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April 28, 2025 William Lockett, Authorized Agent The Micah Halfway House 1523 Nicollet Avenue Minneapolis, MN 55403-2723 License Number: 1009414 Investigation Number: 202410155
CORRECTION ORDER Dear William Lockett: On March 17 and 18, 2025, a Department of Human Services (DHS) licensor conducted a licensing review and investigation at your facility, the Micah House located at 3047 5th Avenue South, Minneapolis, Minnesota 55403. 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 in Minnesota Statutes, section 254B.19, subdivision 1, paragraph (a) for receiving public funding reimbursement from the commissioner for high intensity residential clients. Daily skilled treatment services were not documented on the following dates: a. November 17, 2024 (client file numbered 1); b. December 28 and 29, 2024, January 25 and 26, and February 1 and 2, 2025 (client file numbered 3); and c. January 18, 19, 25, and 26, and February 1, 2 and 9, 2025 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245A.167. 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 the description of treatment services. The description of treatment services did not include the following: a. A description of treatment coordination and the amount provided; and b. Identify which groups and topics a guest speaker could provide services. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1 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. Personnel Files 3. Violation: Two of two personnel files (personnel files numbered 1 and 2) reviewed for requirements governing first date of direct contact did not meet requirements. There was no documentation of the first date that a background study subject had contact with a person served by the program. Statute Violated: Minnesota Statutes, section 245A.041, subdivision 6. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that first date of direct contact documentation meets all applicable requirements. 4. Violation: Two of two 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 of the following to (personnel file numbered 1): i. Staff member’s specific job responsibilities; ii. Policies and procedures; iii. Client confidentiality; and iv. Client needs; b. Within 72 hours of employment to: i. HIV minimum standards (personnel files numbered 1 and 2); c. Within 72 hours of direct client contact to: i. The license holder’s program abuse prevention plan (personnel file numbered 1); and d. Training on maltreatment of minors reporting requirements and definitions in Minnesota Statute, chapter 260E before direct contact with persons served by the program (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3 and 245G.13, subdivisions 1 and 2, paragraph (e). Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. 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 has completed the required orientation. 5. Violation: One of two personnel files (personnel file numbered 2) reviewed for requirements governing personnel file content did not meet requirements. There was no documentation of a completed application for employment signed by the staff member and containing the staff member's qualifications for employment. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 3. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure personnel files meet all applicable requirements. Client Files 6. Violation: One of two client files (client file numbered 2) reviewed for requirements regarding service initiation did not meet requirements. The license holder did not provide opioid educational material approved by the commissioner to the client on the day of service initiation. Statute Violated: Minnesota Statute, section 245G.04, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that opioid educational material meets all requirements. 7. Violation: One of two client files (client file numbered 3) reviewed for requirements governing initial services plans did not meet requirements. The plan was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. 8. Violation: One of two client files reviewed (client file numbered 3) for requirements governing individual abuse prevention plans did not meet requirements. The individual abuse prevention plan was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), 245G.04, subdivision 2, paragraph (b), and 245G.21, subdivision 6. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all requirements. 9. Violation: Two of three client files reviewed (client files numbered 3 and 4) for requirements governing comprehensive assessments did not meet requirements. There was no documentation that a comprehensive assessment that authorized the treatment service was reviewed and updated as clinically necessary to ensure compliance within five calendar days from the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. 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. 10. Violation: Two of two client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. The individual treatment plan was not completed within ten days from the date of service initiation (client file numbered 3); and b. The individual treatment plan was not updated based on new information gathered about the client’s condition (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 11. Violation: Two 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. Signature of the staff person that provided the treatment service for: i. January 17 and 29, and February 7, 11, 12, and 14, 2025 (client file numbered 2); and ii. January 29, 2025 (client file numbered 3); b. Type of treatment service provided on: i. January 24 and 30, 2025 (client files numbered 2 and 3); and ii. February 6, 2025 (client file numbered 3); and c. Client response to treatment service for the following dates: i. January 28 and February 10, 13, 17, and 18, 2025 (client file numbered 2); and ii. December 30, 2024, January 27, and February 3, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. 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: Two of two client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. There was no documentation that the residential treatment program documented medical and other appointments that the client attended on January 29 and February 20, 2025 (client file numbered 2); and b. Entries in the client record were not accurate. The treatment plan review did not indicate the correct span of time covered by the review for the notes signed on: i. January 29 and February 6, 2025 (client file numbered 2); and ii. January 27 and March 11, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraphs (b) and (c). Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 13. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review dated November 12, 2024, did not document client goals addressed since the last treatment plan review and whether the identified methods continue to be effective (client file numbered 1); b. A treatment plan review was not completed every 14 days for a client receiving ASAM level 3.5 high intensity residential. There was no documentation that a treatment plan review was completed by the following dates: i. February 12, 2025 (client file numbered 2); and ii. February 10 and 24, 2025 (client file numbered 3) and; c. The treatment plan review did not include a review and evaluation of the individual abuse prevention plan on February 12, March 7, and 11, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a, paragraph (b). Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 14. Violation: One client file (client file numbered 2) reviewed for requirements governing administration of medications did not meet requirements in the following ways: a. There was no documentation of the time buspirone was administered on March 10, 2025; and b. The medication administration record was not completed for: i. Buspirone on March 8, 9, 10, 13, and 16, 2025; and ii. Olanzapine on March 16, 2025. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5. Repeat Violation: In an Order of Conditional License that DHS issued on July 17, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that administration of medication documentation meets 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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