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July 30, 2025 Lewis Zeidner, Authorized Agent New Beginnings Waverly LLC dba EOSIS New Beginnings 550 Main St Suite 230 New Brighton, MN 55112 License Number 1089816 Report Number 202401222, 202400599, 202307844, 202310744 CORRECTION ORDER Dear Lewis: On May 5, 6, 7, and 8, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, New Beginnings Waverly LLC North Shore Drive dba EOSIS New Beginnings located at 109 North Shore Drive, Waverly, MN 55390. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder 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 governing maltreatment of vulnerable adult reporting. An internal report received February 10, 2024, did not include a written notice of whether the facility reported the incident to the common entry point within two working days in a manner that protects the confidentiality of the reporter. Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1, paragraph (a), clause 1 Repeat Violation: In a Correction Order that DHS issued on May 22, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that maltreatment of vulnerable adult reporting procedures meet all applicable requirements. 2. Violation: The license holder did not respond to the client’s grievance within three days of a staff member’s receipt of the grievances received on July 5, 2023, May 9, 2024, May 31, 2024, July 20, 2024, August 2, 2024, August 4, 2024, August 5, 2024, and January 7, 2025. Statute Violated: Minnesota statutes, section 245G.15, subdivision 2. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure grievances are responded to within three days as required. 3. Violation: The license holder did not meet staff requirements in the following ways: a. The treatment director did not designate a staff member who, when present in the facility, is responsible for the delivery of treatment services during all hours of operation; and b. The license holder failed to ensure that when clients were present at least one staff person on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate and at least one staff member on the premises who has a current American Red Cross community, American Heart Association, or equivalent CPR certificate. There was no documentation that staff were CPR, and first aid certified on the afternoon shift of April 26 and 27, 2025. Statute Violated: Minnesota statutes, section 245G.10, subdivisions 3 and 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that staff requirements meet all applicable requirements. Personnel Files 4. Violation: Five of eight personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of training on: a. Obtaining a release of client information for calendar year 2024 (personnel file numbered 2); b. Annual training for calendar year 2025: 1) Obtaining a release of client information (personnel files numbered 2, 3, 6, and 7); 2) Program abuse prevention plan (personnel files numbered 2 and 11); 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals served (personnel file numbered 2); and 4) Maltreatment of minors reporting (personnel files numbered 2). Statute Violated: Minnesota statutes, 245A.65, subdivision 3 and 245G.13, subdivision 2, paragraph (c). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure annual training meets all applicable requirements. Within 45 days of receipt of this order, submit documentation that the staff listed above have completed the required trainings. 5. Violation: Two of ten personnel files reviewed for requirements governing personnel file contents (personnel file numbered 10) did not meet requirements. The personnel file did not contain: a. A completed application for employment signed by the staff member containing the staff member’s qualifications for employment (personnel file numbered 10); and b. Current licensure (personnel file numbered 1). Statute Violated: Minnesota statutes, sections 245G.11, subdivision 5, paragraph (a) and 245G.13, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on May 22, 2023, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure that staff orientation meets all applicable requirements. Client Files 6. Violation: Seven of seven client files reviewed for requirements governing client rights protection (client files numbered 1 through 7) did not meet requirements. There was no documentation of a written statement of the client rights and responsibilities as identified in sections 144.651 and 148F.165 was provided. Statute Violated: Minnesota statutes, sections 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client rights protection meets all applicable requirements. 7. Violation: One of six client files reviewed for requirements governing initial services plan (ISP) (client file numbered 1) did not meet requirements. The ISP did not identify treatment needs to be addressed during the time between the day of service initiation and development of the individual 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 initial services plans meet all applicable requirements. 8. Violation: Three of eight client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. The IAPP did not include the following: a. An assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and self-abuse (client files numbered 7, and 8); b. An assessment of the person’s risk of abusing other vulnerable adults (client files numbered 7, and 8); c. Statements of the specific measures to be taken to minimize the risk of about to the vulnerable adult and other vulnerable adults when the individual assessment indicates the need for measures in addition to the specific measure identified in the program abuse prevention plan (client files numbered 3). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual abuse prevention plans meet all applicable requirements. 9. Violation: Four of seven client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not document the following: a. Immediate risks to the client’s health and safety (client file numbered 6); b. The reason for the client’s referral (client files numbered 4, 5, and 6); c. Cultural influences on the client (client file numbered 6); d. Substance use history, including: i. Amounts (client file numbered 4); and ii. Frequency (client file numbered 5); e. The client’s strength and resources (client file numbered 6); f. Important developmental incidents in the client’s life (client files numbered 2 and 6); and g. The client’s family health history (client file numbered 6). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 10. Violation: Six of eight client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. An ITP was not updated based on new information gathered (client files numbered 4 and 5); b. ITP did not include how the family or others will be involved in the client’s treatment planning or the reasons why natural supports were not involved (client file numbered 7); and c. ITP did not include a treatment strategy (client files numbered 1, 3, 4, 5, and 6). Statute Violated: Minnesota statutes, section 245G.06, subdivision 1a. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 45 days of receipt of this order, submit an individual treatment plan that meets all applicable requirements. 11. Violation: Two of eight client files reviewed for requirements governing client record keeping and treatment service documentation did not meet requirements in the following ways: a. Assessment and treatment planning documentation did not contain an accurate ASAM level of care (client file numbered 6); and b. The treatment plan review for date span February 11, 2025, through February 25, 2025, did not include the staff member’s signature (client file numbered 3). 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 client record and treatment service documentation meets all applicable requirements. 12. Violation: Four of seven client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. TPR did not indicate the span of time covered by the review (client files numbered 1 and 7); b. TPR did not document monitoring of any physical and mental health problems (client file numbered 7); c. TPR did not document the participation of others involved in the individual’s treatment planning (client files numbered 5 and 7); d. TPR did not include a review and evaluation of the individual abuse prevention plan (client files numbered 1, 3, and 7); e. TPR did not include a review and evaluation of the IAPP according to Minnesota Statutes, section 245A.65 (client files numbered 1 and 3); and f. TPR was not completed within 14 days for a client receiving ASAM level 3.3 high intensity services (client file numbered 3). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3 and 3a, paragraph (b). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. Within 45 days of the receipt of this order, submit a treatment plan review that meets all applicable requirements. 13. Violation: Two of four client files reviewed for requirements governing medication administration (client files numbered 2 and 3) did not meet requirements. The client’s use of medication was not recorded, including staff signatures with date and time. Statute Violated: Minnesota statutes, sections 245G.08, subdivision 5, paragraph (c) and 245G.21, subdivision 8. Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated May 22, 2023 · Correction Order dated December 21, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication administration 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 Charlene.m.hanson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Char Hanson 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 651-431-6617 or at Charlene.m.hanson@state.mn.us. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
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