December 23, 2024                      

Andrew Horowitz, Authorized Agent

Elite Recovery LLC

1137 Grand Ave

Saint Paul, MN 55105

License Number: 1113984 (937 Grand)

License Number: 1120292 (758 Grand)

CORRECTION ORDER

Dear Andrew Horowitz:

On September 3, 4, 5, and 6, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facilities located at the following:

LICENSING VIOLATIONS

DHS determined that your program failed to follow licensing rules and statutes, as described below.

Policies, Practices, and Procedures

Client files reviewed are identified in the following manner:

1. Violation: The license holder (1113984 and 1120292) did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. Treatment coordination services do not include the following:

a. Entering data into DAANES on July 17, 2024 (client file numbered 1), April 21, 2024 (client file numbered 5), and August 1, 2024 (client file numbered 6);

b. Reviewing urinalysis results on July 26, August 2, 9, and 15 (client file numbered 1) and April 25, May 9, and 24, 2024 (client file numbered 5); and

c. Communication with the internal treatment team on August 30, 2024, (client file numbered 1), and April 18, 2024 (client file numbered 5).

Statute Violated: Minnesota Statutes, section 245A.191.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they 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 service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law.

2. Violation: The license holder (1113984) did not meet requirements governing program abuse prevention plans. The plan in the policies and procedures manual was not reviewed at least annually by the license holder's governing body or the governing body’s delegate. The review was due by March 2023 and was not completed until November 2023.

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 program abuse prevention plans meet all applicable requirements.

3. Violation: The license holder did not ensure that at least one staff member on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate, and at least one staff member on the premises had a current American Red Cross community, American Heart Association, or equivalent CPR certificate on:

a. August 2, 9, 16, 23, and 30, 2024 from 3:30 to 4:00 PM (1113984 and 1120292);

b. August 3, 10, 17, 24, and 31, 2024 from 9:00 AM to 1:00 PM (1113984 and 1120292); and

c. August 1, 5 through 8, 12 through 15, 19 through 22, and 26 through 29, 2024 from 3:30 PM to 8:00 PM (1120292).

Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medical emergency staff requirements are met.

Client Files

4. Violation: Five of seven client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation:

a. On the day of service initiation (client file numbered 1) for the following:

1. Client rights and responsibilities; and

2. Grievance procedure;

b. Within 24 hours of admission (client files numbered 1 and 6) for the following:

1. Internal and external maltreatment of vulnerable adults reporting procedures; and

2. Program abuse prevention plan;

c. Within 72 hours of admission for HIV minimum standards (client file numbered 1); and

d. The personal electronic device policy (client files numbered 1 through 4, and 6).

Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a), 245G.09, subdivision 3, and 245G.15.

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

5. Violation: Seven of seven client files reviewed for requirements governing initial services plans did not meet requirements in the following ways:

a. The initial services plan was not person-centered and client-specific. The issues to be addressed during the time between the day of service initiation and development of the individual treatment plan were the same across all files reviewed (client files numbered 1 through 7); and

b. The initial services plan did not address immediate health and safety concerns (client files numbered 5 and 6).

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.

6. Violation: Seven of seven client files reviewed for requirements governing comprehensive assessments did not meet requirements. There was no documentation of the following:

a. The immediate risks to the client's health and safety, including, medical conditions (client file numbered 2);

b. Substance use history, including:

1. Amounts (client files numbered 1 and 6);

2. Frequency (client files numbered 3, 6, and 7);

3. Duration (client files numbered 1, 2, 4, 6, and 7); and

4. Route of administration (client file numbered 6);

c. Topics which will require further assessment during the course of the client's treatment, including:

1. The client’s relationship with family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client files numbered 4 and 6);

2. The client's strengths and resources, including the extent and quality of the client's social networks (client files numbered 1 through 4, 6, and 7);

3. Important developmental incidents in the client's life (client files numbered 1 through 4, 6 and 7); and

4. Family health history (client file numbered 7); and

d. A review of the comprehensive assessment and update to the comprehensive assessment 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 file numbered 5).

Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1 and 3.

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

7. Violation: Seven of seven client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways:

a. The ITP was not signed by the client and there was no documentation of the client’s involvement in the development of the plan (client files numbered 5 and 6);

b. The ITP was not updated based on new information about the client’s condition, the client's level of participation, and on whether methods identified have the intended effect (client file numbered 4);

c. The ITP was not based on the client’s comprehensive assessment (client files numbered 6 and 7);

d. The ITP was not person centered. The treatment goals, objectives, strategies, and schedules were the same for all files reviewed (client files numbered 1 through 7); and

e. There was no documentation of the following:

1. The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 through 7); and

2. The reasons that the license holder did not involve the client’s family or other natural supports in the client’s treatment planning resources to refer the client to when the client's needs will be addressed concurrently by another provider (client files numbered 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.

8. Violation: One of seven client files reviewed for requirements governing documentation of treatment services (client file numbered 5) did not meet requirements. The license holder did not document the treatment service within seven days of providing the treatment service.

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a.

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

9. Violation: Four of seven client files reviewed for client record documentation did not meet requirements in the following ways:

a. The entry in the client’s record for May 30, 2024 (client file numbered 5) and July 10, 2024 (client file numbered 4), did not include the job title of the staff person that made the entry; and

b. The entry in the client’s record was not accurate. Documentation of treatment coordination identified the treatment services as being provided in a group, however through staff interviews it was identified these were individual treatment services on the following dates: on the following dates:

1. April 25, May 9, 24, 31, June 7 and 16, 2024 (client file numbered 5);

2. August 7, 2024 (client file numbered 6); and

3. July 17, 24, August 8 and 9, 2024 (client file numbered 7).

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

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

10. Violation: Five of seven client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways:

a. The treatment plan review did not document client goals addressed since that last treatment plan review and whether the identified methods continue to be effective on:

1. July 24 and August 5, 2024 (client file numbered 1);

2. July 21, 2024 (client file numbered 2);

3. May 10 and June 7, 2024 (client file numbered 5);

4. August 9, 2024 (client file numbered 6); and

5. July 16 and August 1, 2024 (client file numbered 7); and

b. The review did not document participation of others involved in the individual's treatment planning, including when services are offered to the client's family or significant others on:

1. July 21, 2024 (client file numbered 2);

2. May 10 and 24, 2024 (client file numbered 5); and

3. August 9, 2024 (client file numbered 6).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3.

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

11. Violation: Six of seven client files reviewed for requirements governing client records did not meet requirements in the following ways:

a. Two group notes on May 31, 2024, were documented by a staff member who did not provide the treatment service (client file numbered 5); and

b. Client records were not protected against unauthorized disclosure as follows:

1. Treatment coordination notes documented that program staff communicated with sober home staff and there was no release of information on:

i. July 1, 15, 23, and 29, 2024 (client file numbered 1); and

ii. August 26 and 30, 2024 (client file numbered 4); and

2. An individual not identified as staff documented in the client record on:

i. April 18 through 20, 22 through 27, 20 through 31, May 1 through 11, 13 through 19, 21, 22, and 24, 2024 (client file numbered 5);

ii. August 2, 2024 (client file numbered 6); and

iii. August 16, 2024 (client file numbered 7).

Statute Violated: Minnesota Statutes, section 245G.09, subdivisions 1, paragraph (a) and 3.

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

12. Violation: Four of four client files reviewed for requirements governing discharge summaries did not meet requirements. The discharge summary did not document the following:

a. The client’s issues, strengths and needs while participating in treatment, including services provided (client files numbered 2, 7, 10, and 11);

b. The client's progress toward achieving each goal identified in the individual treatment plan (client files numbered 2, 7, 10, and 11);

c. Continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health (client files numbered 2, 7, and 11); and

d. The service termination diagnosis (client files numbered 2, 7, 10, and 11).

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

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

Personnel Files

Personnel files reviewed are identified in the following manner:

13. Violation: Five of eight personnel files reviewed for requirements governing background studies (BGS) did not meet requirements in the following ways:

a. Staff began a position allowing direct contact with persons served by the program on January 11, 2024. During the licensing review, staff person confirmed that they had a legal name change. However, the license holder did not initiate a new background study or notify the commissioner of the name change (personnel file numbered 3); and

b. The license holder failed to affiliate staff to all required rosters, as follows:

1. Staff began a position allowing direct contact with persons served by the program on January 11, 2024. A BGS was submitted under license number 1109334, however, this staff was also working under license number 1120292 (personnel file numbered 3);

2. Staff began a position allowing direct contact with persons served by the program on March 23, 2023. A BGS was submitted under license number 1078616, however, this staff was also working under license number 1120292 (personnel file numbered 4); and

3. Staff began a position allowing direct contact with persons served by the program on July 5, 2024. A BGS was submitted under license number 1109334, however, this staff was also working under license number 1113984 (personnel file numbered 8).

Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 7 and 245C.07, paragraph (a).

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

14. Violation: Seven of seven personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation:

a. Within 24 working hours of starting on the following:

1. The staff member’s specific job responsibilities (personnel files numbered 3, 5, and 9);

2. Client confidentiality (personnel file numbered 3); and

3. Client needs (personnel files numbered 4 and 5);

b. Within 72 hours of employment on HIV minimum standards (personnel file numbered 4);

c. 12 hours of specific training in co-occurring disorders within six months of employment (personnel files numbered 2 through 4); and

d. Emergency overdose treatment training in the specific mode of administration used at the program (personnel files numbered 3, 5, and 8).

Statute Violated: Minnesota Statutes, sections 245A.242, 245A.65 subdivision 3, 245G.08, subdivision 3, and 245G.13, subdivisions 1 and 2, paragraphs (b), (d), and (f).

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

15. Violation: Four of four personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following annual trainings:

a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E, including specific training covering the license holder's policies for obtaining a release of client information for calendar years:

1. 2023 (personnel files numbered 1 and 2); and

2. 2024 (personnel files numbered 1, 2, 4, and 5);

b. Program abuse prevention plan for calendar years:

1. 2023 (personnel files numbered 1 and 2); and

2. 2024 (personnel files numbered 1, 2, 4, and 5);

c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years:

1. 2023 (personnel files numbered 1 and 2); and

2. 2024 (personnel files numbered 1, 2, 4, and 5); and

d. HIV minimum standards for calendar years:

1. 2022 (personnel file numbered 1);

2. 2023 (personnel file numbered 2); and

3. 2024 (personnel files numbered 4 and 5).

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 annual trainings meet all applicable requirements.

16. Violation: Two of two personnel files reviewed for requirements governing every two year trainings did not meet requirements. There was no documentation of the following trainings:

a. Client ethical boundaries due by August 31, 2023 (personnel file numbered 1) and January 31, 2024 (personnel file numbered 2); and

b. Emergency procedures and client rights as specified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03 due by January 31, 2024 (personnel file numbered 2).

Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that every two year trainings meet all applicable requirements.

17. Violation: Four of six personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following:

a. A completed application for employment signed by the staff member and containing the staff member's qualifications for employment (personnel file numbered 5);

b. 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 files numbered 2 and 3); and

c. No documentation of a written annual review of the staff member’s job performance for calendar years 2023 (personnel file numbered 1) and 2024 (personnel files numbered 1 and 5).

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/