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July 24, 2025 Sarah Opitz, Authorized Agent The Lotus Center LLC 1401 8th Street S, Suite 3 Moorhead, MN 56560 License Number: 1090378 CORRECTION ORDER Dear Sarah Opitz: On April 22, 23, 24, 25, 28, and 29, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 1401 8th Street S, Suite 3, Moorhead, MN 56560. 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 for receiving public funding reimbursement from the commissioner for services provided in the following ways: a. Group counseling was billed for services not provided as follows (client file numbered 3): i. 2 hours and 30 minutes of group counseling was documented; however, 3 hours were billed for on September 5, 2024; and ii. 2 hours of group counseling was documented; however, 3 hours were billed for on September 10, 2024; b. Treatment coordination was billed for services not provided as follows: i. 5 minutes of treatment coordination was documented; however, 15 minutes were billed for on May 31, 2024 (client file numbered 6); ii. 1 minute of treatment coordination was documented; however, 15 minutes were billed for on April 2, 2024 (client file numbered 7); and iii. 5 minutes of treatment coordination was documented; however, 15 minutes were billed for on April 9 and 12, 2024 (client file numbered 7); c. Treatment coordination services were provided by a staff member not qualified to provide the service (personnel file numbered 4) on the following dates: i. May 31, June 7, and 21, 2024 (client file numbered 6); and ii. April 2, 9, 12, and October 7, 2024 (client file numbered 7); and d. Treatment coordination was billed on October 7, 2024, prior to the client’s admission to the program (client file numbered 8). Statute Violated: Minnesota Statutes, section 245A.167. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they are billed. Additionally, 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 service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. 2. Violation: The license holder did not meet requirements governing client records. Client records were not protected against unauthorized disclosure according to Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67. Per interviews with the Treatment Director, an individual not considered staff of the licensed substance use disorder treatment program had an account in the license holder’s electronic health records system and was able to access full client records. 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 are protected against loss, tampering, or unauthorized disclosure. 3. Violation: The license holder did not meet requirements governing client rights protection. The client rights protection policy did not include rights according to Minnesota Statutes, sections 148F.165. 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 45 days of receipt of this order, submit a client rights protection policy that meets all applicable requirements. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 45 days of receipt of this order, submit a grievance procedure that meets all applicable requirements. 4. Violation: The license holder did not meet requirements for developing and monitoring implementation of program policies and procedures necessary for maintaining compliance with licensing requirements as follows: a. There was not a personal electronic device policy; b. The grievance procedure did not include the current telephone number and address of the Minnesota Board of Behavioral Health and Therapy; c. The procedures for reporting the maltreatment of minors were not consistent with Minnesota Statutes, chapter 260E; d. There were conflicting hours of operation throughout the policy manual; and e. The chart of the organizational structure indicating lines of authority and responsibilities was inconsistent with the program’s current organizational structure. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraphs (a) and (b), 245G.12, 245G.13, subdivision 1, and 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that they develop and monitor the implementation of program policies and procedures and meet all applicable requirements. Within 45 days of receipt of this order, submit a personal electronic device policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing treatment service descriptions. The treatment service description did not include the following: a. A description of individual and group counseling treatment services; b. An amount of the following types of services: i. Group counseling; ii. Treatment coordination; and iii. Peer recovery support services; c. Which services meet the definition of group counseling under Minnesota Statutes, section 245G.01, subdivision 13a; d. Which groups and topics on which a guest speaker could provide services under the direct observation of an alcohol and drug counselor; and e. The program's treatment week. Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 1 and 2, 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 45 days of receipt of this order, submit a treatment service description that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing medical services. in the following ways: a. The description of health care services did not include the program’s procedures for administering opiate antagonist medications; and b. The license holder did not have a written standing order protocol for opiate antagonists. Statute Violated: Minnesota Statutes, sections 245A.242, subdivision 2, paragraph (b) 245G.08, subdivision 3. 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 45 days of receipt of this order, submit a description of health care services that meets all applicable requirements. 7. Violation: The license holder did not meet requirements governing tuberculosis policies and procedures. The policies and procedures did not include the license holder's methods and resources to provide information on tuberculosis and tuberculosis screening to each client. Statute Violated: Minnesota Statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that tuberculosis policies and procedures meet all applicable requirements. Within 45 days of receipt of this order, submit tuberculosis policies and procedures that meet all applicable requirements. 8. 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 45 days of receipt of this order, submit HIV minimum standards that meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing behavioral emergency procedures. The behavioral emergency procedures did not include the following: a. Contact information for emergency resources that staff must consult when a client's behavior cannot be controlled by the behavioral emergency procedures; and b. Staff members authorized to implement behavioral emergency procedures. 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 45 days of receipt of this order, submit behavioral emergency procedures that meet all applicable requirements. 10. Violation: The license holder did not meet requirements governing program abuse prevention plans. The program abuse prevention plan did not include the following: a. An assessment of the population that includes the evaluation of the following factors: i. Mental functioning; ii. Physical and emotional health or behavioral health of the client; and iii. The need for training of staff to meet identified individual needs; b. An assessment of the physical plant where licensed services are provided that includes and evaluation of the existence of areas in the building which are difficult to supervise; and c. There was no documentation of annual review of the plan by the license holder’s governing body or the governing body's delegated representative review of the calendar years 2023, 2024, and 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. Within 45 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 11. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults reporting. The procedures for reporting the maltreatment of vulnerable adults did not include the following: a. The secondary person or position to whom internal reports may be made; b. The secondary person or position responsible for forwarding internal reports to the common entry point as defined in Minnesota Statutes, section 626.5572, subdivision 5; and c. The secondary person or position who will ensure that, when required, internal reviews are completed. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraphs (a) and (b) and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of vulnerable adults reporting policy meets all applicable requirements. Within 45 days of receipt of this order, submit a maltreatment of vulnerable adults reporting policy that meets all applicable requirements. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of minors reporting policy meets all applicable requirements. Within 45 days of receipt of this order, submit a maltreatment of minors reporting policy that meets all applicable requirements. 12. Violation: The license holder did not meet requirements governing personnel policies and procedures. The personnel policies did not include the following: a. Staff member retention, promotion, job assignment, or pay are not affected by a good faith communication between a staff member and the department, the Department of Health, the Ombudsman for Mental Health and Developmental Disabilities, law enforcement, or a local agency for the investigation of a complaint regarding a client's rights, health, or safety; b. Provide for a job performance evaluation based on standards of job performance conducted on a regular and continuing basis, including a written annual review; c. Describe behavior that constitutes grounds for disciplinary action, suspension, or dismissal, including policies prohibiting personal involvement with a client in violation of chapter 604, and policies prohibiting client abuse described in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E; d. Describe the process for disciplinary action, suspension, or dismissal of a staff person for violating the drug and alcohol policy described in Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c); e. Include orientation within 24 working hours of starting for each new staff member based on a written plan that, at a minimum, must provide training related to the staff member's specific job responsibilities, policies and procedures, client confidentiality, HIV minimum standards, and client needs; and f. Include policies outlining the license holder's response to a staff member with a behavior problem that interferes with the provision of treatment service. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies and procedures meet all applicable requirements. Within 45 days of receipt of this order, submit personnel policies and procedures that meet all applicable requirements. 13. Violation: The license holder did not meet requirements governing reporting a death in the program. Within 24 hours of receiving knowledge of the death of an individual served by the program, the license holder did not notify the commissioner (client files numbered 9 through 11). Statute Violated: Minnesota Statutes, section 245A.04, subdivision 16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that reporting a death in the program meets all applicable requirements. 14. Violation: The license holder did not meet requirements governing plans for transfer of clients and records upon closure. The plan did not meet requirements in the following ways: a. A controlling individual of the program did not review and sign the plan for calendar years 2023, 2024, and 2025; b. The plans for the transfer of open cases and case records did not specify arrangements the program will make to transfer clients to another provider or county agency for continuation of services and to transfer the case record with clients; and c. The plans for the transfer of closed case records were not accompanied by a signed agreement or other documentation indicating that a county or a similarly licensed provider has agreed to accept and maintain the program's closed case records and to provide follow-up services as necessary to affected clients. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure policy meets all applicable requirements. Within 45 days of receipt of this order, submit a plan for transfer of clients and records upon closure policy that meets all applicable requirements. 15. 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 16. Violation: Two of three client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation: a. On the day of service initiation (client file numbered 1): i. Client’s rights and responsibilities identified in Minnesota Statutes, section 148F.165); and ii. Grievance procedure to the client; b. Within 24 hours of admission (client file numbered 1): i. Internal and external reporting procedures for the maltreatment of vulnerable adults; and ii. Program abuse prevention plan; and c. Within 72 hours of admission for HIV minimum standards (client files numbered 1 and 3). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a), and 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meet all applicable requirements. 17. Violation: Two of three client files reviewed for requirements governing initial services plans (client files numbered 2 and 3) did not meet requirements. The initial services plan did not identify treatment needs to be addressed during the time between the day of service initiation and the development of the treatment plan. 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. Within 45 days of receipt of this order, submit two initial services plans that meet all applicable requirements. 18. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include the following information: a. The client’s household members (client file numbered 1); b. The status of the client’s basic needs (client file numbered 1); c. The client’s current medications (client file numbered 1); d. The reason for the client’s referral (client files numbered 1 through 3); e. Substance use history (client file numbered 1), including: i. Amount; and ii. Route of administration; f. An evaluation of the quality of each relationship with the client’s family and other significant personal relationships (client files numbered 1 and 3); g. The client’s resources (client files numbered 1 and 3); h. Important developmental incidents in the client’s life (client file numbered 1); i. The client’s family health history (client file numbered 3); and j. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to section 245.4863 (client files numbered 1 through 3). 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. 19. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not updated based on new information about the client’s condition, the client's level of participation, and on whether methods identified have the intended effect (client files numbered 1 through 3); and b. There was no documentation of the following: i. A treatment strategy (client files numbered 1 through 3); and ii. Resources to refer the client to when the client's needs will be addressed concurrently by another provider (client files 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 individual treatment plans meet all requirements. Within 45 days of receipt of this order, submit two individual treatment plans that meet all applicable requirements. 20. Violation: Two of four 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. The amount of treatment services provided for February 24 and October 7, 2024 (client file numbered 8); and b. The client’s response for January 30, 2025 (client file numbered 1). 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. 21. Violation: Seven of eight client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. The entries in the client’s record were not accurate as follows: i. The span of time covered by the treatment plan reviews were not accurate for notes signed on: 1. November 29, 2024 (client file numbered 1); and 2. July 29, 2024 (client file numbered 3); ii. The ASAM level of care identified on the treatment plan reviews were not accurate for notes signed on November 29, 2024, January 13, March 26, and April 19, 2025 (client file numbered 1); iii. The admission date listed on the discharge summary was not accurate (client file numbered 3 and 4); and iv. The discharge date listed on the discharge summary was inconsistent across the document (client files numbered 3 and 4); and b. The entries did not include the job title or position of the person that made the entry on the following dates: i. November 29, 2024, and January 13, 2025 (client file numbered 1); ii. October 28, November 19, December 17, 2024, and January 29, 2025 (client file numbered 2); iii. May 31, June 7 and 21, 2024 (client file numbered 6); iv. April 2, 9, 12, and October 7, 2024 (client file numbered 7); and v. October 7, 2024, February 24, and March 5, 2025 (client file numbered 8). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 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. 22. Violation: Two of two client files reviewed for requirements governing co-occurring disorders (client files numbered 1 and 3) did not meet all applicable requirements. The treatment plan review did not have continuing documentation of collaboration with continuing care mental health providers. Statute Violated: Minnesota Statutes, section 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that co-occurring disorders requirements meet all applicable requirements. 23. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPRs) did not meet requirements in the following ways: a. The TPR did not document the following: i. Client goals addressed since the last treatment plan review for note signed on November 29, 2024 (client file numbered 1); ii. Whether the identified methods continue to be effective on: iii. November 29, 2024, January 13, March 26, and April 19, 2025 (client file numbered 1); iv. November 19, December 27, 2024, January 29 and March 20, 2025 (client file numbered 2); and v. July 29, August 26, September 9, and October 1, 2024 (client file numbered 3); b. The TPR was not completed once every 30 days as follows: i. A TRP was due by November 21, 2024; however, was not completed until November 29, 2024 (client file numbered 1); ii. A TRP was due by December 29, 2024; however, was not completed until January 13, 2025 (client file numbered 1); iii. A TRP was due by February 12, 2025; however, was not completed until March 26, 2025 (client file numbered 1); iv. A TPR was due by January 16, 2025; however, was not completed until January 29, 2025 (client file numbered 2); v. A TPR was due by February 28, 2025; however, was not completed until March 27, 2025 (client file numbered 2); and vi. A TPR was due by April 26, 2025; however, was not completed (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a, and 245G.20. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 45 days of receipt of this order, submit one treatment plan review that meets all applicable requirements. 24. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination (client files numbered 4 and 5); and b. The discharge summary did not include the following: i. The client's living arrangements at service termination (client files numbered 4 and 5); and ii. 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 files numbered 3 through 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Within 45 days of receipt of this order, submit two discharge summaries that meet all applicable requirements. Personnel Files 25. Violation: One personnel file reviewed for requirements governing treatment director qualifications (personnel file numbered 1) did not meet requirements. There was no documentation that the treatment director knew and understood the implications of Minnesota Statutes, chapters 245A, 245G, and 260E, and sections 626.557 and 626.5572. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment director meets all applicable requirements. 26. Violation: One personnel file reviewed for requirements governing treatment coordinator qualifications (personnel file numbered 4) did not meet requirements. There was no documentation that the treatment coordinator had at least 2,000 hours of supervised experience working with individuals with substance use disorder. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment coordinators meet all applicable requirements. 27. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not contain documentation that orientation was received for the following topics: a. Within 24 working hours of starting: i. The staff member’s specific job responsibilities (personnel file numbered 4); ii. Policies and procedures (personnel files numbered 2 and 4); iii. Client confidentiality (personnel files numbered 2 and 4); and iv. Client needs (personnel files numbered 2 and 4); b. Within 72 hours of employment, HIV minimum standards (personnel files numbered 2 and 4); c. Within 72 hours of first providing direct contact services (personnel files numbered 2 and 4): i. Vulnerable adults’ maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; ii. Program abuse prevention plan; and iii. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. Before direct contact, maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E (personnel files numbered 2 and 4). Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 28. Violation: Three of three personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following annual trainings: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E for calendar years: 1. 2024 (personnel file numbered 3); and 2. 2025 (personnel files numbered 2 and 3); b. Specific training covering the license holder's policies for obtaining a release of client information for calendar years: 1. 2024 and 2025 (personnel files numbered 1 through 3); c. Program abuse prevention plan for calendar years: 1. 2024 (personnel files numbered 1 through 3); and 2025 (personnel files numbered 1); d. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: 1. 2024 (personnel files numbered 1 through 3); and 2. 2025 (personnel files numbered 1); and e. HIV minimum standards for calendar years: 1. 2024 (personnel files numbered 2 and 3); and 2. 2025 (personnel files numbered 1 through 3). 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 ensure that annual trainings meet all applicable requirements. Within 45 days of receipt of this order, submit documentation that the staff mentioned above have completed the trainings identified above. 29. Violation: Two of two personnel file reviewed for requirements governing every two-year trainings did not meet requirements. There was no documentation of the following trainings: a. Client confidentiality and client ethical boundaries for calendar year 2025 (personnel file numbered 3); and b. Emergency procedures and client rights as specified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03 for calendar year 2025 (personnel files numbered 1 and 3). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that every two-year trainings meet all applicable requirements. 30. Violation: Three of three personnel file reviewed for requirements governing additional trainings did not meet requirements. There was no documentation of the following trainings: a. Within six months of employment 12 hours of specific training in co-occurring disorders (personnel files numbered 2 and 5); and b. Training in the specific mode of administration used at the program (personnel files numbered 1, 2, and 4). Statute Violated: Minnesota Statutes, section 245A.242, subdivision 2, paragraph (a) and 245G.13, subdivision 2, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that additional trainings meet all applicable requirements. 31. Violation: Three of four personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. The license holder did not document the date a staff person first had direct contact with persons served by the program (personnel file numbered 5); b. There was no documentation of a completed application for employment containing the staff member's qualifications for employment (personnel file numbered 4); c. There was no documentation of employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (personnel files numbered 1 and 2); and d. The written annual review of the staff member’s job performance was not completed for calendar years: i. 2024 (personnel file numbered 1 and 2); and ii. 2025 (personnel file numbered 1). Statute Violated: Minnesota Statutes, section 245G.13, subdivisions 1 and 3. 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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