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January 27, 2025 Jennifer Donaldson, Authorized Agent Dunatos, Inc. 602 11th Ave NW Suite 300 Rochester, MN 55901 License Number: 1121212 License Number: 1121206 Report: 202406157 CORRECTION ORDER Dear Jennifer: On November 12, 13, 14, and 15, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Dunatos, Inc. located at the following: · 602 11th, Ave NW, Suite 300, Rochester, MN 55901, license number 1121212 · 848 17th St. E Suite 5, Wabasha, MN 55981, license number 1121206 This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under MN 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 Policies, Procedures, and Practices DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder (1121212 and 1121206) submitted requests for payment of public funds for treatment services that did not meet requirements in the following ways: a. The license holder did not offer required services to individuals with co-occurring mental health and substance use disorder as required: 1) A mental health diagnostic assessment was not completed within ten days of admission (client files numbered 1, 2, 3, and 5); 2) A monthly multidisciplinary case review was not documented (client files numbered 1, 2, 3, and 5); 3) Family education that addresses mental health and substance use disorders and the interaction between the two was not offered; and b. Treatment services were not documented in the client file; however, services were billed on the following dates: 1) Nine hours of group counseling services on February 20 and 27, 2024. (client file numbered 3); and 2) Three hours of individual counseling on October 9, 2024 (client file numbered 2). Statute Violated: Minnesota Statute, 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 were 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 (1121212 and 1121206) did not meet requirements for physical plant postings as follows: a. The grievance procedure was not posted in a place visible to clients; and b. The internal and external reporting of maltreatment of vulnerable adult policies and the program abuse prevention plan were not posted in a prominent location. Statute Violated: Minnesota statutes, sections 245A.65, subdivisions 1, paragraph (d), 2, paragraph (a), and 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the physical plant postings meet all applicable requirements. 3. Violation: The license holder did not follow the programs service initiation and termination policy for admitting and discharging a client. The program did not complete service initiation requirements after discharging clients who continued to attend treatment services. Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 1, and 3, paragraph (1). Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure service initiation and termination procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a service initiation and termination policy demonstrates compliance. 4. Violation: The license holder’s grievance procedure (1121212 and 1121206) did not include the current address and phone number of the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 5. Violation: The license holder’s policies and procedures regarding HIV (1121212 and 1121206) did not meet requirements. The policies and procedures were not consistent with the HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19 and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit an HIV policy that demonstrates compliance. Personnel Files Personnel files reviewed are identified in the following manner: · Personnel files numbered 1 through 3 and 5 through 7, license number 1121212 (Rochester) · Personnel file numbered 4, license number 1121206 (Wabasha) 6. Violation: Two of five personnel files reviewed for requirements governing background studies (personnel files numbered 2 and 5) did not meet requirements. There was no documentation of sufficient information, driver’s license number or state identification number or acceptable form of identification as determined by the commissioner to ensure an accurate study. Statute Violated: Minnesota statutes, section 245C.05, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the background studies meet all applicable requirements. 7. Violation: Four of five personnel files reviewed for requirements governing staff qualifications did not meet requirements. There was no documentation of the following: a. Demonstration of the treatment director’s knowledge of Minnesota Statutes, chapters 245G, 245A and 260E and sections 626.557, and 626.5572. (personnel file number 3); and b. Staff members current license on file (personnel files 4, 5, and 7). Statute Violated: Minnesota statutes, sections 148F.11, subdivision 1, paragraph (a), and 245G.11, subdivisions 3, and 5, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications meet all applicable requirements. 8. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of orientation to the following: a. Policies and procedures (personnel files numbered 4 and 5); b. Client needs (personnel files numbered 6 and 7); c. Program abuse prevention plan (personnel files numbered 4 through 7); d. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 4 through 7); e. Maltreatment of minors (personnel files numbered 6 and 7); and f. Drug and alcohol policy (personnel files 4 and 5). Statute Violated: Minnesota statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, 245G.13, subdivisions 1 and 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff above received the required training. 9. Violation: Four of four personnel files reviewed for requirements governing additional staff trainings (personnel files numbered 4 through 7) did not meet requirements. There was no documentation of training in the specific mode of administration of emergency overdose treatment used at the program. Statute Violated: Minnesota statutes, section 245G.08, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that additional staff trainings meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff above received the required training. 10. Violation: Four of four personnel files reviewed for requirements governing personnel contents did not meet requirements. There was no documentation of the following: a. An inquiry of 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 file numbered 5; and b. A written job performance evaluation (personnel files numbered 4 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 personnel file contents meet all applicable requirements. Client Files Client files reviewed are identified in the following manner: · Client files numbered 1 through 4 and 6, license number 1121212 (Rochester) · Client file numbered 5, license number 1121206 (Wabasha) 11. Violation: Four of four client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation of the following: a. Within 72 hours of admission for HIV minimum standards (client files numbered 1, 2, 3, and 5); b. Tuberculosis (client files numbered 1 and 3); c. Personal electronic device (client files numbered 1, and 3); d. On the day of service initiation for the following: 1) Grievance Procedure (client files numbered 1, 2, 3, and 5); and 2) Client bill of rights and Staff reviewing the rights with the client (client files numbered 1 and 2); and e. Within 24 hours of admission (client files numbered 1, 2, 3, and 5): 1) Maltreatment of vulnerable adults (client files numbered 1, 2, 3, and 5); and 2) Program abuse prevention plan (client files numbered 1, 2, 3, and 5). Statute Violated: Minnesota statues, sections 245A.19 245A.65, subdivision 1, paragraph (c), and subdivision 2, paragraph (a), 245G.05, subdivision 3, paragraph (b), 245G.09, subdivision 3, paragraph (1), and 245G.15. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. 12. Violation: Three of four client files reviewed for requirements governing initial service plans (ISP) and vulnerable adult determination did not meet requirements in the following ways: a. The ISP and vulnerable adult determination were not completed within 24 hours of the day of service initiation (client file numbered 1); and b. The ISP was not person centered and client specific (client files numbered 1, 2, and 5). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1a, paragraph (a), and 245G.04, subdivisions 1 and 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans and vulnerable adult assessment meet all applicable requirements. Within 30 days of receipt of this order, submit an initial service plan and vulnerable adult assessment from two recently admitted clients that demonstrates compliance. 13. Violation: Four of four client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. There was no documentation of the following: a. A review and update of the CA was not completed, signed, and dated (client file numbered 2); b. CA did not include the following information: 1. Status of the client’s basic needs (client files numbered 1 and 5); 2. Client’s education level (client file numbered 3); 3. Immediate risks to the client’s health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotional symptoms (client file numbered 1); 4. Client’s perceptions of the client’s condition (client files numbered 1 and 5); 5. Client’s descriptions of the client’s symptoms (client files numbered 1 and 5); 6. Client’s cultural influences on the client (client files numbered 1 and 5); 7. Circumstances of relapse (client file numbered 5); 8. The client’s relationship with the client's family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client file numbered 1); 9. Client’s strengths and resources, including the extent and quality of the client’s social networks (client file numbered 1 and 5); 10. Important developmental incidents in the client’s life (client file numbered 1 and 5); 11. Client’s health history (client file numbered 1); and 12. Recommendation for ASAM level of care (client file numbered 1 and 5). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that meets requirements. 14. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not person centered (client files numbered 1 and 2); b. The ITP was not signed by the client (client file numbered 5); c. A change to the ITP was not signed by the client (client file numbered 1); d. There was no documentation of the following: 1) The ITP did not include how the family or others will be involved in the client’s treatment and did not include 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 3); and 2) The ASAM level of care identified in section 254B.19, subdivision 1 (client files numbered 1, 2, and 5). Statute Violated: Minnesota statutes, sections 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. Within 30 days of receipt of this order, submit an individual treatment plan that meets requirements. 15. Violation: Four of four client files reviewed for requirements governing treatment plan reviews did not meet requirements. Treatment plan reviews from February 22, 2024, to May 2, 2024 (client file number 3) and October 24, 2024 (client file number 5) did not include the span of time covered by the review. Statute Violated: Minnesota statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans and vulnerable adult assessment meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan review that demonstrates compliance. 16. Violation: Three of four client files reviewed for requirements governing documentation of treatment services (client files numbered 1, 2, and 3) did not meet requirements. There was no documentation of the date and type of each treatment service provided to a client and the client’s response to each treatment service. It was the program’s practice to document weekly in the treatment plan reviews the amount of services provided without the required specifics. Statute Violated: Minnesota statute, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of two client treatment service notes that demonstrates compliance. 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 david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely, David Her, Licensor Licensing Division Office of Inspector General
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