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April 15, 2025 Marlin Martin, Authorized Agent Valhalla Place LLC dba BHG Brooklyn Park Treatment Center 5001 Spring Valley Road Ste 600 E Dallas, TX 75244-8217 License Number: 1108976 (245G) CORRECTION ORDER Dear Marlin Martin: On February 4 through 7, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Valhalla Place LLC dba BHG Brooklyn Park Treatment Center located at 2807 Brookdale Drive Brooklyn Park, MN 55444-1844. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment 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. Postings, Policies, Procedures and Practices 1. Violation: The license holder did not meet requirements governing postings for the following: a. The grievance procedure not visible to clients; and b. The internal and external reporting of maltreatment of vulnerable adult policies not located in a prominent location. Statute Violated: Minnesota Statute, section 245A.65 subdivision 1, paragraph (d), and 245G.15 subdivision 2. Corrective Action Required: Immediately and on an ongoing basis the license holder will ensure that all applicable postings are posted in a prominent location. Within 30 days of receipt of this order the license holder will submit verification that postings meet all applicable requirements. 2. Violation: The license holder did not monitor the implementation of policies and procedures. There were two conflicting versions of the grievance procedure and neither met requirements as follows: a. Did not contain the telephone numbers and address of the Department of Human Services Licensing Division, The office of Ombudsman for Mental Health and Development Disabilities, and the Minnesota Board of Behavioral Health and Therapy; and b. Did not require that the license holder respond to the client’s grievance within three days of staff members receipt of the grievance. Statute Violated: Minnesota Statute, section 245A.04, subdivision 14, paragraph (b) and 245G.15 subdivision 2. Corrective Action Required: Immediately and on an ongoing basis the license holder will ensure the grievance procedure is accurate and contains all applicable required information. Within 30 days of receipt of this order submit a grievance procedure that meets all applicable requirements. 3. Violation: The program did not follow the terms of a variance which was granted on October 26, 2023, to allow for a client transferring between Minnesota opioid treatment programs (OTP) without a break in dosing, for the client’s length of time in the transferring OTP to be counted as part of the first 10 weeks (client file numbered 5). The receiving OTP did not have documentation from the transferring OTP and maintain documentation in the client record for the following: a. Confirmation of the time in treatment from transfer facility; b. Discharge summary; c. Recent dosing history; d. Confirmation of dose level; e. Last 3 drug screens with results; and f. Any other applicable documentation. Statute Violated: Minnesota Statutes, section 245G.03 subdivision 1 (b). Corrective Action Required: Immediately and on an ongoing basis you must follow the terms of the variance for clients transferring between Minnesota opioid treatment programs. Personnel Files 4. Violation: One of five personnel files (personnel file numbered 1) reviewed for requirements governing annual training did not meet requirements. There was no documentation of the annual training for HIV minimum standards. Statute Violated: Minnesota Statutes, section 245A.19, paragraph (b)and 245G.13 subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements. Client Files 5. Violation: Three of five client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation to the following: a. On the day of service initiation: i. Written statement of the client’s rights and responsibilities and that staff reviewed the written statement with the client (client files numbered 3, 5 and 7); ii. Grievance Procedure (client files numbered 5 and 7); iii. HIV minimum standards (client files 5 and 7); iv. Opioid educational material approved by the commissioner to clients having an opioid use disorder (client files numbered 3, 5 and 7); and b. The internal and external maltreatment of vulnerable adult policies within 72 hours of admission into the program (client files numbered 5 and 7). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c), 245G.04 subdivision 3, 245G.09, subdivision 3, and 245G.15, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements governing client orientation meets all applicable requirements. 6. Violation: Four of four client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed within 21 days from the day of service initiation. The person-centered reason for the delay and the plan for completion of the comprehensive assessment was not documented (client file numbered 6); b. The comprehensive assessment did not document the following information: i. The client’s age (client file numbered 7); ii. The status of client’s basic needs (client file numbered 7); iii. Immediate risks to the client’s health and safety, including withdrawal symptoms, medical conditions and behavioral and emotional symptoms (client files numbered 6 and 7); iv. Client’s perception of the client’s condition (client file numbered 7); v. The client’s description of the client’s symptoms, including the reason for the client’s referral (client files numbered 6 and 7); vi. Cultural influences on the client (client file numbered 7); vii. Substance use history, including: 1. Amount of substance used (client files numbered 5 and 7); 2. Types of substances (client files numbered 4 through 7); 3. Frequency (client files numbered 4 through 7); 4. Duration (client files numbered 4 through 7); 5. Route of administration (client files numbered 4 through 7); 6. Periods of abstinence (client files numbered 5 and 7); and 7. Circumstances of relapse (client files numbered 4 through 7); and viii. Impact to functioning when under the influence of substances (client file numbered 7); and ix. Determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statues, section 245.4863 (client files 4, 5 and 7); and c. 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: i. The client’s relationship with the client’s family and other significant personal relationships (client file numbered 7); ii. The client’s evaluation of the quality of each relationship (client files numbered 4, 5 and 7); iii. The client’s strengths and resources, including the extent and quality of the client’s social networks (client file numbered 7); iv. Important developmental incidents (client files numbered 4 through 7); and Statute Violated: Minnesota Statutes, section 245G.05. 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 the license holder will submit one comprehensive assessment that meets all applicable statute requirements. 7. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The clients ITP was not based on the client’s comprehensive assessment (client file numbered 6); b. The ITP was not updated when new information was gathered about the client’s: i. level of participation (client files numbered 4 and 8); and ii. whether methods identified have the intended effect (client file numbered 5); c. The ITP did not document the following: i. How family or others will be involved in the client’s treatment planning or the reasons that the license holder did not involve the client’s family or other natural supports in the client treatment planning (client files numbered 3); ii. A treatment strategy (client file numbered 8); iii. ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 2 through 8); iv. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client files numbered 4, 6 and 7); and v. Active interventions to stabilize mental health symptoms (client file numbered 1, 2, and 6). Statute Violated: Minnesota Statutes, section 245G.06 subdivisions 1and 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 the license holder will submit one ITP that meets all applicable requirements. 8. Violation: Six of eight files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. The treatment plan reviews did not document: i. Whether the identified methods continue to be effective for the following treatment weeks starting on: 1. October 1, 2024 (client file numbered 5); 2. November 18, 2024 (client file numbered 6); 3. January 6 and 13, 2025 (client file numbered 4); ii. Participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others the treatment week starting on December 1, 2024 (client file numbered 2); iii. Referrals made since the previous treatment plan review the treatment week starting October 1, 2024 (client file numbered 3); and iv. Collaboration with continuing care mental health providers and involvement of the providers in treatment planning meetings the treatment week starting January 2, 2025 (client file numbered 1); and b. Treatment plan reviews must be completed weekly for the ten weeks following completion of the treatment plan. Missing treatment plan review for the week beginning January 27, 2025 (client file numbered 6). Statute Violated: Minnesota statutes, section 245G.06 subdivision 3 and 3a and 245G.22, subdivision 15, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing treatment plan reviews are met. 9. Violation: Three of three client files reviewed for discharge summaries did not meet requirements. The discharge summary did not include the following information: a. The client’s issues (client files numbered 3, 8 and 9) b. The strengths and needs while participating in treatment (client files numbered 3 and 8); c. The services provided (client files numbered 3 and 8); d. The clients progress toward achieving each of the goals identified in the individual’s treatment plan (client files numbered 3, 8 and 9); e. A description for each of the ASAM six dimensions (client files numbered 8 and 9); and f. The continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services and referrals made with specific attention to continuity of care for mental health as needed (client file numbered 8). Statute Violated: Minnesota statute, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing service discharge summaries meet all applicable requirements. Within 30 days of receipt of this order the license holder will submit one discharge summary that meets all applicable requirements. 10. Violation: Five of five client files reviewed for requirements governing central registry requirements did not meet requirements. The information submitted to the state central registry did not include the following: a. Date of admission (client files numbered 4 through 7); b. Date of birth (client files numbered 4 and 7); and c. Current or previous enrollment status in another opioid treatment program (client files numbered 3 through 5). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure central registry meets all applicable requirements. Within 30 days of receipt of this order the license holder must train all staff on central registry requirements and submit documentation of the training for each staff member. 11. Violation: Three of five client files reviewed for requirements governing the prescription monitoring program (PMP) did not meet requirements. There was no documentation of the following: a. A copy of the PMP data reviewed for PMP reports run on: i. September 26, 2024, and December 18, 2024 (client file numbered 5); and ii. August 6, 2024, October 21, 2024, and January 31, 2025 (client file numbered 7); and b. The licensed practitioner’s decision for frequency of ongoing PMP checks following the PMP run on: i. September 26, 2024, and December 18, 2024 (client file numbered 5); ii. November 13, 2024 (client files numbered 6); and iii. August 6, 2024, and October 21, 2024 (client file numbered 7). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing the prescription monitoring program (PMP) are met. Within 30 days of receipt of this order the license holder must submit two PMP reviews that meet all applicable requirements. 12. Violation: Four of four client files reviewed for requirements governing the criteria for unsupervised use of medication used for the treatment of opioid use disorder did not meet requirements as follows: a. The criteria reviewed on January 12, 2025 (client file numbered 4), September 26, 2024 (client file numbered 5), November 13, 2024 (client file numbered 6) and August 6, 2024 (client file numbered 7) did not include information for the following: i. Absence of active substance use disorders or other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdoses, or the ability to function safely; ii. Absence of serious behavioral problems that endanger the patient, the public or others; iii. Absence of known recent diversion activity; iv. Whether take-home medication can be safely transported and stored; and v. Any other criteria that the medical director or medical practitioner considers relevant to the patient’s safety and public’s health. Statute Violated: Minnesota Statutes, sections 245G.22, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing criteria for unsupervised use of medication used for the treatment of opioid use disorder are met. Within 30 days of receipt of this order the license holder will submit the form they intend on using to document requirements governing the criteria for unsupervised use of medication used to the treatment of opioid use disorder. 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.eppel@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jen Eppel 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 651-431-6698 or at Jennifer.eppel@state.mn.us Sincerely, Jennifer Eppel, Licensor Licensing Division Office of Inspector General
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