|
October 2, 2026 CERTIFIED MAIL Phillip Weiss, Authorized Agent Island Recovery Center LLC 6633 N Kendzie Ave, Apt 616 Chicago, IL 60645 License Application Number 1128523 (245F) ORDER OF LICENSE DENIAL Dear Phillip Weiss: The Department of Human Services (DHS) is denying your application for a withdrawal management program license at 227 McKinley Ave, Eveleth, MN 55734. This denial is based on failure to demonstrate competent knowledge of applicable licensing statutes and rules and failure to submit a substantially complete application. Details of our findings are provided below. Our next steps and your options are also detailed. REASON FOR LICENSE DENIAL 1. Failure to submit a substantially complete application You submitted an application for a license to provide withdrawal management services at 227 McKinley Ave, Eveleth, MN 55734. A DHS licensor reviewed your full policy and procedure manual and determined that the manual was substantially incomplete. A DHS licensor reached out to you via email to schedule a virtual feedback meeting on January 27, March 27, May 12, and June 26, 2026. You did not respond to the requests for a meeting. On February 18, 2026 and April 9, 2026 DHS sent you a Notice of Incomplete Application, notifying you that your application was incomplete and that you had 45 days to submit additional information. Both notices were returned without delivery. On March 27, May 12, and June 26, 2026, DHS emailed you a Notice of Incomplete Application, notifying you that your application was incomplete and that you had 45 days to submit additional information. You did not respond to these emails, however a delivery receipt indicated the notice was delivered on June 26, 2026. The Notice of Incomplete Application indicated your application continued to be substantially incomplete in the following ways: · You failed to submit a policy and procedure manual that met all applicable requirements. The following policies and procedures were not in compliance with 245F requirements: o Admission policy: Missing specific admission criteria for an individual who is eligible under Minnesota statutes, section 245F.05, subdivision 2, a statement the license holder will not admit individuals who do not meet the admission criteria, and staff members designated to authorize admit and discharge. o Discharge and transfer policy: Missing a process for referring an individual to a medical facility upon denial or termination, discharge of a patient that involves the commission of a crime against program staff or license holder’s property, discharge of a patient admitted under Minnesota Statutes, chapter 253B, discharge of a patient leaving against staff or medical advice, guidelines for determining when a patient needs a transfer to a higher level of care, and the requirement that staff must document when the patient was referred after discharge or transfer and if a referral was not made, and reason the patient was not provided a referral. o Protective procedures including: § Use of Protective Procedures: Missing a statement that the program must continuously observe the patient until the patient may be safely left for 15-minute intervals, use of the protective procedures must end when the patient is no longer in imminent danger of harming self or others, and reasons protective procedures may not be used. § Protective procedures plan: Missing emergency conditions under which protective procedures are permitted to be used if the patient’s health conditions limit specific procedures and alternative means of ensuring safety, training staff must have before using protective procedures, documentation of approved therapeutic holds, and standards governing emergency use of seclusion. § Physical holds: Missing standards including who can authorize physical holds, a statement the patients’ health concerns must be considered in deciding whether to use physical holds and which are appropriate for the patient, and a statement that only approved holds can be utilized. § Use of law enforcement: Missing the program must maintain a central log documenting the date and time law enforcement arrived and left the program, if law enforcement used force or a protective procedure and which protective procedure was used, and whether any injuries occurred. § Administrative review: The record of administrative review of the use of protective procedures must state whether the required documentation was recorded for each use of a protective procedure, the protective procedure was used according to policy and procedure, that staff who implemented the protective procedure were properly trained, and the behavior met the standards for imminent danger of harming self or others. o Grievance procedures including: An initial response must be made to the patient who filed the grievance within 24 hours of the program’s receipt of the grievance, and missing/incorrect contact information for the Department of Human Services Licensing Division, The Office of Ombudsman for Mental Health and Developmental Disabilities, The MDH Office of Health Facilities Complaints, The Board of Medical Practice, The Board of Nursing, and the Minnesota Board of Behavioral Health and Therapy. o Medical services including: § Health services plan: Missing an initial assessment conducted by a registered nurse upon admission and the ability to be seen within 24 hours or sooner by a qualified medical professional if the initial health assessment indicates the need to be seen. § Medication control plan: Missing a requirement that Schedule II drugs must be stored in a separately locked compartment that is permanently affixed to the physical plan or medication cart, a procedure for recording that patients use of medication including staff signatures, and a statement that no legend drug supply for one patient may be given to another patient. o Maltreatment of vulnerable adults reporting policy including: Must allow but not mandate an internal report, identify the primary and secondary persons to whom and internal report may be made and who is responsible for forwarding reports to common entry point, indicate when the secondary person must be involved, and establish and maintain policies and procedures for an internal review and corrective action. o Personnel policies and procedures including: § Access to client records: Missing a policy that prohibits access to patient’s clinical records by a staff member who has had a personal relationship with the patient within two years prior to the patient’s admission, unless the patient consents in writing. § Job descriptions: Missing policies that include a job description for each position that specifies responsibilities, degree of authority to execute job responsibilities, and that standards of job performance related to specified job responsibilities and qualifications. § Orientation: Missing orientation to the facility policy on obtaining releases of information, and motivational counseling techniques and identifying stages of change. § Annual training: Missing annual training on motivational counseling techniques and identifying stages of change. o Patient to staff ratios: Missing a written policy documenting staff-to-patient ratios for each shift and actions to take when staffed capacity is reached. · You failed to include the following items in the policies and procedures manual: o Description of Patient Education Services o Susceptibility for Risk of Abuse o Stabilization Services o Client Rights o Medical Services including: § Health Monitoring Plan § Emergency Opiate Antagonist Medications o Program Abuse Prevention Plan o Maltreatment of Minors Reporting Policy o Personnel Policies and Procedures including: § Access to Client Records § Job Descriptions § Policies prohibiting patient maltreatment § Organizational Structure § Drug and Alcohol policy o Reporting a Death o Plan for Transfer of Clients and Records Upon Closure · The following policies were not developed/approved by the Medical Director: o Admission Policy o Discharge and Transfer Policy o Protective Procedures o Medical Services Data Collection Tool o Procedures for Nursing to Assess and Monitor Patient Health o Health Services Plan o Physical Indicators for Physician, Registered Nurse, or Hospital, and Procedures for Referral o Procedures to follow in case of accident, injury or death of a patient o Formulation of condition-specific protocols regarding the medications that require a withdrawal regimen that will be administered to patients o Infection Control Program o Medication Control Plan · The following policies were not developed by, or in collaboration with a Registered Nurse: o Medical Services Data Collection Tool o Medication Administration o Health Monitoring Plan o Medication control plan o Training and competency evaluations for staff performing delegated medical and nursing functions o Handling serious illness, accident or injury to patients o An infection control program o First aid kit o Condition specific protocols Legal Authority: 245A.05, subdivision (a)(1). 2. Failure to demonstrate competent knowledge of applicable licensing statutes and rules You were not able to submit a substantially complete application and did not respond to DHS meeting requests to offer assistance. The DHS website where you found the online application provides the application process and hyperlinks to the Minnesota statutes applicable to withdrawal management programs. A DHS licensor also provided you with written feedback on the policies and procedures manual you submitted with your application. Despite these resources, you did not submit policies and procedures that met statute requirements. Your inability to follow the laws and rules during the application process make it less likely you will be able to do so when operating a substance use disorder treatment program. Legal Authority: Minnesota Statutes, sections 245A.04, subdivision 6(a)(5); and 245A.05, subdivision (a)(8). 3. Commissioner’s evaluation of program Before issuing, denying, suspending, revoking, or making conditional a license, the commissioner shall evaluate information gathered under Minnesota Statutes, section 245A.04, subdivision 6. The commissioner’s evaluation shall consider the applicable requirements of statutes and rules for the program or services for which the applicant seeks a license including disqualification standards set forth in chapter 245C. The commissioner shall evaluate facts, conditions, or circumstances concerning the programs operation; the well-being of persons served; available evaluations of the program by persons receiving services; the qualifications of personnel employed by the applicant; and applicant’s ability to demonstrate competent knowledge of applicable statutes and rules. Your inability to submit a complete application in 45 days after receiving information from DHS calls into question your ability to follow the applicable laws and rules; to be able to operate a program; and to ensure the well-being of persons served. DHS has determined that the denial of your license is appropriate based on the violations identified above and the program evaluation. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. YOUR RIGHT TO APPEAL You have the right to appeal the denial. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 20 calendar days from when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: 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 Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for two years. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.05, subdivision (a), which describes under which conditions DHS may deny an application. · “Controlling individual” is defined under Minnesota Statutes, section 245A.02, subdivision 5a. · License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (2), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has been denied a license under this chapter within the past two years. Questions If you have any further questions regarding this matter, you may contact Kathryn Schesso, Supervisor, at 651-431-2734. Sincerely,
Katie Leuer, Unit Manager Licensing Division Office of Inspector General
|
