Transcript Document

Riders on the Storm
Rule 31 compliance in the first nine
months
• Presented by Rick Moldenhauer, MS,
LADC, ICADC, LPC
Treatment Services Consultant/State
Methadone Authority
P: (651) 431 2474
F: (651) 431 7449
Chemical Health Division, DHS
PO Box 64977
St Paul, Minnesota 55164-0977
[email protected]
RULE 31
TABLE OF CONTENTS
Part Number
Title
9530.6405
Definitions
9530.6410
Applicability
9530.6415
Licensing Requirements
9530.6420
Initial Service Plans
9530.6422
Comprehensive Assessment
9530.6425
Individual Treatment Plans
9530.6430
Treatment Services
9530.6435
Health Care Services
9530.6440
Client Records
9530.6445
Staffing Requirements
9530.6450
Staff Qualifications
9530.6455
Provider Policies and Procedures
9530.6460
Personnel Policies and Procedures
9530.6465
Service Initiation and Termination Policies
9530.6470
Policies and Procedures/Client Rights
9530.6475
Emergency Procedures
9530.6480
Evaluation
9530.6485
Additional Requirements/Adolescents
9530.6490
Additional Requirements/Clients with Children
9530.6495
Additional Requirements/Co-occurring Mental Health
9530.6500
Additional Requirements/Methadone
9530.6505
Additional Requirements/Room and Board
Rule 31 Programs as of 09/30/05
• # of programs: 280
• # serving adolescents:
133
• # serving clients with
children: 1
• # serving cooccurring: 4
• # serving methadone:
7
• # providing room and
board: 89
Rule 31 Program surveys released as
of 9/30/05
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# of programs: 44
# total citations 1338
Mean: 30.41
Range 1-117
Generally Speaking
• Six stated they had not
prepared for Rule 31
• Three were given
Conditional Licenses
• 1338 total citations to date
(09/29/05)
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•
•
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•
•
•
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44 released 1/1/05-9/30/05
Jan 05: none
Feb 05: 7
March 05: 6
April 05: 7
May 05: 4
June 05: 8
July 05: 4
August 05: 7
Sept 05: 1
Analysis by section
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•
•
•
•
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1) Postings/Physical plant
2) Policies, Procedures and Practices
3) Vulnerable Adult
4) Client Recordkeeping
5) Personnel Policies
6) Staffing Requirements
7) Personnel Files
8) Client Records
Citations by month
• Jan:
• Feb:
11,12,10,12,34,30,28
• Mar: 35, 19, 99, 111,
30
• Apr: 26, 5, 9, 25, 21,
113, 9
• May: 8, 26, 22, 15
• June: 25, 27, 20, 18,
22, 1, 18, 15,
• July: 23, 19, 19, 1
• Aug: 1, 1, 21, 117,
117, 117, 24 1,
• Sept: 18
LICENSING REVIEW REPORT AND CORRECTION ORDER
Date Correction Order Issued: _________________ License Holder Representative who received this report: __________________________
Program Name: ________________________________
Address: _________________________________________________________
License Number: _______________ Type of License: _______________ Licensor(s): __________________________________________
 Initial Licensing Review

 Full Review
Announced Visit
 Modified Review
Unannounced Visit
VIOLATIONS AND CORRECTION ORDERS
At the time of the licensing review on ______________________________________________, the following _______ violation(s) of state and (or) federal laws
and rules were observed. Each violation is identified in numerical order in the first column titled “Violation Number.”
Violations that were corrected during the licensing review are indicated in the sixth column titled "Corr. on Site." During the licensing review, ________
violation(s) were corrected and no further corrective action is necessary. These violations are listed to assist in ensuring ongoing compliance with all applicable
rule requirements.
Violations that were included in the Order from the last licensing review, and any subsequent Order(s) issued by DHS Licensing, are identified by a check in the
third column, titled “Prev. Cited.”
Compliance with licensing requirements are indicated in the fifth column, titled “Item met or not met” using the following codes: (+) denotes that there was no
violation of the applicable law or rule; (-) denotes a violation of the applicable law or rule; (NR) denotes the applicable law or rule was not reviewed and (NA)
denotes the law or rule was not applicable.
CORRECTIVE ACTION ORDERED FOR VIOLATIONS
For those violation(s) that were not corrected during the licensing review, corrective action for each violation is required by Minnesota Statutes, section 245A.06,
and is hereby ordered by the Commissioner of Human Services. Beginning immediately, and on a continuing basis, you must ensure compliance with all
applicable laws and rules. Evidence of correction must be submitted to DHS Licensing by _______________________ only for those violations that are
identified by a check in the seventh column entitled "Submission Required." All documentation and other evidence of compliance required by this correction
order must be submitted to the Department of Human Services, Division of Licensing, 444 Lafayette Road, St. Paul, Minnesota 55155-3842. Failure to correct
the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections
245A.06 and 245A.07.
Postings
Postings
Maltreatment of Minors
MALTREATMENT OF MINORS REPORTING POLICY
Who Should Report Child Abuse and Neglect

Any person may voluntarily report abuse or neglect.

If you work with children in a licensed facility, you are legally required or mandated to report and cannot shift
the responsibility of reporting to your supervisor or to anyone else at your licensed facility. If you know or have
reason to believe a child is being or has been neglected or physically or sexually abused within the preceding
three years you must immediately (within 24 hours) make a report to an outside agency.
Where to Report

If you know or suspect that a child is in immediate danger, call 911.

All reports concerning suspected abuse or neglect of children occurring in a licensed facility should be made to
the Department of Human Services, Licensing Division’s Maltreatment Intake line at (651) 297-4123.

Reports regarding incidents of suspected abuse or neglect of children occurring within a family or in the
community should be made to the local county social services agency at ________________ or local law
enforcement at _______________.

If your report does not involve possible abuse or neglect, but does involve possible violations of Minnesota
Statutes or Rules that govern the facility, you should call the Department of Human Services, Licensing Division
at (651) 296-3971.
What to Report

A report to any of the above agencies should contain enough information to identify the child involved, any
persons responsible for the abuse or neglect (if known), and the nature and extent of the maltreatment and/or
possible licensing violations. For reports concerning suspected abuse or neglect occurring within a licensed
facility, the report should include any actions taken by the facility in response to the incident.

An oral report of suspected abuse or neglect made to one of the above agencies by a mandated reporter must
be followed by a written report to the same agency within 72 hours, exclusive of weekends and holidays.
Retaliation Prohibited
An employer of any mandated reporter shall not retaliate against the mandated reporter for reports made in good
faith or against a child with respect to whom the report is made. The Reporting of Maltreatment of Minors Act
contains specific provisions regarding civil actions that can be initiated by mandated reporters who believe that
retaliation has occurred.
Failure to Report
A mandated reporter who knows or has reason to believe a child is or has been neglected or physically or sexually
abused and fails to report is guilty of a misdemeanor. In addition, a mandated reporter who fails to report
maltreatment that is found to be serious or recurring maltreatment may be disqualified from employment in
positions allowing direct contact with persons receiving services from programs licensed by the Department of
Human Services and by the Minnesota Department of Health, and unlicensed Personal Care Provider
Organizations.
THIS REPORTING POLICY SHOULD BE POSTED IN A PROMINENT LOCATION AND BE MADE AVAILABLE
UPON REQUEST.
Vulnerable Adult
MALTREATMENT OF VULNERABLE ADULTS REPORTING POLICIES
In Chemical Dependency Rehabilitation Programs federal law specifically prohibits a person from disclosing patient
identifying information in connection with a report of suspected maltreatment, unless the vulnerable adult, or the
vulnerable adult's guardian, conservator, or legal representative, has consented to disclosure in a manner which
conforms to federal requirements. All residents are covered by this federal law. Verify that upon the resident's
admission to the facility the resident , or a guardian, conservator, or legal representative has given written consent
to the disclosure of suspected maltreatment. If no written consent is in the client’s file, you must immediately seek
consent to make a report and are prohibited by federal law from reporting the incident of suspected maltreatment
without that consent.

If you know or suspect that a vulnerable adult has been maltreated, you must report it
immediately (within 24 hours).

You can report to the Common Entry Point at _______________________ (phone number).

Or, you can report internally to (name or position) _________________________________.
If the individual listed above is involved in the alleged or suspected maltreatment, you must
report to ___________________________________ (name or position).

When an internal report is received, _____________________________ (name or position)
is responsible for deciding if the report must be forwarded to the Common Entry Point.
If that person is involved in the suspected maltreatment, __________________________
(name or position) will assume responsibility for deciding if the report must be forwarded to
the Common Entry Point. The report must be forwarded within 24 hours.

If you have reported internally, you will receive, within two working days, a written notice that
tells you whether or not your report has been forwarded to the Common Entry Point. The
notice will be given to you in a manner that protects your identity. It will inform you that, if
you are not satisfied with the facility’s decision on whether or not to report externally, you
may still make the external report to the Common Entry Point yourself. It will also inform you
that you are protected against any retaliation if you decide to make a good faith report to the
Common Entry Point.

An internal review of the report must be completed if the facility has reason to know that an
internal or external report of alleged or suspected maltreatment has been made. The review
will be completed by _________________________________ (name or position). If this
individual is involved in the alleged or suspected maltreatment, _____________________
(name or position) will be responsible for completing the internal review.

The internal review must include: whether related policies and procedures were followed;
whether the policies and procedures were adequate; whether there is a need for additional
staff training; and whether further action is necessary to protect the health and safety of
vulnerable adults.

The internal review must be documented, and made available to the Commissioner of the
Department of Human Services upon request.
THIS REPORTING POLICY MUST BE POSTED IN A PROMINENT LOCATION, AND BE
MADE AVAILABLE UPON REQUEST.
4747.1500
http://www.revisor.leg.state.mn.us/arule/4747/1500.html
626.556
http://www.revisor.leg.state.mn.us/stats/626/556.html
626.557
http://www.revisor.leg.state.mn.us/stats/626/557.html
626.5572
http://www.revisor.leg.state.mn.us/stats/626/5572.html
144.651
http://www.revisor.leg.state.mn.us/stats/144/651.html
Policies, Procedures and
Practices
Policies, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
ADDITIONAL CLIENT RIGHTS POLICIES AND PROCEDURES
RESIDENTIAL PROGRAMS (continued)
9530.6505,
subpart 3,
items A-D
(continuted)
Comments:
Client Property Management (continued)
D. The license holder returned all property held in trust to the client
upon service termination regardless of the client's service termination
status, except:
. (1) drugs, drug paraphernalia, and drug containers that are forfeited under
Minnesota Statutes, section 609.5316, were destroyed by staff or given over to
the custody of a local law enforcement agency, according to Code of Federal
Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67-1;
. (2) weapons, explosives, and other property which can cause serious harm
to self or others were given over to the custody of a local law enforcement
agency, and the client was notified of the transfer and the right to reclaim any
lawful property transferred; and
. (3) medications that were determined by a physician to be harmful after
examining the client, except when the client's personal physician approved the
medication for continued use.
Item
met
or
not
met
Notes
Submission
Required
Requirement

Applicable
Law or Rule
Corr. on site

Violation
Number
Prev. Cited

Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Polices, Procedures and Practices
Vulnerable Adult Maltreatment
Prevention and Reporting Policies
Vulnerable Adult Maltreatment
Vulnerable Adult Maltreatment
Vulnerable Adult Maltreatment
Vulnerable Adult Maltreatment
Policies, Procedures and
Practices-Client Recordkeeping
Client Recordkeeping
Personnel Policies, Procedures
and Practices
Personnel Policies,
Procedures and Practices
PERSONNEL POLICIES, PROCEDURES and PRACTICES
ALL PROGRAMS - continued
9530.6460,
subpart 1,
items A-G
(continued)
D. described behavior that constitutes grounds for disciplinary
action, suspension or dismissal, including:
policies that address chemical use problems and that stated
the timeline requirements for freedom from chemical use
problems described in part 9530.6450, subpart 1. (Two years for
treatment directors, supervisors, nurses, counselors, and other professionals.
One year for paraprofessionals and all other staff with direct client contact. The
time period begins to run on the date the employee begins receiving treatment
services or the date of the last incident.)
policies prohibiting personal involvement (sexual contact) with
clients or former clients within two years of receiving
psychotherapy, in violation of Minnesota Statutes, chapter 148A.
 policies
prohibiting client abuse as specified under Minnesota
Statutes, sections 245A.65, 626.556, 626.557, and 626.5572;
E. listed behaviors or incidents that are considered chemical use
problems that included:
1. receiving treatment for chemical use within the period
specified for the position in the staff qualification requirements;
2. chemical use that has a negative impact on the staff
member's job performance;
3. chemical use that affects the credibility of treatment
services with clients, referal sources, or other members of the
community; and
(4) symptoms of intoxication or withdrawal on the job.
Notes
Submission
Required
Item
met
or
not
met

Requirement
Corr. on site

Applicable
Law or Rule
*
Violation
Number
Prev. Cited

Personnel Policies,
Procedures and Practices
Personnel Policies,
Procedures and Practices
Staffing Requirements
Staffing Requirements
Staffing Requirements
Staffing Requirements
Staffing Requirements
Personnel Files
Personnel Files
Personnel Files
Personnel Files
Personnel Files
Personnel Files
ALCOHOL AND DRUG COUNSELOR
QUALIFICATIONS
ALL PROGRAMS continued
9530.6450,
subpart 5,
item B
*
File A File B File C File D File E
B. The personnel file of alcohol and drug counselor
exempt under Minnesota Statutes, chapter 148C,
contained documentation of competence, as evidenced
by one of the following:
(1) completion of at least a baccalaureate degree with a
major or concentration in social work, nursing, sociology,
human services, or psychology, or licensure as a
registered nurse; successful completion of a minimum of
120 hours of classroom instruction in which each of the
core functions listed in Minnesota Statutes, chapter
148C, is covered; and successful completion of 440
hours of supervised experience as an alcohol and drug
counselor, either as a student or as a staff member;
(2) completion of 270 hours of alcohol and drug
counselor training in which each of the core functions
listed in Minnesota Statutes, chapter 148C, is covered,
and successful completion of 880 hours of supervised
experience as an alcohol and drug counselor, either as a
student, or as a staff member;
(3) current certification as an alcohol and drug counselor
or alcohol and drug counselor reciprocal, through the
evaluation process established by the International
Certification and Reciprocity Consortium Alcohol and
Other Drug Abuse, Inc., and published in the Case
Presentation Method Trainer's Manual, copyright 1993;
Requirement
Personnel Files
Submission
Required 
Applicable
Law or Rule
Corr. on site
Violation
Number
Prev. Cited

(4) completion of a bachelor's degree including 480
hours of alcohol and drug counseling education from an
accredited school or educational program and 880 hours
of alcohol and drug counseling practicum; or
Notes
Personnel Files
Personnel Files
Personnel Files
Personnel Files
Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
Requirement
Client Files
COMPREHENSIVE ASSESSMENT
ALL PROGRAMS (continued)
File 1 File 2 File 3 File 4 File 5
Notes
D. chemical use history including amounts and types of chemicals
used, frequency of use, and period of abstinence;
E. specific problem behaviors exhibited by the client when under the
influence of chemicals;
F. current family status, family history, including history or presence
of physical or sexual abuse, level of family support, and chemical
use, abuse, or dependency among family members and significant
others;
G. physical concerns or diagnoses that may influence the treatment
plan;
H. mental health history and current psychiatric status, including
symptoms, disability, current treatment supports, and psychotropic
medications needed to maintain stability;
I. Arrests and legal interventions related to chemical use;
J. Ability to function appropriately in a work and educational setting;
K. ability to understand written treatment materials, including rules
and client rights;
L. risk-taking behavior, including behavior that puts the client at risk
of exposure to blood borne or sexually transmitted diseases;
M. social network in relation to expected support for recovery and
leisure time activities that have been associated with chemical use;
and
N. a determination whether a client is a vulnerable adult as defined in
Minnesota Statutes, section 626.5572, subdivision 21. An individual
abuse prevention plan was required for all clients who met the
definition of "vulnerable adult."
Submission
Required
Applicable
Law or Rule
Corr on site
Violation
Number
Prev. Cited

Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
Client Record Contents
RECOMMENDATIONS
The following recommendations are not requirements of Minnesota Rules or laws governing your services or facility. These
recommendations are provided to call your attention to areas where your facility or service is in minimum compliance with the
requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas.
Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to
follow recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject
to fines or action against your license.
http://www.leg.state.mn.us/leg/statutes.asp