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November 25, 2024 Tim Walsh, Authorized Agent Northstar Regional 500 Marschall Road Suite 300 Shakopee, MN 55379-2690 License Number: 1108772 Report Number: 202306876, 202309662, 202404486 CORRECTION ORDER Dear Tim Walsh: On August 5 through 9, 12 and 13, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Riverwood Treatment Center located at 10990 95th Street NE, Otsego, MN, 55362. 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 Statute, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement under Minnesota Statutes, section 254B.05, subdivision 5 from the commissioner for services provided. There was no documentation that co-occurring counseling staff received eight hours of co-occurring disorder training for calendar year: a. 2023 (personnel files numbered 2 and 5); and b. 2024 (personnel file numbered 4). Statute Violated: Minnesota Statutes, section 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all requirements under MN Statutes, section 254B.05, subdivision 5 are met for which services 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 services; 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 the plan for transfer of clients and records upon closure. There was no documentation that the plan was reviewed annually and signed by a controlling individual for May 2024. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. Within 60 days of receipt of this order, submit documentation that the plan for transfer of clients and records upon closure has been reviewed. 3. Violation: The license holder did not meet requirements governing the maltreatment of vulnerable adults. There was no documentation that internal reviews were completed within 30 calendar days after the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made of the following dates: a. May 24, 2023; and b. July 6, 2023. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policies and procedures related to suspected or alleged maltreatment of vulnerable adults meet all applicable requirements. 4. 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 annually reviewed the plan for calendar years 2023 and 2024. Statute Violated: Minnesota Statutes, 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 plan meets all applicable requirements. Within 60 days of receipt of this order, submit documentation of the program abuse prevention plan being reviewed. 5. Violation: The license holder did not meet requirements governing administration of medication and assistance with self-medication. The license holder’s policies and procedures did not include guidelines for when to inform a nurse of problems with self-administration of medication, including a client’s failure to administer, refusal of a medication, adverse reaction, or error. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies regarding administration of medication and assistance with self-medication meet all applicable requirements. Within 60 days of receipt of this order, submit an administration of medication and assistance with self-medication policy that meets all applicable requirements and documentation that all staff who administer medications have been trained on revised policy. 6. Violation: The license holder did not meet requirements governing grievance procedures. There was no documentation that the license holder responded to client’s grievance within three days of a staff member’s receipt of the grievance on the following dates: a. January 15, 2023; b. October 1, 2023; c. November 22, 2023; d. December 14, 2023; e. March 26, 2024; and f. June 22, 2024. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing visitors for licensed residential treatment in the following ways: a. Visiting rules and hours were not posted; and b. Visiting hours were not set and did not include both day and evening times. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that visitor rules and hours meet all applicable requirements. Within 60 days of receipt of this order, submit a notice of visitor rules and hours that meet all applicable requirements. Personnel Files 8. Violation: Seven of eight 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 years: 1. 2022 (personnel files numbered 5, 8, and 9); 2. 2023 (personnel files numbered 2, 5, 6, 8, and 9); and 3. 2024 (personnel files numbered 2, 3, 4, 5, 6, 8, and 9); ii. Program abuse prevention plan for calendar years: 1. 2022 (personnel file numbered 5); 2. 2023 (personnel file numbered 2); and 3. 2024 (personnel file numbered 4); iii. Training on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: 1. 2022 (personnel files numbered 5, 8, and 9); 2. 2023 (personnel files numbered 2, 5, 6, 8 and 9); and 3. 2024 (personnel files numbered 2 through 6, 8, and 9); and iv. HIV minimum standards for calendar years: 1. 2022 (personnel file numbered 5); 2. 2023 (personnel file numbered 2); and 3. 2024 (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements. Within 60 days of receipt of this order, submit documentation that the staff identified above have completed all required annual trainings for calendar year 2024. 9. Violation: Two of eleven personnel files reviewed for requirements governing staff qualifications did not meet requirements. There was no documentation that a treatment director knew and understood the implications of Minnesota Statutes chapter 245G, sections 626.557 and 626.5572, and chapters 245A and 260E (personnel files numbered 5 and 8). 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 staff qualifications meet all applicable requirements. 10. Violation: Two of two personnel files reviewed for requirements governing individuals with a temporary permit did not meet requirements. There was no documentation of the following: a. Amount and type of supervision provided at least on a weekly basis for the weeks of: i. January 19 through February 2, February 16 through April 12, May 3 through June 13, and June 28 through August 2, 2024 (personnel file numbered 1); and ii. August 1, 2022, through April 30, 2024 (personnel file numbered 5); and b. That supervision was related to clinical practice for the weeks of May 1 through August 4, 2024 (personnel file numbered 5). 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 requirements regarding individuals with a temporary permit meet all applicable requirements. 11. Violation: Nine of nine personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation as follows: a. Orientation was provided within 24 working hours for the following: i. Staff member’s specific job responsibilities (personnel files numbered 5 and 11); and ii. Client needs (personnel files numbered 1 through 4, 6, 7, 10, and 11); b. Training on the maltreatment of minors reporting requirements and definitions in Minnesota Statute, chapter 260E before the mandatory reporter has direct contact with a person served by the program (personnel file numbered 7); c. There was no documentation that orientation was provided within 72 hours of providing direct contact services on the following (personnel file numbered 11): i. The reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; ii. The license holder’s program abuse prevention plan; and iii. All internal policies and procedures related to the reporting of maltreatment of individuals receiving services; and d. Twelve hours of co-occurring disorders training within 6 months of hire (personnel files numbered 1, 2, 4, and 5,). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Statutes, section 245G.13, subdivision 1, 2, paragraphs (e) and (f). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 12. Violation: Nine of eleven personnel files reviewed for requirements governing personnel file contents did not meet requirements as follows: a. There was no completed application for employment signed by the staff member (personnel files numbered 1 and 11); b. The file did not include employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel files numbered 2 and 3); c. There was no documentation that an alcohol and drug counselor was licensed. The documentation in the personnel file was for an expired license. Professional documentation expired in personnel file personnel file numbered 5); and d. There was no documentation of a written annual review for calendar years: i. 2022 (personnel files numbered 5 and 9); ii. 2023 (personnel files numbered 5, 6, 8, and 9); and iii. 2024 (personnel files numbered 3 and 4). 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. Client Files 13. Violation: Eight of eight 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 8); b. The person’s risk of abusing other vulnerable adults (client files numbered 1 through 8); c. Statements of specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults (client files numbered 4, 6, and 8); and d. Measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility if unsupervised when the facility knows that the vulnerable adult has committed a violent crime or an act of physical aggression toward others (client files numbered 5, 6, and 8). 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 60 days of receipt of this order, submit individual abuse prevention plans from two client files that meet all requirements. 14. Violation: Eight of eight client files reviewed for requirements governing initial services plans (ISP) did not meet requirements. The ISP was not person-centered and client specific (client files numbered 1 through 8). 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. Within 60 days of receipt of this order, submit two initial services plans that meet requirements. 15. Violation: Five of eight client files reviewed did not meet requirements for comprehensive assessments in the following ways: a. There was no documentation of a review of the comprehensive assessment and an update as clinically necessary to ensure compliance with Minnesota Statutes, section 245G.05, subdivision 1 when the client received a comprehensive assessment that authorized the treatment service (client files numbered 4, 5, and 8); and b. The comprehensive assessment was missing the following information: i. The status of the client’s basic needs (client file numbered 6); ii. Cultural influences on the client (client file numbered 6); iii. The client’s strengths and resources, including the extent and quality of the client’s social networks (client file numbered 6); iv. Level of family support (client file numbered 7); and v. Important developmental incidents in the client’s life (client file numbered 6). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1 and 3. 16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not developed within ten days from the day of service initiation for a client in a residential program (client file numbered 7); b. The ITP did not use a person-centered, culturally appropriate planning process (client files numbered 1 through 8); c. The ITP was not updated based on the client’s level of participation (client file numbered 7); and d. The ITP did not include documentation of the following: i. How family or others will be involved in the client’s treatment if the client chooses to have family or others involved in treatment services and document the reasons that the license holder did not involve the client’s family or other natural supports in the client’s treatment planning (client files numbered 2, 6 and 7); ii. Measurable treatment objectives (client file numbered 3); iii. Amount and frequency of treatment services (client files numbered 5 and 7); iv. A treatment strategy (client files numbered 1 through 4, and 8); and v. Active interventions to stabilize mental health symptoms (client file numbered 8). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1, 1a, 2, and 245G.20. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order, submit two individual treatment plans that meet requirements. 17. Violation: Eight of eight client files reviewed for requirements governing documentation of treatment services did not meet requirements. Documentation of treatment services did not include: a. Type of treatment service provided on the following dates: i. August 3 through August 22, 2023 (client file numbered 5); ii. August 7 through 13, August 21 through 27, and September 4 through 10, 2023 (client file numbered 7); iii. January 19 through 26, and February 5 through 9, 2024 (client file numbered 3); iv. February 7, 9, and 22, 2024 (client file numbered 4); v. April 2 through 26, 2024 (client file numbered 8); vi. May 16 and 21, 2024 (client file numbered 6); vii. June 18 through 21, July 8 through 12, and July 22 through July 24, 2024 (client file numbered 2); and viii. August 1 though 5, 2024 (client file numbered 1); b. Amount of treatment service provided for: i. August 21, 2023 (client file numbered 7); ii. February 9, 2024 (client files numbered 3 and 4); and iii. February 21 and April 12, 2024 (client file numbered 4); and c. Client response to each treatment service for: i. August 7, 9, 11, 22, 24, 25, and September 8, 2023 (client file numbered 7); ii. August 3, 8, 11, 14, 16, and 17, 2023 (client file numbered 5); iii. January 25, February 5, 7, and 9, 2024 (client file numbered 3); iv. February 9, 21, and 22, 2024 (client file numbered 4); v. April 9, 2024 (client file numbered 8); and vi. May 16, 2024 (client file numbered 6). 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. Within 60 days of receipt of this order, submit two treatment service documentation notes that meet requirements. 18. Violation: Eight of eight client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. There was no documentation about concerns related to attendance for treatment services, including the reason for any client absence from a treatment service on the day that it occurred for: i. May 16 and 17, 2024 (client file numbered 6); and ii. April 5, 10, and 25, 2024 (client file numbered 8); and b. Each entry did not: i. Contain accurate information about the amount of treatment services provided for: 1. August 3, 8, 10, 11, 14, 17, 18, 21 through 23, 2023 (client file numbered 5); 2. August 9 through 11, 22 through 25, and September 8, 2023 (client file numbered 7); 3. January 19 and 22 through 26, 2024 (client file numbered 3); 4. February 19, 20, and 23, 2024 (client file numbered 4); 5. April 2 through 4, 8 through 11, and 22 through 24, 2024 (client file numbered 8); 6. May 16, 17, and 20 through 22, 2024 (client file numbered 6); 7. June 17 through 21, July 9, 12, and 22 through 24, 2024 (client file numbered 2); and 8. August 1 and 2, 2024 (client file numbered 1); ii. Contain signatures of the staff person making the entry for: 1. January 31 and February 9, 2024 (client file numbered 3); 2. February 9, 2024 (client file numbered 4); 3. July 24, 2024 (client file numbered 2); 4. June 22, August 9 and 22, 2023 (client file numbered 5); and 5. July 31, 2024 (client file numbered 1); and iii. Include the job title or position of the staff person making the entry for: 1. August 3 through 23, 2023 (client file numbered 5); 2. August 7 through 11, August 21 through 25, and September 8, 2023 (client file numbered 7); 3. January 19, 22, and 24 through 26 and February 7 and 9, 2024 (client file numbered 3); 4. February 5 through February 9, February 21 and 23, April 15, April 17, and May 1, 2024 (client file numbered 4); 5. April 3, 8 through 12, and 23 through 26, 2024 (client file numbered 8); 6. May 14 through 17 and May 20 through 22, 2024 (client file numbered 6); 7. June 14 through 21, July 8 through 14, and July 22 through 25, 2024 (client file numbered 2); and 8. July 31 through August 5, 2024 (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 2b and 2c. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 19. Violation: Seven of seven client files reviewed for requirements treatment plan reviews did not meet requirements. The treatment plan reviews did not: a. Document the time span covered by the review for treatment plan reviews dated: i. August 21, 2023 (client file numbered 5); and ii. April 10 and 24, 2024 (client file numbered 8); b. Document client goals addressed since the last treatment plan review for the review period starting: i. August 21, 2023 (client file numbered 5); and ii. January 29 and February 19, 2024 (client file numbered 4); c. Document monitoring of any physical and mental health problems for the review period starting: i. August 21, 2023 (client file numbered 5); and ii. May 20, 2024 (client file numbered 6); d. Document the participation of others involved in the individual’s treatment planning for the review period starting: i. August 21, 2023 (client file numbered 5); ii. February 2 through May 9, 2024 (client file numbered 4); and iii. May 20, 2024 (client file numbered 6); e. Document staff recommendations for changes in the methods identified in the treatment plan for the review period starting: i. August 21, 2023 (client file numbered 5); and ii. April 10, 2024 (client file numbered 8); f. Document any referrals made since the previous treatment plan review for the review period starting April 3, 2024 (client file numbered 8); g. Document a review of the individual abuse prevention plan for the review period starting on August 21, 2023 (client file numbered 5); h. Document a review of all treatment services weekly for weeks starting on August 7 through October 16, 2023 (client file numbered 7); and i. Document a review every 14 days for time periods starting January 22 and February 12, 2024 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a, paragraphs (b) and (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 60 days of receipt of this order, submit two treatment plan reviews that meet requirements. 20. Violation: Seven of seven client files reviewed for requirements governing service discharge summaries did not meet requirements. The service discharge summary: a. Was not completed within five days of service termination (client file numbered 3); and b. Did not include the following information: i. The client’s issues, strengths, and needs while participating in treatment, including services provided (client files numbered 2 through 8); ii. The client’s progress toward achieving each goal identified in the individual treatment plan (client file numbered 7); iii. The reasons for and circumstances of service termination (client file numbered 6); iv. The client’s living arrangements at service termination (client file numbered 3); and v. Service termination diagnosis (client file numbered 8). Statutes Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client records meet all applicable requirements. Within 60 days of receipt of this order, submit two service discharge summaries that meet requirements. 21. Violation: Eight of eight client files reviewed for requirements governing client records did not meet requirements. There was no documentation that the client was given information on tuberculosis education on a form approved by the commissioner (client files numbered 1 through 8); Statutes Violated: Minnesota Statutes, section 245G.09, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client records 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, Maura McGarry, SUD Licensing Supervisor Licensing Division Office of Inspector General
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