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December 11, 2024 CERTIFIED MAIL Emma Fernandez, Authorized Agent Community Medical Services Montana Private LLC 8444 N 90th St. Suite 100 Scottsdale, AZ 85258-4437 License Number: 1118288 ORDER OF CONDITIONAL LICENSE Dear Emma: The Department of Human Services (DHS) is placing your license to provide at Community Medical Services Minneapolis on Broadway, 1020 W Broadway Ave, Minneapolis, MN 55411, on conditional status for one year, beginning December 11, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Substance Use Disorder licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On October 7, 8, 9, 10, and 11, 2024, DHS licensors conducted a licensing review at your facility located at 1020 W Broadway Ave, Minneapolis, MN 55411. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Substance Use Disorder treatment programs, citing 17 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature and Severity: The license holder failed to follow requirements which affected the health, safety, and rights of persons served: o The program failed to complete individual treatment plans and reviews as required (violation numbered 1 and 2). o The program failed to ensure medication orders were signed by the prescriber (violation numbered 3). o The program failed to comply with specific measures to reduce the possibility of diversion (violation numbered 4). o The license holder failed to ensure staff were qualified (violation numbered 5). o The program failed to comply with the prescription monitoring program (violation numbered 6). o The program failed to complete treatment service documentation as required (violation numbered 7). o The program failed to complete discharge summaries as required (violation numbered 8) o The program failed to provide staff orientation and annual training as required (violation numbered 9 and 10). Due to the serious nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder treatment is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: Twenty four of Fifty-seven client files reviewed for requirements governing individual treatment plans (ITP) failed to meet requirements in the following ways: a) No ITP in client file (client files numbered 1, 2, and 8 through 26); b) The ITP was not completed within 21 days from the day of service initiation: 1) ITP was 22 days late (client file numbered 3); 2) ITP was 135 days late (client file numbered 5); and 3) ITP was 28 days late (client file numbered 4); c) The ITP was not signed by the client (client file numbered 5); d) The client’s involvement in the development of the plan was not documented (client file numbered 5); e) The ITP was not developed upon the qualified staff member’s dated signature (client files numbered 3 and 5); f) The client’s ITP did not include how the family or others will be involved in the client’s treatment (client files numbered 3 and 5); g) The ITP did not document the ASAM level of care identified in section 254B.19, subdivision 1 (client files numbered 3 and 5); h) The ITP did not identify the participants involved in the client’s treatment planning (client files numbered 3, 4, and 5); and i) The ITP did not identify maintenance strategy goals and methods designed to address relapse prevention and to strengthen the client’s protective factors (client files numbered 3 and 4) Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1, 1a, and 245G.09, subdivision 3, paragraph (5). 2. Violation: Three of three client files reviewed for requirements governing treatment plan reviews and their frequency failed to meet requirements in the following ways: a. No documentation of the following (client files numbered 2 and 3): 1) The span of time covered by the review; 2) A review of the client goals and whether the identified methods continue to be effective; 3) Physical and mental health problems, including toxicology results for alcohol and substance use; 4) Participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others; 5) Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change if changes are determined to be necessary; 6) A review and evaluation of the individual abuse prevention plan according to section 245A.65; 7) Any referrals made since the previous treatment plan review; and 8) Collaboration with continuing care mental health providers and involvement of the providers in treatment planning meetings; b. A treatment plan review was not completed once every 30 days (client file numbered 4); and c. A treatment plan review was not completed once every 90 days when the client received less than five hours of skilled treatment services (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 3 and 3a, 245G.20, and 245G.22. 3. Violation: Two of five client files reviewed for requirements governing medication orders for the treatment of opioid use disorder failed to meet the requirements in the following way: a. The signed order was not documented in the client’s record: 1) 10/4/24 order was not signed as of 10/9/24 (client file numbered 4); and 2) 9/27/24 order was not signed as of 10/10/24 (client file numbered 5); b. The order was not signed within 72 hours of the medication being ordered: 1) 8/19/24 order signed 9/24/24 (client file numbered 4); 2) 8/21/24 order signed 9/3/24 (client file numbered 4); 3) 8/28/24 order signed 9/6/24 (client file numbered 4); 4) 9/23/24 order signed 9/27/24 (client file numbered 4) 5) 10/4/24 order not signed as of 10/9/24 (client file numbered 4); 6) 2/16/24 order signed 2/20/24 (client file numbered 5); 7) 2/22/24 order signed 2/28/24 (client file numbered 5); 8) 3/4/24 order signed 3/8/24 (client file numbered 5); 9) 3/20/24 order signed 3/25/24 (client file numbered 5); 10) 4/30/24 order signed 5/5/24 (client file numbered 5); 11) 9/13/24 order signed on 9/19/24 (client file numbered 5); 12) 9/16/24 order signed 9/24/24 (client file numbered 5); 13) 9/18/24 order signed 9/24/24 (client file numbered 5); and 14) 9/23/24 order signed 9/27/24 (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 3. 4. Violation: The license holder failed to follow their own process for performing diversion control measures. The license holder contacted less than five percent of clients who had unsupervised use of medication to require the clients to physically return to the program from September 2023 through September 2024. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (c). 5. Violation: Two of two personnel files reviewed for staff qualifications for peer recovery specialist failed to meet requirements in the following ways: a. No documentation of recovery peer having a minimum of one year in recovery from substance use disorder (personnel files numbered 2 and 4); and b. Staff member’s credentials to provide peer recovery support services expired 7/6/2024 and the staff continued to provide services to clients (personnel file (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245G.11, subdivision 8. 6. Violation: Five of five client files reviewed for requirements governing the prescription monitoring program (PMP) data (client files numbered 1 through 5) did not meet requirements. The license holder failed to maintain a copy of the PMP in the client file. The programs practice was to review the PMP at client visits and then summarize the contents in a document summary. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b). 7. Violation: Two of four client files reviewed for requirements governing treatment services documentation (client files numbered 1 and 5) failed to meet requirements. There was no documentation of treatments services provided. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. 8. Violation: Three of four client files reviewed for requirements governing discharge summaries failed to meet requirements in the following ways: a) Discharge summary was not completed (client file numbered 2); and b) The discharge summary was not completed within five days of the client’s service termination: 1) Discharge summary was 11 days late (client file numbered 5); and 2) Discharge summary was 57 days late (client file numbered 7). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. 9. Violation: Five of five personnel files reviewed for requirements governing staff orientation failed to meet requirements. There was no documentation of orientation to the following: a. The staff members specific job responsibilities (personnel files numbered 2 through 6); b. Policies and procedures (personnel files numbered 2 through 6); c. Client confidentiality (personnel files numbered 2, 4, 5, and 6); d. Client needs (personnel files numbered 2, 4, 5, and 6); e. HIV minimum standards (personnel files numbered 2 through 6); f. Maltreatment of vulnerable adults reporting including all internal policies and procedures (personnel files numbered 2 through 6); g. Program abuse prevention plan (personnel files numbered 2 through 6); h. Maltreatment of minors; and i. Drug and alcohol policy. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivisions 1 and 2, paragraph (e). 10. Violation: Two of two personnel files reviewed for requirements governing annual and additional training failed to meet requirements in the following ways: a. No documentation of annual training in calendar year 2023 (personnel file numbered 1): 1) Vulnerable adult maltreatment; 2) Policies for obtaining a release of client information; 3) Program abuse prevention plan; 4) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; 5) Reporting of maltreatment of minors; 6) Reporting of prenatal exposure to controlled substances; 7) HIV minimum standards including: i. HIV basics; ii. HIV transmission and prevention; iii. Substance use and HIV; iv. Opioid overdose prevention; and v. Resources for support with HIV or SUD; 8) Programs policies and procedures for working with HIV-infected clients and referring client to individual HIV counseling and services when needed; and b. 12 hours of training in co-occurring disorders (personnel files numbered 1 and 5). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, and 245G.13, subdivision 2, paragraph (c) and (e). 11. Violation: Five of five client files reviewed for requirements governing the central registry for opioid treatment programs failed to meet requirements. The information submitted did not include: a. Full name and all aliases (patient files numbered 1 and 4); b. Social security number (patient file numbered 5); c. Current or previous enrollment status in another opioid treatment program (patient files numbered 3 and 5); d. Government issued photo identification card number (patient file numbered 2, 3, and 5); and e. Driver’s license number (patient file numbered 2, 3, and 5). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14. 12. Violation: Five of five client files reviewed for requirements governing client rights protection and client orientation failed to meet requirements. a. Documentation was not completed on the day of service initiation (client file numbered 1): 1) Client bill of rights was signed four days late; and 2) Grievance procedure was reviewed four days late; b. No documentation of the following (client files numbered 1 through 5): 1) Personal electronic device policy; and 2) Maltreatment of vulnerable adults’ policy including internal and external reporting; and c. Opioid use disorder educational information provided was not current (client files numbered 1 through 5). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (c), 245G.09, subdivision 3, paragraph (1), and 245G.15, subdivisions 1 and 2. 13. Violation: Three of five client files reviewed for requirements governing initial service plans (ISP) failed to meet requirements. Documentation was not completed within 24 hours of the day of service initiation: a. ISP completed 4 days late (client file numbered 1); b. ISP completed 26 days late (client file numbered 5); and c. ISP was not completed (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.04, subdivisions 1 and 245G.09, subdivision 3, paragraph (2). 14. Violation: Three of five client files reviewed for requirements governing vulnerable adult determination failed to meet requirements. Documentation was not completed within 24 hours of the day of service initiation: a. VA determination was completed 14 days late (client file numbered 1); b. VA determination was completed 3 days late (client file numbered 2); and c. VA determination was completed 2 days late (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245A.54, subdivision 1a, and 245G.04, subdivision 2, paragraph (a). 15. Violation: Three of five client files reviewed for requirements governing record keeping failed to meet requirements. The client record entries were not signed by the staff member making the entry: a. 6/25/24 comprehensive assessment and 10/7/24 treatment plan review (client file numbered 3); b. 10/4/24 patient order (client file numbered 4); and c. 2/5/24 initial service plan (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). 16. Violation: One of six personnel files reviewed for requirements governing personnel file contents (personnel file numbered 1) failed to meet requirements. Job performance evaluation was not completed on time for calendar year 2023. Evaluation was completed April 2024. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. 17. Violation: The license holder’s transfer of clients and records upon closure policy was not reviewed in calendar year 2023 by a controlling individual. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with Substance Use Disorder treatment requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Submit documentation to your licensor as outlined in the Conditional License terms below: 1. By secure email to: David.her@state.mn.us 2. By Mail to: Commissioner, Department of Human Services ATTN: David Her Licensing Division PO Box 64242 St. Paul, MN 55164-0242 CONDITIONAL LICENSE TERMS In addition to the Substance Use Disorder treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this order, you must notify current clients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by your DHS Licensor prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving services. The notification to new clients must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file. Within 30 days of receipt of this order, you must submit to your DHS Licensor, a copy of the notice and a list of all referral sources that received the notice. 2. Within 30 days of the receipt of this order, you must implement DHS Licensing self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapters 245A and Chapter 245G, including 245G.22. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 1 year from the effective date of the conditional license or otherwise determined by DHS licensing. 3. Within 30 days from receipt of this order, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the program’s DHS Licensor and must include: a. Identification of the specific individual designated for Human Resources (HR) duties and responsibilities. The person must not be the treatment director, LADC supervisor, or clinical staff person who is involved with the day-to-day treatment services; b. A description of how the program will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; and c. A description of how the program will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation that the responsible person has received training on these duties. 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 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 Conditional license stayed pending reconsideration. If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Substance Use Disorder treatment laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Substance Use Disorder programs are required to follow Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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