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December 17 ,2024 Marlin Martin, Authorized Agent BHG Brainerd Treatment Center dba Valhalla Place Brainerd 5001 Spring Valley Road STE 600E Dallas, TX 75244-8217 License Number: 1108974 (245G) CORRECTION ORDER Dear Marlin Martin, On September 9,10,11,12 and 13, 2024 Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, BHG Brainerd Treatment Center located at 2215 S 6th Street, Brainerd MN 56401. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under Minnesota Statute, 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 comply with term 6 of the Order of Conditional License (self-monitoring plan) that DHS issued on October 2,2023. The license holder is required to complete 10 client file chart audits per month for monitoring compliance with applicable rules and statute requirements. Through staff interviews (SP1 and SP2) it was identified that for the months of April 2024 through June 2024, less than 10 client file chart audits were completed and the license holder did not discuss this change to the self-monitoring plan with DHS licensing. Statute Violated: Minnesota Statutes, section 245A.06, subdivision 3. Corrective Action Required: Immediately and throughout the duration of the conditional license, the license holder must ensure that all terms of the conditional license are being followed. Personnel Files 2. Violation: One of one personnel file reviewed for requirements governing staff orientation (personnel file numbered 1) did not meet requirements. There was no documentation of the following orientation being completed: a. Within 24 working hours of starting: (1) Policies and procedures; (2) Client confidentiality; and (3) Client needs; and b. Within 72 working hours of starting: (1) HIV minimum standards; (2) Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E; (3) Program abuse prevention plan; and (4) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 1. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. Client Files 3. Violation: Three of three client files reviewed for requirements governing client orientation (client files numbered 3, 5, and 7) did not meet requirements. There is no documentation of orientation within 24 hours of admission to the following: a. All internal and external policies and procedures for reporting maltreatment of vulnerable adults; and b. Opioid educational material. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (c), 245G.05 subdivision 3, paragraph (b) and 245G.09 subdivision 3. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 4. Violation: One of four client files reviewed for requirements governing initial services plans (client file numbered 3) did not meet requirements. The initial services plan did not comply with the following: a. The plan was not person-centered and client specific; and b. Did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans meet all applicable requirements. 5. Violation: One of three client files reviewed for requirements governing comprehensive assessment (client file numbered 7) did not meet requirements. The comprehensive assessment was not completed within 21 days from the day of service initiation and there was no person-centered reason for the delay and the planned completion date documented in the client’s file. Statute Violated: Minnesota statutes, section 245G.05 subdivision 1. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 6. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not updated when new information was gathered about the client’s condition, the client’s level of participation, and on whether methods identified have the intended effect (client file numbered 7); and b. The ITP did not include the following: (1) How family or others will be involved in the client’s treatment and reasons they did not involve the client’s family or other natural supports in the treatment planning (client files numbered 3 and 5); (2) Treatment strategy for accomplishing the client’s treatment goals and objectives (client file numbered 7); (3) ASAM level of care under which the client is receiving services (client files numbered 3, 5 and 7); (4) Resources to refer the client to when the needs are to be addressed concurrently by another provider (client files numbered 3 and 7); and (5) Interventions to stabilize mental health symptoms (client file numbered 7). Statute Violated: Minnesota Statutes, sections 245G.06 subdivisions 1, 1a and 245G.20. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing individual treatment plans meet all applicable requirements. 7. Violation: One of six client files reviewed for client record documentation requirements (client file numbered 4) did not meet requirements. The license holder did not document in the client record a significant event that occurred within the program within 24 hours of the event. Statute Violated: Minnesota Statutes, section 245G.06 subdivision 2b. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing client record documentation are met. 8. Violation: Four of six client files reviewed for treatment plan reviews did not meet requirements in the following ways: a. The client file did not include a treatment plan review for the following treatment weeks starting on: (1) 6/29/2024 and 7/6/2024 (client file numbered 5); and (2) 6/3/2024, 6/10/2024, 6/17/2024, 6/24/2024, 7/1/2024, 7/8/2024, 7/15/2024, 7/22/2024, 7/29/2024, and 8/5/2024 (client file numbered 7); and b. The treatment plan reviews did not document: (1) Goals addressed since last treatment plan review and whether the identified methods continue to be effective for the following treatment weeks starting on: i. 6/14, 6/21, 6/28, and 7/4/2024 (client file numbered 6); and ii. 5/20/2024 (client file numbered 7); and (2) Participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant other for the following treatment weeks starting on: i. 6/17/2024 (client file numbered 2); ii. 6/17, 6247, 7/1, and 7/8/2024 (client file numbered 6); and iii. 6/10, 7/1, 7/15, and 7/22/2024 (client file numbered 7). Statute Violated: Minnesota Statutes, section 245G.06 subdivisions 3 and 3a. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing treatment plan reviews are met. 9. Violation: Two of two client files reviewed for discharge summaries did not meet requirements. The discharge summary did not include the following information: a. Issues, strengths and needs while participating in treatment (client file numbered 6); and b. Risk rating and description for each of the ASAM six dimensions (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.06 subdivision 4. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing service discharge summaries meet all applicable requirements. 10. Violation: One of four client files reviewed (client file numbered 7) for requirements governing central registry requirements did not meet requirements. The information submitted to the state central registry did not include the following: a. Current or previous enrollment status in another opioid treatment program; and b. Government-issued photo identification card number. Statute Violated: Minnesota Statutes, section 245G.22 subdivision 14 paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure central registry meets all applicable requirements. 11. Violation: One of four client files reviewed for requirements governing the prescription monitoring program (PMP) (client file numbered 7) did not meet requirements. The medical director or the medical director’s designee did not review the PMP data at least every 90 days. The PMP review was due 8/18/2024 and was completed 22 days late on 9/9/2024. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b). Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing the prescription monitoring program are met. 12. Violation: Three of four client files reviewed for requirements governing the criteria for unsupervised use of methadone hydrochloride did not meet requirements as follows: a. There was no documentation by a practitioner with the authority to prescribe reviewing and determining whether dispending medication for a client’s unsupervised use was appropriate to implement, increase, or extend the amount of time between visits to the program on 5/9/2024 (client file numbered 3); b. The criteria reviewed on 5/20/2024 (client file numbered 7) and 6/18/2024 (client file numbered 5) did not include information for the following: (1) Absence of active substance use disorders or other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdoses, or the ability to function safely; (2) Absence of serious behavioral problems that endanger the patient, the public or others; (3) Whether take-home medication can be safely transported and stored; (4) Absence of known recent diversion activity; and (5) Any other criteria that the medical director or medical practitioner considers relevant to the patient’s safety and public’s health. i. Absence of active substance use disorders or other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdoes, or the ability to function safely; ii. Absence of serious behavioral problems that endanger the patient, the public or others; iii. Whether take home medication can be safely transported and stored; iv. Absence of known recent diversion activity; and v. Any other criteria that the medical director or medical practitioner considers relevant to the patient’s safety and the public’s health. Statute Violated: Minnesota Statutes, sections 245G.22, subdivision 6. Repeat Violation: In a Conditional Order that DHS issued on October 2, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing criteria for unsupervised use of methadone hydrochloride are met. 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.eppel@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jen Eppel 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 651-431-6698 or at Jennifer.eppel@state.mn.us. Sincerely, Jennifer Eppel, Licensor II Licensing Division Office of Inspector General
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