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April 8, 2025 Margot Kelsey, Authorized Agent Northern Minnesota Addiction Wellness Center LLC 4851 Stacy Ann Dr NW Bemidji, MN 56601-0009 License Number: 1103246 Report Numbers: 202310821, 202400479, 202403264
CORRECTION ORDER Dear Margot Kelsey: On February 3 through 6, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigations at your facility, Northern Minnesota Addiction Wellness Center located at 4851 Stacy Ann Dr NW, Bemidji, Minnesota. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment services 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 meet requirements governing client property management. The license holder did not have policies and procedures that meet the requirements for handling client funds and property. Therefore, the license holder did not immediately document receipt and disbursement of the person's funds or other property at the time of receipt or disbursement, including the person's signature. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c) and 245G.21, subdivision 3. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Order for Conditional License dated March 15, 2024; and · Correction Order dated March 29, 2022 Corrective Action Required: Immediately, and on an ongoing basis, the license holder must maintain a policy on client property management that meets all applicable requirements. Within 30 days, submit a client property management policy that meets all applicable requirements. 2. Violation: The license holder did not meet requirements governing the description of treatment services. The description of treatment services did not: a. Include treatment coordination; and b. Identify which services meet the definition of group counseling. Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 1, paragraph (5) and subdivision 4, and 245G.12. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the treatment service description meets all requirements. Within 30 days of receipt of this order, submit a treatment services description that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing emergency overdose treatment. The emergency overdose policy did not: a. Include a written standing order protocol; b. Identify the specific mode of administration used at the program; and c. Include procedure for monitoring the available supply of an opiate antagonist; Statute Violated: Minnesota Statutes, sections 245A.242 and 245G.08, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that emergency overdose treatment policies meet all requirements. 4. Violation: The license holder did not meet requirements governing HIV training in substance use disorder treatment programs. The license holder did not develop written policies and procedures that were consistent with the HIV minimum standards approved by the commissioner. Statute Violated: Minnesota Statutes, section 245A.19. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must maintain written policies and procedures that meet all applicable requirements. 5. Violation: The license holder did not meet requirements governing administration of medication and assistance with self-medication and control of drugs. The license holder’s policies and procedures did not include: a. Guidelines for when to inform a nurse of problems with self-administration of medication, including a client’s failure to administer, refusal of a medication, adverse reaction, or error; b. A procedure to destroy a discontinued, outdated, or deteriorated medication; and c. A procedure for monitoring the available supply of an opiate antagonist. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c) and subdivision 6, paragraph (4). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies regarding administration of medication and assistance with self-medication meet all applicable requirements. Within 30 days of receipt of this order, submit administration of medication and assistance with self-medication and control of drugs policies that meet all applicable requirements. 6. Violation: The license holder did not meet requirements governing behavioral emergency procedures. The procedures did not list staff members authorized to implement behavioral emergency procedures. Statute Violated: Minnesota Statutes, section 245G.16. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure behavioral emergency procedures meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing provider personnel policies. The license holder did not have personnel policies that included orientation within 24 working hours of starting for each new staff member based on a written plan that, at a minimum, must provide training to the staff member’s specific job responsibilities, policies and procedures, client confidentiality, HIV minimum standards, and client needs. Statute Violated: Minnesota Statutes, section 245G.13 Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure provider personnel policies meet all applicable requirements. Personnel Files 8. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of orientation for the following: a. Within 24 working hours (personnel files numbered 1 through 4): i. Policies and procedures; and ii. Client needs; b. Within 72 hours of employment: i. HIV minimum standards (personnel files numbered 1, 2, and 4); ii. The reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 (personnel files numbered 1 through 4); iii. Program abuse prevention plan (personnel files numbered 1 through 4); and iv. All internal policies and procedures related to the reporting of maltreatment of individuals receiving services (personnel files numbered 1 through 4). c. Training on the maltreatment of minors reporting requirements and definitions in Minnesota Statute, chapter 260E before the mandatory reporter has direct contact with persons served by the program (personnel files numbered 1 through 4). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivisions 1 and 2, paragraphs (d) and (e). Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above-mentioned staff have completed the required orientation. 9. Violation: Two of two personnel files reviewed for requirements governing annual training (personnel files numbered 5 and 7) did not meet requirements. There was no documentation of annual training for calendar year 2024 on: a. Program Abuse Prevention Plan; and b. Mandatory reporting as specified in Minnesota Statute, chapter 260E. Statute Violated: Minnesota Statute, section 245G.13, subdivision 2, paragraph (c). Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure staff development meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above-mentioned staff have completed the required annual staff development. Client Files 10. Violation: The license holder did not follow their own policy governing client rights protection. Clients were not allowed to use a supplier of their choice as identified in Minnesota Statute, section 144.651, subdivision 24. Through client and staff interviews, it was identified that clients were required to use health care providers preferred by the license holder rather than preferred by the client (client files numbered 3 and 6). Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client rights meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that all staff have been trained on the client rights identified in Minnesota Statute, sections 144.651, 148F.165, and 253B.03, 11. Violation: Three of three client files (client files numbered 1 through 3) reviewed for client orientation did not meet requirements. Clients assessed for opioid use disorder were not provided educational material within 24 hours of service initiation using materials that are approved by the commissioner. Statute Violated: Minnesota Statutes, section 245G.045, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that opioid education meets all applicable requirements. 12. Violation: Two of three client files reviewed for requirements governing initial services plans did not meet requirements in the following ways: a. The plan was not completed within 24 hours of the day of service initiation (client file numbered 1); and b. The plan was not person-centered and client-specific (client files numbered 1 and 2). 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 service plans meet all applicable requirements. 13. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways: a. The IAPP was not completed within 24 hours of the day of service initiation (client file numbered 1); and b. The IAPP did not contain documentation of the following: i. An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults (client files numbered 1 through 3); ii. An assessment of the person’s risk of abusing other vulnerable adults (client files numbered 1 through 3); and iii. Measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility if unsupervised when the facility knows that the vulnerable adult has committed a violent crime or an act of physical aggression toward others (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b) and 245G.04, subdivision 2, paragraph (b). Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all requirements. Within 30 days of receipt of this order, submit individual abuse prevention plans for two client files that meet all requirements. 14. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include or identify which of the following topics will require further assessment during the course of the client’s treatment: a. The client’s resources (client files numbered 1 and 2); b. The client’s health history and the client’s family health history, including the client’s physical, chemical, and mental health history (client file numbered 1); c. The client’s family health history (client file numbered 2); and d. The client’s physical health history (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit comprehensive assessments from two client files that meet all requirements. 15. Violation: Five of five client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not person-centered (client files numbered 1 and 2); b. The ITP was not updated based on new information gathered about the client’s condition (client files numbered 6 and 7); and c. The ITP did not: i. Identify a treatment strategy (client files numbered 1 through 3); and ii. Document the ASAM level of care identified in section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 through 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. 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 individual treatment plans from client files that meet all requirements. 16. Violation: Three of three client files reviewed for requirements governing documentation of treatment services did not meet requirements. Documentation of treatment services did not include the: a. Type of treatment services provided on December 16, 19, and 27, 2024, and January 28, 2025 (client file numbered 3); b. Amount of treatment services on December 21, 2024 (client file numbered 3); and c. Client response to treatment service for the following dates: i. December 4, 5, 19 and 24, 2024, and January 1, 2, 3, 6, and 7, 2025 (client file numbered 1); ii. November 27, 29, and 30, and December 1, 11, 12, 13, 15, 16, 25, and 28, 2024 (client file numbered 2); and iii. December 19, 20, 24, 25, and 27, 2024, and February 2 and 3, 2025 (client file numbered 3). 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. Within 30 days of receipt of this order, submit two treatment service documents that meet all applicable requirements. 17. Violation: Two of five client files reviewed for requirements governing client record documentation did not meet requirements. Entries in the client record were not accurate. Through staff interviews, it was identified that the name of the treatment service facilitator was auto populated by the electronic health record and was not able to be changed. Documentation of treatment services had inaccurate staff listed as providing the treatment service as follows: a. December 13, 2024 (client file numbered 2); and b. December 17, 2024 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraphs (b) and (c) Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 18. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. The treatment plan reviews on January 2, 15, and 30, 2025 did not include a review and evaluation of the individual abuse prevention plan according to Minnesota Statute, section 245A.65 (client file numbered 3); and b. A treatment plan review was not completed once every 14 days for a client receiving ASAM level 3.5 high intensity residential for the review period ending: i. January 31, 2025 (client file numbered 1); ii. January 15, 2025 (client file numbered 2); and iii. January 1 and 29, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3 and 3a. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 19. Violation: Five of five client files reviewed for requirements governing administration of medications did not meet requirements as follows: a. Medications were ordered but were not documented as administered for: i. Multivitamin and Vitamin D on December 13 through 17, 2024 (client file numbered 3); ii. Aripiprazole on July 15 and 17, 2023 (client file numbered 7); iii. Budesonide on July 7, 13, 14, 27, 28, and August 15, 2023 (client file numbered 7); iv. Suboxone on July 4 and 5, 2023 (client file numbered 7); v. Nicoderm on July 7, 13, 14, 18, 20, 21, 25, 28, and August 3, 4, 10, and 11, 2023 (client file numbered 7); vi. Polyethylene Glycol on July 7, 18, 27, 28, and August 3, 4, 10, and 11, 2023 (client file numbered 7); vii. Buproprion on July 1, 5, 7, 8, 12 through 15, 17, 29, and 29-21, 2023 (client file numbered 7); viii. Citalopram on July 5 and 18, 2023 (client file numbered 7); ix. Olanzapine on July 26, 2023 (client file numbered 7); x. Pregablin on July 26, 2023 (client file numbered 7); xi. Trazodone on July 26 and August 12 through 14, 2023 (client file numbered 7); xii. Diclofemac on July 20 and 21, 2023 (client file numbered 7); xiii. Topiramate on August 3 through 6, 2023 (client file numbered 7); xiv. Suboxone on July 13, 27, 30, August 21, 31, September 11 through 13, 20, October 1 through 5, 7 through 11, 14 and 15, 2023 (client file numbered 6); xv. Multivitamin on December 12, 2023 and January 8, 2024 (client file numbered 1); xvi. Sertraline on December 29 and 30, 2023, and January 8 and 12, 2024 (client file numbered 1); xvii. Vitamin D3 on January 8, 2024 (client file numbered 1); xviii. Naltrexone on January 8, 2024 (client file numbered 1); xix. Prazosin on January 10 through 13, 2025 (client file numbered 1); xx. Vitamin D3 and Multivitamin on January 3, 4, and 12, 2025 (client file numbered 2); xxi. Buspirone on January 1 through 4, 2025 (client file numbered 2); xxii. Suboxone on December 18 and 19, 2024 (client file numbered 3); xxiii. Escitalopram on January 14, 21, 22, 27, and February 4, 2025 (client file numbered 3); xxiv. Omeprazole on January 16, 2025 (client file numbered 3); xxv. Amoxicillin on January 22, 23, 27 through 29, and February 1, 2025 (client file numbered 3); and xxvi. Nabumetone on January 22, 23, and 27 through 29, 2025 (client file numbered 3); and b. There was no documentation of signature of the staff member who completed the administration of the medication with the time and date for: i. December 7, 10, 25, and 26, 2024 (client file numbered 2); and ii. December 30 and 31, 2024, and January 1, 8, 16, 20, and 21, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 29, 2022. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that administration of medication documentation meets all applicable requirements. 20. Violation: Three of five client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. Discharge summary not completed within five days of service termination (client file numbered 7); b. Discharge summary did not contain the following: i. The client’s progress toward achieving each goal identified in the individual treatment plan (client files numbered 5 through 7); ii. A risk rating and description for each of the ASAM six dimensions (client files numbered 5 and 7); and iii. For a client discharged at staff request, why the decision to discharge is warranted, the reasons for the discharge, and the alternatives considered or attempted before discharging the client (client files numbered 5 and 7). Statutes Violated: Minnesota Statutes, sections 245G.06, subdivision 4 and 245G.14 Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional license dated March 15, 2024. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries 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 Jennifer.White@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer White 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) 431-6282 or at Jennifer.White@state.mn.us Sincerely,
Jennifer White, Licensor 2 Licensing Division Office of Inspector General
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