Minnesota

April 1, 2025

Jason Vanderscoff, Authorized Agent

NorthStar Regional

500 Marschall Rd, Ste 300

Shakopee, MN 55379

License Number: 1096701 (Jail Program)

License Number: 1077852 (Voyager Program)

License Number: 1096700 (Sugar Creek Program, 1045 Stoughton Ave, Chaska)

License Number: 1096703 (Sugar Creek Program, 1055 Stoughton Ave, Chaska)

CORRECTION ORDER

Dear Jason Vanderscoff:

On December 9, 10, 11, 12, and 13, 2024 Department of Human Services (DHS) licensor conducted a licensing review at your facilities located at the following:

· Jail Program, 606 E 4th St, Chaska, MN 55318, license number 1096701

· Voyager Program, 500 Marschall Rd, Ste 300, Shakopee, MN 55379, license number 1077852

· Sugar Creek Program, 1045 Stoughton Ave, Chaska, MN 55318, license number 1096700

· Sugar Creek Program, 1055 Stoughton Ave, Chaska, MN 55318, license number 1096703

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.

Client Files

Client files reviewed are identified in the following manner:

· License Number 1096701: Client files numbered 1 through 3

· License Number 1077852: Client files numbered 4 through 6

· License Number 1096700: Client file numbered 10

· License Number 1096703: Client files numbered 7 through 9 and 11

1. Violation: Six of eleven 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 files 1 and 4 through 6):

1. Written statement of client rights and responsibilities and that staff reviewed the written statement with the client; and

2. Grievance procedure;

b. Within 24 hours of admission:

1. The internal and external maltreatment of vulnerable adults reporting procedures (client files numbered 1 and 4 through 6); and

2. For an individual assessed for opioid use disorder, educational information according to Minnesota Statutes, section 245G.05, subdivision 3, paragraph (b) (client files numbered 5, 9, and 10);

c. Within 72 hours of admission on HIV minimum standards (client files numbered 4 through 6); and

d. The personal electronic device policy (client files numbered 1 and 4 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.

2. Violation: One of eleven client files reviewed for requirements governing tuberculosis education (client file numbered 4) did not meet requirements. There was no documentation that the client was given information on 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.

3. Violation: Four of eleven client files reviewed for requirements governing initial services plans did not meet requirements in the following ways:

a. The initial services plan was not completed within 24 hours of the day of service initiation (client file numbered 1);

b. The initial services plan was not person-centered and client-specific (client files numbered 1 through 3); and

c. The initial services plan did not address immediate health and safety concerns (client file numbered 5).

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.

4. Violation: Four of eleven client files reviewed for requirements governing vulnerable adult determinations did not meet requirements in the following ways:

a. Within 24 hours of the day of service initiation, the license holder did not determine whether a client is a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21 (client files numbered 4 through 6); and

b. Within 24 hours on an incident that was reported under Minnesota Statutes, section 626.557, the license holder did not determine whether a client is a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21 (client file numbered 9).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (a) and 245G.04, subdivision 2, paragraph (a).

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

5. Violation: Four of eleven client files reviewed for requirements governing comprehensive assessments did not meet requirements as follows:

a. The comprehensive assessment was not completed by the end of the fifth day on which a treatment service was provided and there was no documentation of the person-centered reason for the delay and planned completion date (client file numbered 2);

b. 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 7 and 9);

c. The comprehensive assessment did not include:

1. The status of the client’s basic needs (client file numbered 1);

2. Cultural influences on the client (client file numbered 2);

3. Substance use history, including amounts (client file numbered 2); and

4. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 and 2); and

d. The comprehensive assessment did not document or identify which of the following topics will require further assessment during the course of the client’s treatment:

1. The client’s relationship with family and other significant personal relationships (client file numbered 2);

2. The client’s evaluation of the quality of each personal relationship (client files numbered 1 and 2); and

3. Important developmental incidents in the client's life (client files numbered 1 and 2).

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.

6. Violation: Eleven of eleven 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 files numbered 6 and 8);

b. The ITP was not person-centered (client files numbered 1, 2, 3, 5, and 8);

c. The ITP was not updated based on new information about:

1. The client’s condition (client files numbered 7, 9, and 10);

2. The client’s level of participation (client files numbered 9 and 10); and

3. Whether methods identified have the intended effect (client file numbered 9);

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, 5, 6, 10, and 11); and

e. There was no documentation of the following:

1. A treatment strategy (client files numbered 1 through 3, 4, and 11);

2. A schedule for accomplishing the client’s treatment goals and objectives (client files numbered 4 through 6, 8, and 9);

3. The ASAM level of care identified in section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1, 2, 4, and 11);

4. Resources to refer the client to when the client's needs will be addressed concurrently by another provider (client file numbered 3); and

5. The participants involved in the client's treatment planning (client files numbered 4 through 6, and 11).

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 that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit one individual treatment plan that meets all applicable requirements.

7. Violation: Five of eleven client files reviewed for client record documentation did not meet requirements in the following ways:

a. The entries in the client’s record did not document the following:

1. Type of treatment service provided to the client on:

i. April 23, May 13, June 3, 5, July 23, August 28, September 3, 5, October 14, 15, November 18, 19, and 21, 2024 (client file numbered 1); and

ii. October 17, 2024 (client file numbered 7);

2. The amount of treatment service provided to the client on:

i. April 23, May 13, June 3, 5, July 23, August 28, and 29, 2024 (client file numbered 1);

ii. December 3, 2024 (client file numbered 3);

iii. November 21, 2024 (client file numbered 7); and

iv. October 8, 2024 (client file numbered 8); and

3. The client’s response to the treatment service on:

i. August 29, 2024 (client file numbered 1); and

ii. September 27, 2024 (client file numbered 8); and

b. The entries in the client’s record were not completed within seven days of providing the treatment service for:

1. November 5, 2024 (client file numbered 5);

2. October 11, 2024 (client file numbered 7);

3. October 7, 2024 (client file numbered 8); and

4. October 23 and November 12, 2024 (client file numbered 9).

Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b.

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

8. Violation: Eight of nine client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways:

a. For a client receiving ASAM level 1.0 or 2.1 outpatient services, the treatment plan review was not completed once every 30 days. There was no documentation of a treatment plan review due on:

1. August 30, September 29, October 29, and November 28, 2024 (client file numbered 1);

2. July 3, August 2, September 1, October 1, and November 1, 2024 (client file numbered 2);

3. November 3, 2024 (client file numbered 8); and

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

b. The treatment plan review did not document the following:

1. The span of time covered by the review for notes signed on:

i. April 29, May 9, 17, 31, June 7, 28, July 26, August 23, and 30, 2024 (client file numbered 1);

ii. June 14, August 8, 23, and 30, 2024 (client file numbered 2); and

iii. June 10, 17, 24, July 1, 8, 15, 22, 29, August 5, 12, 19, and 25, 2024 (client file numbered 6);

2. Client goals addressed since the last treatment plan review for the review periods ending on:

i. September 1, 2024 (client file numbered 4);

ii. December 1, 2024 (client file numbered 5);

iii. October 20, November 17, and December 15, 2024 (client file numbered 7); and

iv. November 3, 2024 (client file numbered 8);

3. Monitoring of any physical and mental health problems for the review periods ending on:

i. September 1, 2024 (client file numbered 4); and

ii. December 12, 2024 (client file numbered 5);

4. Toxicology results for alcohol and substance use for the review period ending on December 12, 2024 (client file numbered 5); and

5. The participation of others involved in the individual's treatment planning, including when services are offered to the client's family or significant others for the review periods ending on:

i. September 1, 2024 (client file numbered 4); and

ii. December 12, 2024 (client file numbered 5).

Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a.

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

9. Violation: Four of eight client files reviewed for requirements governing the service of persons with co-occurring disorders (client files numbered 2, 4, 5, and 9) did not meet requirements. The license holder did not have continuing documentation of collaboration with continuing care mental health providers, and involvement of the providers in treatment planning meetings.

Statute Violated: Minnesota Statutes, section 245G.20.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service of persons with co-occurring disorders meets all applicable requirements.

10. Violation: Two of ten client files reviewed for requirements governing client records did not meet requirements in the following ways:

a. The client’s entry was not signed by the staff member making the entry on June 12 and July 9, 2024 (client file numbered 11); and

b. Client records were not protected against unauthorized disclosure (client file numbered 9). A report was made to the Minnesota Adult Abuse Reporting Center on September 26, 2024, and there was no release of information documented.

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

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

11. Violation: Four of six 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 4, and 8); and

b. A risk rating and description for each of the ASAM six dimensions (client files numbered 2, 4, 6, and 8).

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 that discharge summaries meet all applicable requirements.

Personnel Files

Personnel files reviewed are identified in the following manner:

· License Number 1096701: Personnel file numbered 1

· License Number 1077852: Personnel file numbered 2

· License Numbers 1096700 & 1096703: Personnel files numbered 3 through 7

12. Violation: One of seven personnel files reviewed for requirements governing background studies (BGS) did not meet requirements. Staff began a position allowing direct contact with person served by the program on September 13, 2021. A BGS was submitted under license number 1096700, however, this staff was also working under license number 1096703. The license holder failed to affiliate staff to all required rosters (personnel file numbered 7).

Statute Violated: Minnesota Statutes, section 245C.07, paragraph (a).

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

13. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following:

a. Orientation on the maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E before the mandatory reporter had direct contact (personnel file numbered 4);

b. Orientation on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services to a vulnerable adult (personnel file numbered 4); and

c. 12 hours of specific training in co-occurring disorders within six months of employment (personnel file numbered 5).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 2, paragraphs (e) and (f).

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

14. Violation: Five of six 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 for the calendar years: