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March 25, 2025 Elizabeth Jarve, Authorized Agent Genesis Recovery Services LLC 5 N 3rd Ave W, Ste 310 Duluth, MN 55802 License Number: 1074059 CORRECTION ORDER Dear Elizabeth Jarve: On January 13, 14, 15, 16, and 17, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Genesis Recovery Services LLC located at 5 N 3rd Ave W, Ste 310, Duluth, MN 55802. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder statutes 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 statutes, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements governing service initiation and service termination policies in the following ways: a. The license holder did not have a written protocol for: 1. Assisting a client in need of care not provided by the license holder; and 2. A client who poses a substantial likelihood of harm to the client or others, if the behavior is beyond the behavior management capabilities of the staff members; and b. The service termination policy did not include the following: 1. Procedures consistent with section 253B.16, subdivision 2, that staff members must follow when a client admitted under chapter 253B is to have services terminated; and 2. Procedures staff must follow when a client leaves against staff or medical advice and when the client may be dangerous to self or others; including a policy that requires staff members to assist the client with assessing needs of care or other resources. Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 2, paragraph (a) and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation and service termination policies meet all applicable requirements. Within 30 days of receipt of this order, submit a service initiation policy and service termination policy that meet all applicable requirements. 2. Violation: The license holder did not meet requirements governing client rights protection. The client rights protection policy did not include all rights identified in Minnesota Statutes, section 253B.03. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client rights protection policy meets all applicable requirements. Within 30 days of receipt of this order, submit a client rights protection policy that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults reporting in the following ways: a. The internal reporting policy included more than one secondary person or position: 1. To whom internal reports may be made; 2. Responsible for forwarding internal reports to the common entry point; and 3. Involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; b. The internal review policy included more than one secondary person or position: 1. Who will ensure that, when required, internal reviews are completed; and 2. Involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and c. The internal review policy did not include the following: 1. A facility with an internal reporting procedure that receives an internal report by a mandated reporter shall give the mandated reporter a written notice stating whether the facility has reported the incident to the common entry point. The written notice must be provided within two working days and in a manner that protects the confidentiality of the reporter; 2. The written response to the mandated reporter shall note that if the mandated reporter is not satisfied with the action taken by the facility on whether to report the incident to the common entry point, then the mandated reporter may report externally; and 3. A facility may not prohibit a mandated reporter from reporting externally, and a facility is prohibited from retaliating against a mandated reporter who reports an incident to the common entry point in good faith. The written notice by the facility must inform the mandated reporter of this protection from retaliatory measures by the facility against the mandated reporter for reporting externally. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1 and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of vulnerable adults reporting policy meets all applicable requirements. Within 30 days of receipt of this order, submit a maltreatment of vulnerable adults reporting policy that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing grievance procedures. The grievance procedure did not identify the current address of the Office of Ombudsman for Mental Health and Developmental Disabilities. 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. Within 30 days of receipt of this order, submit a death reporting policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing reporting a death in the program. The policy did not identify that a report must be made if the license holder receives knowledge of the death of an individual served by the program whether the death occurs inside or outside of the program premises. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the death reporting policy meets all applicable requirements. Within 30 days of receipt of this order, submit a death reporting policy that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing policies and procedures for program administration. The implementation of policies and procedures was not monitored by program staff for the following: a. Internal and external maltreatment of vulnerable adults reporting procedures; b. The program abuse prevention plan; and c. The grievance procedure. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policies and procedures for program administration meet all applicable requirements. Within 30 days of receipt of this order, submit a client orientation packet that meets all applicable requirements. Client Files 7. Violation: Six of six client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation: a. Within 24 hours of service initiation, the client with an opioid use disorder was not provided educational information according to Minnesota Statutes, section 245G.04, subdivision 3 (client file numbered 4); b. Within 72 hours of admission for HIV minimum standards (client files numbered 1 through 6); and c. The personal electronic device policy. The client was not informed of their right to refuse being photographed or recorded (client files numbered 1 through 6). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c), 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. 8. Violation: Three of three client files reviewed for requirements governing tuberculosis education (client files numbered 4 through 6) did not meet requirements. The client was not provided tuberculosis education on a form approved by the commissioner. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that tuberculosis education meets requirements. 9. Violation: Three of six client files reviewed for requirements governing initial services plans (client files numbered 1, 2, and 5) did not meet requirements. The initial services plan did not identify treatment needs to be addressed during the time between the day of service initiation and the development of the 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 that initial services plans meet all applicable requirements. 10. Violation: Six of six client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment did not include 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 files numbered 1 and 4 through 6); b. The comprehensive assessment did not include: 1. The status of the client’s basic needs (client files numbered 1 and 5); 2. The client’s education level and employment status (client file numbered 1); 3. The client’s current medications (client files numbered 1 and 4); 4. Any immediate risks to the client's health and safety, including: i. Withdrawal symptoms (client files numbered 1 through 3, and 5); ii. Medical conditions (client files numbered 1, 3, and 5); and iii. Behavioral and emotional symptoms (client files numbered 1 through 3, and 5); 5. The client’s description of the client’s symptoms (client file numbered 5); 6. The reason for the client's referral (client files numbered 3, 5 and 6); 7. The client’s history of substance use disorder treatment (client file numbered 2); and 8. Cultural influences on the client (client file numbered 1); c. Substance use history, including: 1. Amounts (client files numbered 1 and 6); 2. Frequency and duration (client files numbered 1 through 3); 3. Route of administration (client file numbered 1); and 4. Circumstances of relapse (client file numbered 2); and d. Topics which will require further assessment during the course of the client’s treatment, including: 1. The client's strengths (client file numbered 1); 2. The client’s resources (client file numbered 3); 3. Potential brain injuries that the client has suffered (client file numbered 1); 4. The client’s family health history (client files numbered 1 and 4 through 6); 5. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to section 245.4863 (client file numbered 2); and 6. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 and 8). 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 that comprehensive assessments meet all applicable requirements. 11. Violation: Six of six client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed by the end of the tenth day on which a treatment session was provided from the day of service initiation (client file numbered 2); b. The ITP was not signed by an alcohol and drug counselor (client file numbered 1); c. 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 files numbered 1, 3, and 4); d. The ITP did not include how the family or others will be involved in the client’s treatment and 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 1 and 3); and e. There was no documentation of the following: 1. The client's treatment goals in relation to any or all of the applicable ASAM six dimensions identified in section 254B.04, subdivision 4, to ensure measurable treatment objectives (client files numbered 1 and 3 through 6); 2. A treatment strategy (client file numbered 6); 3. A schedule for accomplishing the client’s treatment goals and objectives (client files numbered 1, 3, 5, and 6); 4. The ASAM level of care identified in section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 and 3 through 6); and 5. Resources to refer the client to when the client's needs will be addressed concurrently by another provider (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1 and 1a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit two client individual treatment plans that meet all applicable requirements. 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. 12. Violation: Four of six client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. The entries in the client’s record were not accurate as follows: 1. The risk rating on the comprehensive assessment was inconsistent with the initial risk rating identified on the individual treatment plan (client files numbered 1, 5 and 6); and 2. The individual treatment plan on April 1, 2024, and discharge summary on September 5, 2024, identified the client’s admission date as March 11, 2024, however, the client was admitted on March 27, 2024 (client file numbered 3); and b. Treatment plan reviews on June 6 and 27, 2024 documented that individual counseling was provided for two hours and one quarter of an hour, respectively, however, individual counseling notes were not documented in the client’s file (client file numbered 1). 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 that client record documentation meets all applicable requirements. 13. Violation: Five of five client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. The TPR was completed prior to the span of time indicated on the review on: 1. June 6, 27, and July 24, 2024 (client file numbered 1); 2. July 24, 2024 (client file numbered 3); 3. October 29 and December 16, 2024 (client file numbered 4); 4. December 4, 2024 and January 6, 2025 (client file numbered 5); and 5. September 26, November 27, and December 26, 2024 (client file numbered 6); b. The TPR did not document client goals addressed since the last treatment plan review and whether the identified methods continue to be effective on: i. June 6, 27, and July 24, 2024 (client file numbered 1); ii. May 1, June 4, July 3, and July 24, 2024 (client file numbered 3); iii. October 29, December 12, and 19, 2024 and January 16, 2025 (client file numbered 4); iv. November 11 and December 9, 2024 and January 6, 2025 (client file numbered 5); and v. September 26, October 31, November 27, and December 26, 2024 (client file numbered 6); c. Monitoring of any physical and mental health problems and include toxicology results for alcohol and substance use from: 1. May 15 through June 13, June 10 through 30, and July 1 through 31, 2024 (client file numbered 1); and 2. April 1 through May 1, 2024 (client file numbered 3); d. Continuing documentation of collaboration with continuing care mental health providers (client file numbered 3); and e. The TPR was not completed once every 30 days (client files numbered 3 through 6). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit two treatment plan reviews that meet all applicable requirements. 14. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. The service discharge summary must be completed within five days of the client's service termination (client file numbered 3); b. The client’s issues, strengths and needs while participating in treatment, including services provided (client file numbered 1); and c. A risk rating and description for each of the ASAM six dimensions (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Personnel Files 15. Violation: One of three personnel files reviewed for requirements governing background studies (BGS) did not meet requirements. The license holder did not document the date a staff person first had direct contact with persons served by the program (personnel file numbered 3). Statute Violated: Minnesota Statutes, section 245A.041, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that background studies meet all applicable requirements. 16. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit (personnel file numbered 3) did not meet requirements. There was no documentation of supervision for the weeks of November 11, 25, December 9, 23, and 30, 2024. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individuals with a temporary permit meet all applicable requirements. 17. Violation: Two of three personnel files reviewed for requirements governing staff orientation did not contain documentation that orientation was received for the following topics: a. Within 24 working hours of starting: 1. Policies and procedures (personnel file numbered 2); and 2. Client needs (personnel files numbered 2 and 3); b. Within 72 hours of employment, HIV minimum standards (personnel files numbered 2 and 3); c. Within 72 hours of first providing direct contact services to a vulnerable adult, the license holder’s program abuse prevention plan, all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 2); and d. Within six months of employment 12 hours of specific training in co-occurring disorders (personnel file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 18. Violation: Three of three 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 file numbered 2); and 2. 2024 (personnel files numbered 1 through 3); b. Program abuse prevention plan for calendar years: 1. 2022 and 2023 (personnel file numbered 1); and 2. 2024 (personnel files numbered 1 through 3); c. Reporting of maltreatment of minors for calendar years: 1. 2022 and 2023 (personnel file numbered 1); and 2. 2024 (personnel files numbered 1 through 3); and d. HIV minimum standards for calendar years: 1. 2022 and 2023 (personnel file numbered 1); and 2. 2024 (personnel files numbered 1 through 3). 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. Within 30 days of receipt of this order, submit documentation that the staff mentioned above have completed the trainings identified above. 19. Violation: One personnel file reviewed for requirements governing every two-year trainings (personnel file numbered 1) did not meet requirements. There was no documentation of the following trainings: a. Client confidentiality for calendar years 2022 and 2024; b. Client ethical boundaries for calendar year 2024; and c. Emergency procedures for calendar year 2022. 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. 20. Violation: One of three personnel files reviewed for requirements governing personnel file contents (personnel file numbered 2) did not meet requirements in the following ways: a. There was no documentation of 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; and b. The written annual review of the staff member’s job performance was not completed for calendar year 2024. 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. Kayla Northrop, Licensor II Licensing Division Office of Inspector General
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