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July 24, 2025
Mae Pearl Maurer Rogers, Authorized Agent Recovery Center LLC 109 Washburne Avenue Paynesville, MN 56362 License Number: 1098227 (245G) Compliant numbers: 202502149 AMENDED CORRECTION ORDER NOTICE: This Amended Correction Order supersedes a Correction Order issued April 24, 2025, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on April 24, 2025. This Amended Order reflects the final decision on the request for reconsideration issued on July 1, 2025. Dear Mae Pearl Maurer Rogers: On March 12 and 13, 2025 a Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Recovery Center located at 109 Washburne Avenue, Paynesville, MN 56362. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment services 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 for receiving public funding reimbursement from the commissioner for services provided. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.05, subdivision 1, paragraph (d) and 254B.052 as follows: a. The license holder was not an eligible vendor to deliver peer recovery support services to clients once discharged from substance use disorder treatment. License holder billed for peer recovery support services after the client (client file numbered 5) was discharged on October 16, 2024 for the following dates: January 2, 3, 4, 8, 9, 10, 12, 15, 22, 23, 24, 25, and 28, 2025; and b. Documentation of peer recovery services did not meet requirements as a billable treatment service for peer recovery support services. The documentation did not describe which specific goal in the treatment plan was discussed and addressed or reflect a conversation pertaining to recovery. The documentation only described a task completed that is not defined as a treatment service in Minnesota Statutes, chapter 245G.07 for the following: a. Urinalysis collection on: 1. December 9 ,13, 16, 18, 30, 2024 and January 1, 6, 8, 10, 13, 17, and 20, 2025 (client file numbered 4); and 2. October 10, 16, 23, and 30, 2024 (client file numbered 2); and b. Transportation on: 1. January 20 and 21, 2025 (client file numbered 4); and 2. October 14 and 24, 2025 (client file numbered 2). Statute Violated: Minnesota Statutes, 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 in the amount 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 have the current Vulnerable Adult Maltreatment Reporting policies and procedures posted in their main location. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that Vulnerable Adult Maltreatment Reporting policies and procedures meets all applicable requirements. 3. Violation: The license holder’s service termination policy did not address procedures consistent with Minnesota Statutes, section 253B.16, subdivision 2, that staff members must follow when a client admitted under Minnesota Statutes, Chapter 253B (civil commitment), is to have services terminated. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that their termination policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy that meets all applicable requirements. 4. Violation: The license holder client rights protection policy and procedures did not contain the client rights as identified in Minnesota Statutes, section 253B.03. Statute Violated: Minnesota Statutes, sections 245G.12 and 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the client rights protection policy meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy that meets all applicable requirements. 5. Violation: A controlling individual did not annually review and sign the plan for transfer of clients and records upon closure for January 2025. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the client rights protection policy meets all applicable requirements. Within 30 days of receipt of this order, submit verification that the transfer of clients and records upon closure plan was reviewed and signed. Client files 6. Violation: Four out of four client files reviewed for requirements governing comprehensive assessments did not requirements under Minnesota Statutes, section 245I.10, subdivision 6, paragraphs (b) and (c). The comprehensive assessment did not contain the following: a. The client’s description of the client’s symptoms (client files numbered 4 and 5); b. The client’s history of mental health and substance used disorder treatment (client files numbered 2, 4 and 5); c. Circumstances of relapse (client file numbered 2); d. The client’s strengths (client files numbered 4 and 5) and resources (client files number 1 and 2); e. Potential brain injuries (client file numbered 5); and f. The client’s and family health history (client files numbered 1 and 4). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on June 9, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the comprehensive assessment meets all applicable requirements. 7. Violation: Four out of four client files reviewed for requirements governing the individual treatment plan contents and process did not meet requirements. The treatment plan contents, or process did not comply with the following: a. The individual treatment plan was not based on the comprehensive assessment. The treatment plan did not address health care needs identified in the comprehensive assessment (client file numbered 2); b. The individual treatment plan did not have measurable treatment objectives (client files numbered 4 and 5); and c. Identify treatment strategies to be implemented by staff (client files numbered 1, 2, 4 and 5). Statute Violated: Minnesota Statutes, section 245G..06, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on June 9, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the treatment plan contents and process meets all applicable requirements. Within 30 days of receipt of this order, submit two client treatment plans that meet all applicable requirements. 8. Violation: Three out of four client files reviewed for requirements governing treatment plan requirements for clients with co-occurring disorders (client files numbered 1, 2, and 4) did not meet requirements. The treatment plans did not have documentation of the following: a. Active interventions to stabilize mental health symptoms present in the individual treatment plans; and b. Collaboration with continuing care mental health providers and involvement of the providers in treatment planning. Statute Violated: Minnesota Statutes, section 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the requirements for clients with co-occurring disorders meets all applicable requirements. Within 30 days of receipt of this order, submit two treatment plans that demonstrate compliance with co-occurring treatment plan requirements. 9. Violation: One of four client files reviewed for requirements of documentation of treatment services (client file numbered 3) did not meet requirements as follows: a. Documentation of treatment services were not completed within seven days of providing the treatment service as follows: a. Group sign in sheets from February 23, 2025 show client attended 6 hours of group treatment; however, there is no corresponding documentation; and b. Client attendance log on February 3, 2025 shows client received one hour of peer recovery support services; however, there is no corresponding documentation. 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. 10. Violation: Three of three client files reviewed for requirements governing client record documentation of did not meet requirements in the following ways: a. Discharge summary identifies several significant events that were not documented within the client file (client file numbered 1); and b. Client record was not accurate as follows: a. The discharge summary had wrong date of admission (client file numbered 2); b. The documentation of treatment services had conflicting information on type of treatment service provided (client file numbered 1 and 2); c. The documentation of treatment services had conflicting information amount of treatment service provided (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraphs (a) and (c). Repeat Violation: In a Correction Order that DHS issued on June 9, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the client record documentation meets all applicable requirements. 11. Violation: One out of three client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan review for November 23 through 29, 2024 was completed late on December 10, 2024 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3a, paragraph (e). Repeat Violation: In a Correction Order that DHS issued on June 9, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the frequency of treatment plan reviews meets all applicable requirements. Personnel Files 12. Violation: Four of six personnel files reviewed for requirements governing orientation and training did not meet requirements. No documentation of the following: a. Orientation training within 24 working hours to policies and procedures (personnel files numbered 3 and 6); and b. Annual training on the following: a. Mandatory reporting as specified in sections 245A.65, 626.557, and 626.5572, including specific training covering the license holder's policies for obtaining a release of client information for January 2025 (personnel filed numbered 1); and b. License holder’s program abuse prevention plan for calendar year 2024 (personnel files numbered 1, 4, 5 and 6). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivisions 1 and 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation and training meets 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.eppel@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer Eppel Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Final Agency Decision As stated, above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated April 24, 2025. As such, the decision is not subject to appeal. 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 651-431-6671 or maura.mcgarry@state.mn.us Sincerely, Maura McGarry, Licensor Supervisor Licensing Division Office of Inspector General
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