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July 8, 2025 Marlin Martin, Authorized Agent BHG Brainerd Treatment Center dba Valhalla Place Brainerd 5001 Spring Valley Road STE 600E Dallas, TX 75244-8217 License Number: 1108974 (245G) CORRECTION ORDER Dear Marlin Martin: On April 30 through May 2, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at BHG Brainerd Treatment Center located at 2215 S 6th Street, Brainerd MN, 56401. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment 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. Personnel Files 1. Violation: Three of three personnel files reviewed for requirements governing annual staff training did not meet requirements. There was no documentation of annual trainings completed for the calendar year 2025 as follows: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E (personnel file numbered 3); b. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 3); and c. HIV minimum standards (personnel files numbered 2, 3 and 4). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual trainings meet all applicable requirements. PO Box 64242 * Saint Paul, Minnesota * 55164-0242 * An Equal Opportunity Employer https://mn.gov/dhs/general-public/licensing/ 2. Violation: One of three personnel files reviewed for requirements governing personnel file contents (personnel file numbered 2) did not meet requirements. There was no written annual review of the staff members job performance for the calendar year 2024. Statute Violated: Minnesota Statutes, sections 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. Client Files 3. Violation: One of three client files reviewed for requirements governing initial services plan (client file numbered 4) did not meet requirements. The initial service plan was not completed within 24 hours of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements. 4. Violation: One of three client files reviewed for requirements governing vulnerable adult determinations (client file numbered 4) did not meet requirements. The vulnerable adult determination was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (a) and 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult determinations meet all applicable requirements. 5. Violation: Two of three client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include: a. The clients age (client file numbered 4); b. The client’s health history and the client’s family health history, including the client’s chemical health history (client file numbered 2); and c. Diagnosis of a substance use disorder or a finding that the client does not meet the criteria for a substance use disorder (client file numbered 2). 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. 6. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not developed within 21 days from the day of service initiation (client file numbered 2); 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 (client files numbered 1 through 3 and 5). Statute Violated: Minnesota Statutes, section 245G.06 subdivisions 1and 1a. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated December 17, 2024 · Order of Conditional Licensed dated October 02, 2023 Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit one ITP that meets all applicable requirements. 7. Violation: One of four client files reviewed for requirements governing treatment plan reviews (client file numbered 2) did not meet requirements. Treatment plan reviews were not completed weekly for the ten weeks following completion of the treatment plan. There was no documentation of a treatment plan review for the weeks beginning November 25, 2024, December 2, 9, 16, 23 and 30, 2024 and January 6, 2025. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3a, paragraph (f). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated December 17, 2024 · Order of Conditional Licensed dated October 02, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 8. Violation: One of five client files reviewed for client records (client file numbered 1) did not meet requirements. The license holder did not accurately document in clients discharge summary living arrangements upon discharge. Statute Violated: Minnesota Statutes, section 245G.09 subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client records meet all applicable requirements. 9. Violation: Four of four client files reviewed for requirements governing discharge summaries did not meet requirements as follows: a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 2); and b. The discharge summaries did not include the following information: i. The client’s issues, and needs while participating in treatment, including services provided (client file numbered 1 and 2); ii. The client’s strengths (client file numbered 2); iii. The client’s progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 3); iv. A risk rating and description for each of the ASAM six dimensions (client file numbered 4); and v. Continuing care recommendations, including transitions between more or less intense services or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health, as needed (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated December 17, 2024 · Order of Conditional Licensed dated October 02, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Within 30 days of receipt of this order, submit one discharge summary that meets all applicable requirements. 10. Violation: One of three client files reviewed for requirements governing central registry requirements (client file numbered 1) did not meet requirements. The information submitted to the state central registry did not include current or previous enrollment status in another opioid treatment program. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on December 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 central registry meets all applicable requirements. 11. Violation: One of three client files reviewed for requirements governing the prescription monitoring program (PMP) (client file numbered 1) did not meet requirements as follows: a. The medical director or medical directors delegate did not review PMP data at least every 90 days. The PMP review was due December 9, 2024, and was not completed until January 6, 2025; and b. There was no documentation of the copy of the PMP data reviewed on September 9, 2024, and January 6, 2025. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated December 17, 2024 · Order of Conditional Licensed dated October 02, 2023 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing the prescription monitoring program are met. 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.eppel@state.mn.us or by mail: · Commissioner, Department of Human Services ATTN: Jen Eppel 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 in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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: Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This substance use disorder treatment program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes 245G. · 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 651-431-6698. Sincerely, Jennifer Eppel, Licensor II Licensing Division Office of Inspector General
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