|
November 21, 2025
Samantha Sorensen, Authorized Agent HealthEast St John Hospital 1575 Beam Ave Maplewood, MN 55109 License Number: 1034899 CORRECTION ORDER Dear Samantha Sorensen: On August 25 through 29, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, St Johns Chemical Dependency Maplewood, located at 1655 Beam Ave Ste 207, Maplewood, MN 55109. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder Treatment 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 did not follow licensing rules and statutes, as described below. Policies, Procedures, and Practices 1. Violation: The license holder did not meet requirements governing service initiation and service termination policies as follows: a. There was no written protocol for assisting clients in need of care not provided by the license holder; b. The denial of service initiation protocol did not include the following: 1) Protocol for an individual that poses an immediate threat to the health of any individual or requires immediate medication intervention to be referred to a medical facility capable of admitting the client; and 2) Protocol that the commission of a crime against a license holder’s staff member or on a license holder’s premises, as provided under Code of Federal regulations, title 42, section 2.12 (c)(5), and title 45, parts 160 to 164, must be reported to a law enforcement agency with jurisdiction; c. The service termination policy did not include the following: 1) Procedures for clients who services were terminated under Minnesota Statutes, section 245G.14, subdivision 2; 2) A description of a process for providing information to the client on client behavior that constitutes reason for a staff-requested service termination; 3) Procedures staff must follow when a client leaves against staff or medical advice and when the client may be dangerous to the client or others, including a policy that requires a staff member to assist the client with assessing needs of care or other resources; and 4) Procedures for communicating staff-approved service termination criteria to a client, including the expectations in the client’s individual treatment plan according to Minnesota Statutes, section 245G.06. Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 2 and 3, clauses (1), (2), (5) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service initiation and service termination policies meet all applicable requirements. Within 60 days of receipt of this order, submit an updated service initiation and service termination policy that meets all applicable requirements. 2. Violation: The license holder did not meet requirements for policies and procedures that protect client rights. The policy did not include the rights identified in Minnesota Statutes, section 148F.165. Statute Violated: Minnesota Statutes, sections 245G.12, clause (5) and 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client rights policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated client rights policy that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing grievance procedures. The grievance procedure did not include current telephone numbers and addresses of the Department of Human Services, Licensing Division, the Office of the Ombudsman for Mental Health and Developmental Disabilities, and the Board of Behavioral Health and Therapy. Statute Violated: 245G.15, subdivision 2, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 60 days of receipt of this order, submit an updated grievance procedure that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing the treatment services description. The treatment services description did not include a description of the types and amounts of services provided. Statute Violated: Minnesota Statutes, section 245G.12, clause (10). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 60 days of receipt of this order, submit an updated treatment service description that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing client record requirements. The license holder did not have a policy and procedure that identifies how the program will track and record client attendance at treatment activities, including the date, duration, and nature of each treatment service provided to the client. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client attendance policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated client attendance policy that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing co-occurring disorders. The co-occurring policies did not include the following: a. A description of how the program has continuing access to a medical provider with appropriate expertise in prescribing psychotropic medications; b. A description of how the program has a mental health professional available for staff members supervision and consultation; and c. Flexibilities for clients who may lapse in treatment or may have difficulty adhering to established treatment rules as a result of a mental illness, with the goal of helping a client successfully complete treatment. Statute Violated: Minnesota Statutes, section 245G.20, clauses (2), (3), and (8). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the co-occurring policies meet all applicable requirements. Within 60 days of receipt of this order, submit an updated co-occurring policy that meets all applicable requirements. 7. Violation: The license holder did not meet requirements governing tuberculosis policies. The tuberculosis policy did not include resources to provide information on tuberculosis education on a form approved by the commissioner. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a), clause (2) and 245G.12, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the tuberculosis policy meets all applicable requirements. 8. Violation: The license holder did not meet requirements governing behavioral emergency policies and procedures. The procedures did not include the staff members authorized to implement behavioral emergency procedures. Statute Violated: Minnesota Statutes, section 245G.12, clause (7) and 245G.16, paragraph (a), clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the behavioral emergency policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated service initiation and service termination policy that meets all applicable requirements. 9. Violation: The license holder did not meet requirements governing program abuse prevention plans. The program abuse prevention plan did not include an evaluation of the following factors: a. The need for specialized programs of care for clients; and b. The type of internal programming. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. Within 60 days of receipt of this order, submit an updated program abuse prevention plan that meets all applicable requirements. 10. Violation: The license holder did not meet requirements governing personnel policies. The license holder did not have policies that contain the following requirements: a. Policies prohibiting personal involvement with a client in violation of Minnesota Statutes, chapter 604; b. Policies prohibiting client abuse described in Minnesota Statues, sections 245A.65, 626.557, 626.5572, and chapter 260E; and c. Policies outlining the license holder’s response to a staff member with a behavior problem that interferes with the provision of treatment services. Statute Violated: Minnesota Statutes, sections 245G.12, clause (4) and 245G.13, subdivision 1, clauses (4) and (8). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies meet all applicable requirements. Within 60 days of receipt of this order, submit updated personnel policies that meets all applicable requirements. 11. Violation: The license holder did not meet requirements governing plan for transfer of clients and records upon closure. The written plan did not provide for notifying affected clients of the closure at least 25 days prior to the closure, including information on how to access their records. Statute Violated: Minnesota Statutes, 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. Within 60 days of receipt of this order, submit an updated plan for the transfer of clients and records upon closure that meets all applicable requirements. Personnel Files 12. Violation: Two of two personnel files reviewed for requirements governing staff orientation and did not meet requirements. There was no documentation of orientation as follows: a. Within 24 working hours to: 1) The staff member’s specific job responsibilities (personnel files numbered 1 and 2); 2) Policies and procedures (personnel file numbered 2); 3) Client confidentiality (personnel file numbered 2); and 4) Client need (personnel file numbered 2); b. HIV minimum standards within 72 hours of employment (personnel file numbered 2); c. Within 27 hours of first providing direct contact services (personnel file numbered 2): 1) Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; 2) The program abuse prevention plan; and 3) All internal and external reporting policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E before the mandatory report has direct contact with a person served by the program (personnel file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3 and 245G.13, subdivisions 1, clause (7), and subdivision 2, paragraphs (d) and (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 13. Violation: Two of three personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following annual trainings: a. The maltreatment of vulnerable adult reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, including specific training covering the license holder’s policies for obtaining a release of client information for calendar year: 1) 2024 (personnel file numbered 1); and 2) 2025 (personnel file numbered 2); b. The program abuse prevention plan for calendar year: 1) 2024 (personnel file numbered 1); and 2) 2025 (personnel file numbered 2); c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar year 2025 (personnel file numbered 2); d. Mandatory reporting requirements as specified in Minnesota Statutes, chapter 260E for calendar year 2025 (personnel file numbered 2); and e. HIV minimum standards for calendar year 2025 (personnel file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 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 annual training meets all applicable requirements. Client Files 14. Violation: Three of three client files reviewed for requirements governing client orientation (client files numbered 1 through 3) did not meet requirements. There was no documentation that the client was provided opioid educational material approved by the commissioner on the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 60 days of receipt of this order, submit client orientation documentation from one client that meets all applicable requirements. 15. Violation: One of three client files reviewed for requirements governing individual services plans (client file numbered 1) did not meet requirements. The individual services plan did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual treatment plan. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual services plans meet all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (client files numbered 1, 2, and 3) did not meet requirements. A comprehensive assessment that authorized the treatment services was not reviewed and updated as clinically necessary to ensure compliance with Minnesota Statutes, section 245G.05 by the end of the fifth day on which a treatment service is provided. Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 17. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not signed by the client (client files numbered 1 through 3); b. A change to the ITP was not signed by the client (client file numbered 1); and c. The ITP did not document a schedule for accomplishing the client’s treatment goals and objectives (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a, paragraph (a), clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 18. Violation: Two of three client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan was not completed once every 30 days for clients receiving nonresidential ASAM level 1.0 or 2.1 services as follows: a. A treatment plan review was due by May 21, 2025; however, was not completed until May 28, 2025 (client file numbered 1); and b. A treatment plan review was due by July 15, 2025; however, was not completed until July 28, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 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. 19. Violation: One of two client files reviewed for requirements governing service discharge summaries (client file numbered 2) did not meet requirements. The services discharge summary did not include the client’s living arrangements at service termination. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b), clause (5). 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 the licensor by email at Kayla.Northrop@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Kayla Northrop 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 651-431-6671 or at Maura.McGarry@state.mn.us Sincerely, Maura McGarry, Licensing Supervisor Licensing Division Office of Inspector General
|
