exam. After the exam, a nurse evaluates the exam and observes staff in the medication room. The observation includes direct oversight of staff accurately dispensing medication, documenting it on the Medication Administration Record (MAR), and counting controlled substances with appropriate documentation. Although the nurse was not present during the licensing visit, you indicate you informed the licensor that the nurse monitors staff during the training period and the licensor did not request additional information. You provide a copy of the program’s Medication Administration training materials.
Reconsideration Determination. Pursuant to Minnesota Statutes, section 245I.05, subdivision 5, paragraph (b), prior to administering medications to a client under delegated authority, a staff person must successfully complete a: medication administration program for unlicensed personnel through an accredited Minnesota postsecondary educational institution with completion of the course documented in writing and placed in the staff person’s personnel file; or formalized training program taught by a registered nurse or licensed practitioner that is offered by the license holder. A staff person’s successful completion of the formalized training program must include direct observation of the staff person to determine the staff person’s areas of competency. After further review, the Commissioner has determined it is appropriate to rescind the citation. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support citations 4 and 22, and they are affirmed. The Commissioner finds it is appropriate to rescind citations 1, 24 as to violation d, and 25. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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