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April 11, 2025 Kinsi Mirreh, Authorized Agent Ultimate Health Inc 2266 2nd St N, Suite 200 North St. Paul, MN 55109-2914 License Number: 1086986 Report Numbers: 202408739, 202500512, 202500977
CORRECTION ORDER Dear Kinsi Mirreh: On January 21 through 23, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigations at your facility, Addiction Health Center located at 2266 2nd St N, Suite 200, North St. Paul, 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 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 for receiving public funding reimbursement from the commissioner for services provided. a. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c) for services provided to individuals with co-occurring mental health and substance use disorder problems: i. No diagnostic assessment completed within 10 days of admission (client files numbered 1 and 4); ii. No documentation of the monthly multidisciplinary case review for November 2024 (client file numbered 4); and iii. No documentation of co-occurring counseling staff receiving 8 hours of co-occurring disorder training annually for calendar years 2023 and 2024 (personnel files 2, 4, and 5); and b. The license holder did not provide the amount of services for which they billed as required under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (b). Group counseling treatment services were documented as being 90 minutes in duration, however they were billed for 2 hours on the following dates: I. February 21 (12:30-2:05pm), March 18 (2:20-3:50pm), and April 16 (2:20-3:50pm), 29 (10:15-11:45am), and 30 (8:30-10:00am and 12:35-2:05pm), 2024 (client file numbered 6); and II. December 9 (10:15-11:45am), 12 (12:35-2:05pm), 16 (8:30-10:00am and 11:15-11:45am), 17 (8:30-10:00am), 18 (8:30-10:00am and 12:35-2:05pm), 23 (8:30-10:00am and 12:35-2:05pm), and 24 (8:30-10:00am and 11:15-11:45am), 2024 (client file numbered 4). Statute Violated: Minnesota Statute, sections 245A.167 and 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 for which they are billed. 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 services; disenrollment in the public payment program; or other administrative, civil, or criminal penalties provided by law. 2. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults. The internal and external reporting policies and procedures, including the telephone number of the common entry point were not posted in a prominent location in the program. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adult policies meet all requirements. 3. Violation: The license holder did not meet requirements governing service initiation policy. The service initiation criteria was not posted in the area of the facility where services for a client are initiated or given to each interested person upon request. Statute Violated: Minnesota Statute, section 245G.14. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the service initiation policy is posted or given to each interested person upon request. 4. Violation: The license holder did not meet requirements governing emergency overdose treatment. The license holder did not have a written standing order protocol. Statute Violated: Minnesota Statute, sections 245G.08, subdivision 3 and 245A.242. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that emergency overdose treatment policies meet all requirements. 5. Violation: The license holder did not meet requirements governing grievance procedures. The grievance procedure: a. Did not include the correct address or phone number for the Board of Behavioral Health and Therapy; and b. Identified the highest level of authority in the program as the board of directors and there is no board of directors. Statute Violated: Minnesota Statute, section 245G.15, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program’s grievance procedure meets all requirements. Within 45 days of receipt of this order, submit a grievance procedure that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing descriptions of treatment services. The description of treatment services did not include the following: a. Types of required treatment services provided including: i. Client education on drug and alcohol use during pregnancy; and ii. Treatment Coordination; b. Which services meet the definition of group counseling; and c. The program’s treatment week. Statute Violated: Minnesota Statute, section 245G.12, paragraph (10). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program’s grievance procedure meets all requirements. Within 45 days of receipt of this order, submit a description of treatment services that meets all applicable requirements. 7. Violation: The license holder did not meet requirements governing program abuse prevention plans in the following ways: a. The plan did not contain an assessment and evaluation of the following factors: i. The condition and design of the building as it relates to the safety of the clients; ii. The existence of areas in the building which are difficult to supervise; iii. The location of the program in a particular neighborhood or community; iv. The type of grounds and terrain surrounding the building; v. The type of internal programming; and vi. The program’s staffing patterns; b. No documentation of the license holder’s governing body or the governing body’s delegated representative reviewed the plan in calendar years 2023 and 2024. c. The plan was not posted in a prominent location in the program. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all requirements. Within 45 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 8. Violation: The license holder did not monitor the implementation of their own policies and procedures as required for the following: a. The license holder did not follow their policy on taking disciplinary action on a behavior that was outlined in their policy. The Treatment Director acknowledged that there had been multiple complaints about a specific staff member and that little had been done in response. As a result of no action taken, the situation escalated and a significant event occurred; and b. The comprehensive assessment and treatment planning policies contained outdated statute references. Statute Violated: Minnesota Statute, sections 245A. 04, subdivision 14, paragraph (b) and 245G.13. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures are followed and meet all requirements. Within 45 days of receipt of this order, submit comprehensive assessment and treatment planning policies that meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. There was no documentation that the plan was reviewed and signed annually by a controlling individual for calendar years 2023 and 2024. Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. Personnel Files 10. Violation: One of five personnel files reviewed for requirements governing background studies did not meet requirements. The file did not contain documentation of verification about an individual who is the subject of the background study is correct. (personnel file numbered 3). Statute Violated: Minnesota Statute, sections 245C.05, subdivision 2 and 245G.13, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that background studies meet all applicable requirements. 11. Violation: Three of three personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual training for calendar years 2023 and 2024 (personnel files numbered 2, 4, and 5) on: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E including specific training covering the license holder’s policies for obtaining a release of client information; and ii. HIV minimum standards; and b. Every two year training on: i. Client confidentiality rules and regulations and client ethical boundaries for calendar year: 1. 2023 (personnel file numbered 5); and 2. 2024 (personnel files numbered 2 and 4); and ii. Emergency procedures and client rights for calendar year: 1. 2023 (personnel file numbered 5); and 2. 2024 (personnel files numbered 2 and 4). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (b) through (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with staff development requirements. Within 45 days of receipt of this order, submit documentation which demonstrates that the above personnel completed annual and every two year training that meets requirements. 12. Violation: Five of five personnel files reviewed for requirements governing personnel files did not meet requirements. The license holder had no documentation of the following: a. The staff member met the qualifications of an alcohol and drug counselor supervisor (personnel file numbered 2) for the following: i. The staff knew and understood the implications of Minnesota Statutes, chapter 245G, sections 245A.65, 626.557, and 626.5572, and chapter 260E; and ii. The staff was licensed or exempt from licensure under Minnesota Statutes, chapter 148F as an alcohol and drug counselor; b. The staff qualifications to determine eligibility to provide treatment services (personnel file numbered 3); c. An inquiry 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 employer names and addresses for the past five years for which the staff member provided psychotherapy services (personnel file numbered 1); and d. A written annual review for calendar year: i. 2023 (personnel files numbered 2 and 5); and ii. 2024 (personnel files numbered 2, 4, and 5). Statute Violated: Minnesota Statute, sections 245G.07, subdivision 3, 245G.11, subdivisions 4 and 5, and 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. Client Files 13. Violation: Seven of seven client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation that the client: a. Received a written statement of client rights and responsibilities on the day of service initiation (client files numbered 1 through 7); b. Received orientation to HIV minimum standards within 72 hours of admission to the program (client files numbered 1 through 7); c. Received an explanation of the grievance procedure (client files numbered 4 and 5); and d. Obtained opioid educational material approved by the commissioner on the day of service initiation (client files numbered 2 through 6). Statute Violated: Minnesota Statute, sections 245A.19, 245G.04, subdivision 3, and 245G.15, subdivisions 1 and 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 14. Violation: Three of seven client files reviewed for requirements governing client records did not meet requirements. There was no documentation that the client was given information about tuberculosis on the form approved by the commissioner (client files numbered 1, 3, and 4). Statute Violated: Minnesota Statute, section 245G.09, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that tuberculosis education meets all applicable requirements. 15. Violation: Four of seven client files reviewed for requirements governing vulnerable adult determinations did not meet requirements. The license holder did not: a. Determine whether a client is a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21, within 24 hours of the day of service initiation (client files numbered 2 through 5); and b. Seek consent to the disclosure of suspected maltreatment from the client after an incident of suspected maltreatment was reported as required in MN Statutes, sections 626.557, subdivision 3a (client file numbered 2). Statute Violated: Minnesota Statute, section 245G.04, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that vulnerable adult status determinations meet all applicable requirements. 16. Violation: Six of seven client files reviewed for requirements governing initial service plans did not meet requirements. The initial service plan was not: a. Completed within 24 hours of the day of service initiation (client files numbered 2 through 6); and b. Person-centered and client specific (client files numbered 6 and 7). Statute Violated: Minnesota Statute, 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. 17. Violation: Six of seven client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed by the end of the fifth day on which a treatment service is provided and there was no documentation identifying the client-centered reason why the assessment was not completed within this timeframe (client files numbered 1, 2, and 4 through 6); b. The comprehensive assessment did not include a description of the client’s symptoms, including the reason for the client’s referral (client file numbered 6); and c. 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: i. The client’s evaluation of the quality of each significant personal relationship (client file numbered 2); ii. The extent and quality of the client’s social networks (client file numbered 6); and iii. The client’s family health history (client files numbered 2, 6, and 7). Statute Violated: Minnesota Statute, section 245G.05. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 18. Violation: Six of seven client files reviewed for requirements governing individual treatment plans did not meet requirements. a. The individual treatment plan was not: i. Completed by the end of the tenth day on which a treatment session had been provided from the day of service initiation (client files numbered 1 through 6); ii. Signed by the client (client files numbered 1 and 2); iii. Updated based on new information gathered about the client’s level of participation (client file numbered 1); and iv. Signed by the client following an update (client file numbered 2); b. The individual treatment plan did not include the following: i. How the family or others will be involved in the client’s treatment (client file numbered 3); ii. A schedule for accomplishing the client’s treatment goals and objectives (client file numbered 6); iii. The participants involved in the client’s treatment planning (client file numbered 3); and iv. Active interventions to stabilize mental health symptoms (client file numbered 6). Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 1 and 1a and 245G.20. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 45 days of receipt of this order, submit two individual treatment plans that meet all applicable requirements. 19. Violation: Three of four client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Documentation was not completed within seven days of providing the treatment service on February 3, 2025 (client file numbered 2); b. Documentation was not accurate about toxicology results on September 6, 2024. Treatment plan reviews stated that client’s toxicology results were negative for all substances; however, lab reports showed otherwise (client file numbered 1); c. Documentation of a significant event was not completed within 24 hours of an event occurring on February 3, 2025 (client file numbered 2); and d. Client documentation did not record: i. The signature of the staff person who provided the treatment service on January 6, 2025 (client file numbered 6); ii. Type of treatment service provided for the following timeframe: 1. July 22 through 26, August 12 through 16, and September 23, 26, and 27, 2024 (client file numbered 1); and 2. August 26 through 30, September 9 through 13, and November 11 through 15, 2024 (client file numbered 2); iii. Client response for the following dates: 1. July 22, 25, and 26, and August 14 and 16, 2024 (client file numbered 1); and 2. August 26 and 30, September 11 and 12, and November 12, 2024 (client file numbered 2); and iv. Job title of the staff person making the entry for the following timeframe: 1. July 22 through 26, August 12 through 16, and September 23, 26, and 27, 2024 (client file numbered 1); and 2. August 26 through 30, and September 9 through 13, 2024 (client file numbered 2); Statute Violated: Minnesota Statute, section 245G.06, subdivisions 2a and 2b, paragraphs (a) and (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. Within 45 days of receipt of this order, submit two client documentation of group treatment services that meet all applicable requirements. 20. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review did not document a time span covered by the review for treatment plan reviews dated: i. September 6 and 10, 2024 (client file numbered 1); ii. September 17 and 26, October 17, and December 6, 2024 (client file numbered 2); and iii. December 16, 2024 (client file numbered 6); and b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1 intensive outpatient. There was no documentation of a treatment plan review due on the following dates: i. January 5, 2025 (client file numbered 2); and ii. December 18, 2024, and January 18, 2025 (client file numbered 6). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 3 and 3a, paragraph (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 45 days of receipt of this order, submit two treatment plan reviews that meet all applicable requirements. 21. Violation: Three of three client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of service termination (client files numbered 1, 3, and 4); and b. The discharge summary did not include the client’s (client files numbered 3 and 4): i. Issues, strengths, and needs while participating in treatment, including services provided; and ii. Progress toward achieving each goal in the individual treatment plan. Statute Violated: Minnesota Statute, section 245G.06, subdivision 4. 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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