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June 4, 2025 Kristine Swanson, Authorized Agent Center for Alcohol and Drug Treatment 314 W Superior St Ste 400 Duluth, MN 55802 License Number: 801491 CORRECTION ORDER Dear Kristine Swanson: On March 24, 25, 26, and 27, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Howard Friese Hillside located at 2211 Greysolon Rd, Duluth, MN 55812. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment statutes 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 failed to follow licensing rules and statutes, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements governing grievance procedures. The grievance procedure did not include the current telephone number for the Minnesota Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 2. Violation: The license holder did not meet requirements governing client rights. The license holder did not protect client’s rights according to Minnesota Statutes, section 144.651, subdivision 23. The license holder required residents to perform labor for the facility and those activities were not included for therapeutic purposes and appropriately goal-related in the client’s individual medical records. Through staff and client interviews and review of the program’s policy entitled Residential House Guidelines, the program’s practice was to require all clients to clean the communal bathrooms, laundry room, and kitchen; stock supplies, vacuum, and cook. If assigned chores were not completed, clients were given a consequence, which could include a requirement to complete additional chores, wash additional dishes, be given the last choice of communal chores, be given an early curfew, or be restricted from leaving the property; These chore requirements were not identified in clients’ individual treatment plans. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights meet all applicable requirements. Within 30 days of receipt of this order, submit updated client rights policies that meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing treatment service descriptions. The treatment services description did not include the following: a. A description and amount of the following types of services: 1. Stress management and physical well-being; 2. Living skills development; 3. Socialization skills development; and 4. Peer recovery support services; and b. Identification of the categories or types of service provided through telehealth. Statute Violated: Minnesota Statutes, section 245G.07, subdivisions 2 and 4, paragraph (c) and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing medical services. The medical services policy did not include procedures for acceptance of a prescription. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that the medical services policy meets all applicable requirements. Within 30 days of receipt of this order, submit a medical services policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing HIV policies and procedures. The policies and procedures were not consistent with the HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19 and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that HIV minimum standards meet all applicable requirements. Within 30 days of receipt of this order, submit HIV minimum standards that meet all applicable requirements. 6. Violation: The license holder did not meet requirements governing behavioral emergency procedures. The procedures did not incorporate person-centered planning and trauma-informed care. Statute Violated: Minnesota Statutes, section 245G.16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that behavioral emergency procedures meet all applicable requirements. Within 30 days of receipt of this order, submit behavioral emergency procedures that meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adult internal reviews. Two of six internal reviews were not completed within 30 days when the facility had reason to know a report of alleged or suspected maltreatment was made on May 24 and June 4, 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult internal reviews meet all applicable requirements. 8. Violation: The license holder did not meet requirements governing responsible staff members. The treatment director did not designate a staff member who, when present in the facility, is responsible for the delivery of treatment service. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that responsible staff member designations meet all applicable requirements. Client Files 9. Violation: Two of three client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment did not include: 1. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client file numbered 2); 2. Important developmental incidents in the client’s life (client file numbered 1); and 3. The client’s family health history (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 10. Violation: One of three client files reviewed for requirements governing individual treatment plans (ITP) (client file numbered 2) did not meet requirements in the following ways: a. The ITP was not completed within ten days from the day of service initiation; and b. The ITP did not document the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all requirements. 11. Violation: Two of three client files reviewed for requirements governing documentation of treatment services did not meet requirements. The entries in the client’s record did not document the following: a. Amount of treatment service provided for July 10, 11, 12, August 6, 7, 8, 9, 26, 27, and 28, 2024 (client file numbered 1); and b. The client’s response for December 17, 2024 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. 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: One of three client files reviewed for requirements governing client record documentation (client file numbered 1) did not meet requirements. The license holder did not document a significant event that occurred on September 1, 2024, within 24 hours of the event. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 13. Violation: One of three client files reviewed for requirements governing discharge summaries (client file numbered 2) did not meet requirements. The service discharge summary was not completed within five days of the client’s service termination. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. 14. Violation: Three of three client files reviewed for client property management (client files numbered 1 through 3) did not meet requirements. There was no documentation of disbursement of the person’s funds or other property at the time of disbursement, including the person’s signature, or the signature of the conservator or payee. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client property management meets all applicable requirements. Within 30 days of receipt of this order, submit one documentation of disbursement of a person’s funds or other property from a recently discharged client that meets all applicable requirements. Personnel Files 15. Violation: One of six personnel files reviewed for requirements governing annual trainings (personnel file numbered 7) did not meet requirements. There was no documentation of the following annual trainings for calendar year 2024: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; and b. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual trainings meet all applicable requirements. 16. Violation: Three of six personnel files reviewed for requirements governing personnel file contents did not meet requirements. The written annual review of the staff member’s job performance was not completed for calendar years: a. 2023 (personnel file numbered 4); b. 2024 (personnel files numbered 4 and 6); and c. 2025 (personnel file numbered 2). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents 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 your 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 651-431-5843 or at Kayla.Northrop@state.mn.us. Sincerely, Kayla Northrop, Licensor Licensing Division Office of Inspector General
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