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July 14, 2025 Asad Hassan, Authorized Agent Summit Integrated Services 4205 Lancaster Lane North, Suite 100 Plymouth, MN 55441-1702 License Number 1120695 CORRECTION ORDER Dear Asad Hassan: On June 2 through 4, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 4205 Lancaster Lane North, Suite 100, Plymouth, MN 55441-1702. As a result of this visit, DHS determined that you are in violation of substance use disorder treatment services 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. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. a. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c) for higher rates for services provided to individuals with co-occurring mental health and substance use disorder problems. There was no documentation of the following: i. Diagnostic assessment completed within 10 days of admission (client files numbered 1 through 3); and ii. Co-occurring counseling staff receiving 8 hours of co-occurring disorder training annually for calendar year 2025 (personnel file 1); b. Peer recovery support services were not provided in accordance with Minnesota Statutes, section 254B.052. Peer recovery services were not offered on a one-on-one basis on the following dates: i. September 25, 2024 (client file numbered 21); ii. September 26, 2024 (client files numbered 1, 21, and 22); iii. October 21, 2024 (client files numbered 1, 21, and 22); iv. February 12, 2025 (client file numbered 23); v. March 19, 2025 (client file numbered 24); vi. May 14, 2025 (client file numbered 17); and vii. May 15, 2025 (client file numbered 14); and Statute Violated: Minnesota Statute, sections 245A.167 and 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services are provided according to the applicable requirements for which they are billed. The noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the services; disenrollment in the public payment program; or other administrative, civil, or criminal penalties provided by law. 2. Violation: The license holder did not meet requirements governing policy and procedures manuals. The manual did not contain procedures for reporting the maltreatment of minors according to Minnesota Statute, chapter 260E. Statute Violated: Minnesota Statute, section 245G.12. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program’s policy and procedure manual meets all requirements. Within 30 days of receipt of this order, submit a maltreatment of minors reporting policy that meets all applicable requirements. Personnel Files 3. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit did not meet requirements (personnel file numbered 2). There was no documentation of the amount and type of supervision provided on at least a weekly basis for the weeks of April 1, 7, 14, 21, and 28, and May 5, 19, and 26, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements regarding individuals with a temporary permit meet all applicable requirements. Within 30 days of receipt of this order, submit 3 weeks of supervision documents that meet all applicable requirements. 4. Violation: Two of two personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual training for calendar years 2025 (personnel files numbered 1 and 4) on: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of client information; and ii. HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19, 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 comply with staff development requirements. Within 30 days of receipt of this order, submit documentation which demonstrates that the above personnel completed annual training that meets requirements. 5. Violation: Four of four personnel files reviewed for requirements governing personnel files did not meet requirements. There was no documentation of the following: a. The date that the employee first had contact with a person served by the program (personnel file numbered 1); b. A completed application for employment signed by the staff member (personnel files numbered 1 through 3); and c. A job performance evaluation completed for calendar year 2025 (personnel files numbered 1 and 4). Statute Violated: Minnesota Statute, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all personnel file requirements. Client Files 1. Violation: Two of two client files reviewed for requirements governing the contents of client records did not meet requirements. The following client education was not provided with the commissioner approved materials for: a. Opioid treatment options (client files numbered 1 and 2); and b. Tuberculosis (client file numbered 1). Statute Violated: Minnesota Statute, sections 245G.04, subdivision 3 and 245G. 09, subdivision 13. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures are followed and meet all requirements. 2. Violation: One of two client files reviewed for requirements governing client orientation (client file numbered 1) did not meet requirements. There was no documentation that the client was oriented to the internal and external vulnerable adult maltreatment reporting procedures within 24 hours of admission to the program. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that orientation to vulnerable adult maltreatment reporting policies meets all requirements. 3. Violation: Nineteen of twenty-two client files reviewed for requirements governing service initiation did not meet requirements in the following ways: a. The initial service plan and vulnerable adult determination was not completed within 24 hours of the day of service initiation (client files numbered 1 through 10 and 12 through 20); b. The initial service plan did not identify treatment needs to be addressed between the day of service initiation and development of the individual treatment plan (client files numbered 1). Statute Violated: Minnesota Statute, section 245G.04, subdivisions 1 and 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that initial service plans and vulnerable adult determinations meet all applicable requirements. Within 30 days of receipt of this order, submit initial service plans and vulnerable adult determinations, including date of service initiation, from two client files that meet all requirements. 4. Violation: One file reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways (client file numbered 3): a. The IAPP was not completed as part of the initial individual service plan; b. The IAPP did not assess the person’s susceptibility to abuse by other individuals, including other vulnerable adults; c. The IAPP did not assess the person’s risk of abusing other vulnerable adults; and d. There was no documentation that the person participated in the development of the IAPP to the full extent of the person’s abilities. Statute Violated: Minnesota Statute, sections 245A.65, subdivision 1, paragraph (b) and 245G.04, subdivision 2, paragraph (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. 5. Violation: Ten of twenty-two client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed by the end of the fifth day on which a treatment service was provided and there was no documentation identifying the client-centered reason why the assessment was not completed within this timeframe (client files numbered 1, 2, 4, 5, 9, 11 through 13, and 15); b. There was no documentation of a review of the comprehensive assessment and an update as clinically necessary to ensure compliance with Minnesota Statutes, section 245G.05, subdivision 1 when the client received a comprehensive assessment that authorized the treatment service (client file numbered 3); and c. The comprehensive assessment did not include the following: i. The client’s current medications (client file numbered 1); ii. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client file numbered 1); iii. The client's relationship with the client's family and other significant personal relationships, including the client's evaluation of the quality of each relationship (client files numbered 1 and 2); iv. The client's resources, including the extent and quality of the client's social networks (client file numbered 2); v. Important developmental incidents in the client's life (client file numbered 2); and vi. The client's family health history (client file numbered 1). Statute Violated: Minnesota Statute, section 245G.05. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 6. Violation: Two of three client files reviewed for requirements governing individual treatment plans did not meet requirements in the following ways: a. A change to the individual treatment plan was not signed by the alcohol and drug counselor (client file numbered 1); and b. A change to the individual treatment plan was not signed by the client (client file numbered 2). Statute Violated: Minnesota Statute, sections 245G.06, subdivision 1 a Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 7. Violation: Three of three client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Documentation was not completed within seven days of providing the treatment service on August 30, 2024 (client file numbered 1); b. Client documentation did not include: i. Client response for the following dates: 1. February 19, 2025 (client file numbered 1); and 2. March 14, 2025 (client file numbered 2); and ii. Job title of the staff person making the entry for the following timeframes: 1. August 22, October 29, 2024, and February 3 through 6, 10 through 13, 18, and 19, 2025 (client file numbered 1); 2. March 13 and April 21 and 23 through 25, 2025 (client file numbered 2); and 3. May 21 and 22, 2025 (client file numbered 3); and c. Treatment plan review entries in the client record did not have the accurate span of time covered by the review for the following dates: i. October 1, 2024, and February 12, 2025 (client file numbered 1); and ii. May 19, 2025 (client file numbered 2). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 2a and 2b, paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 8. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review did not document: i. A time span covered by the review for the treatment plan review dated February 13, 2025 (client file numbered 1); ii. Client goals addressed since the last treatment plan review on; 1. March 14, 2025 (client file numbered 1); and 2. May 19, 2025 (client file numbered 2); iii. Monitoring of any physical and mental health problems on March 14, 2025 (client file numbered 1); iv. Participation of others involved in the individual’s treatment planning on March 14, 2025 (client file numbered 1); v. If changes to the treatment plan on determined to be necessary on March 14, 2025 (client file numbered 1); vi. A review and evaluation of the IAPP on March 14, 2025 (client file numbered 1); and vii. Document any referrals made since the last treatment plan review on March 14, 2025 (client file numbered 1); and b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1 intensive outpatient. There was no documentation of a treatment plan review due on the following dates: i. August 31 and November 30, 2024, and April 13, 2025 (client file numbered 1); and ii. April 6 and May 6, 2025 (client file numbered 2). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 3 and 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. 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.White@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer White 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 Statute, chapter 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 651-431-6282. Sincerely,
Jennifer White Licensor II Licensing Division Office of Inspector General
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