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August 12, 2025 Kristine Swanson, Authorized Agent Center for Alcohol and Drug Treatment 400 Torrey Building 314 W SUPERIOR ST STE 400 Duluth, MN 55802 License Number 1100930 Withdrawal Management Program License Number 1033822 Detoxification Program CORRECTION ORDER Dear Kristine: On June 9, 10, 11, and 12, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 1402 East Superior St., Duluth, MN 55805. As a result of this visit, DHS determined that you are in violation of the withdrawal management statutes under Minnesota Statutes, chapter 245F and detoxication services under Minnesota Rules, parts 9530.6590 (Rule 32). 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. Throughout the correction order, references to the statute or rule requirement will be identified as follows: · Withdrawal Management Program as (245F); and · Detoxification Program as (Rule 32) Policies, Practices, and Procedures 1. Violation: The license holder did not monitor the implementation of their policy and procedure for admission criteria requirements (245F). On March 14, 2025, patient documentation indicated that the patient was lowered from an ASAM 3.7 level of care to ASAM 3.2 level of care due to a change in the severity of the patient’s withdrawal symptoms (patient file numbered 2). Per interview with the Program Director and Authorized Agent, the level of care change occurred based on staffing and lack of RN on duty rather than patient need. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), clause (3) and 245F.05, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission criteria are followed and meets all applicable requirements. 2. Violation: The license holder did not meet requirements (245F) for addressing the needs of individuals who are denied admission to the program. Documentation did not include: a. The time of the admission request on May 23, 2024, and November 21, 2024; b. The reason for the denial of admission on November 23, 2024; and c. Where the individual was referred on June 14, 2023, and December 14, 2024. Rule and Statute Violated: Minnesota Statutes, section 245F.05, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission denials meet all applicable requirements. 3. Violation: The license holder did not ensure that documentation of each incident involving the use of law enforcement (245F) included the following: a. The date and time law enforcement arrived and left the program on August 10, 2023, March 15, 2024, June 17, 2024, and May 25, 2025; b. If law enforcement used force or a protective procedure and which protective procedure was used on August 10, 2023, and February 21, 2024; and c. Whether any injuries occurred on August 10, 2023, February 21, 2024, and January 24, 2025. Statute Violated: Minnesota Statutes, section 245F.09, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the involvement of law enforcement meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing grievance procedures (245F). The license holder did not ensure that an initial response to the patient who filed the grievance was completed within 24 hours of the programs receipt of the grievance for the following: a. May 10, 2025, grievance was responded to on May 12, 2025; and b. September 7, 2024, grievance was responded to on October 8, 2024. Statute Violated: Minnesota Statutes, section 245F.10, clause 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Personnel Files 5. Violation: One of four personnel files reviewed for requirements governing staff orientation (personnel file numbered 4) did not meet requirements. There was no documentation of orientation training on motivational counseling techniques and identifying stages of change (245F) being completed within 72 hours of beginning employment. Rule and Statute Violated: Minnesota Statutes, section 245F.16, subdivision 2, paragraph (b), clause (7) and Minnesota Rules 9530.6570, subpart 2, item E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that staff orientation meets all applicable requirements. 6. Violation: Four of ten patient files reviewed for requirements governing personnel file documents did not meet requirements (245F and Rule 32). There was no documentation of an annual job performance evaluation for the calendar year: a. 2024 (personnel files numbered 1, 6, 8, and 9); and b. 2025 (personnel file numbered 9). Rule and Statute Violated: Minnesota Statutes, section 245F.17 and Minnesota Rules 9530.6575, item E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file documents meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for the above personnel files that demonstrates compliance. Patient Files · 245F: Patient files numbered 1, 2, and 3 · Rule 32: Patient file numbered 4: 7. Violation: Two of four patient files reviewed for requirements governing patient orientation (patient files numbered 2 and 3) did not meet requirements. There was no documentation for consent to the disclosure of suspected maltreatment from the patient upon the patient’s admission. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient orientation meets all applicable requirements. 8. Violation: One of four patient files reviewed for requirements governing individual abuse prevention plans (patient file numbered 2) did not meet requirements. There was no documentation that an individual abuse prevention plan was developed as part of the initial service plan. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b) and 245F.19, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that individual abuse prevention plans meet all applicable requirements. 9. Violation: Three of three patient files reviewed for requirements governing medical services did not meet requirements in the following ways: a. The follow up screening conducted between 4 and 12 hours after service initiation did not include the behavioral risk factors that the patient may not have communicated at service initiation (patient files numbered 1, 2, and 3); and b. An initial health assessment was not conducted by a registered nurse upon admission as required for medically monitored programs (patient file numbered 3). Statute Violated: Minnesota Statutes, section 245F.12, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services meet all applicable requirements. Within 30 days of receipt of this order, submit a nursing assessment and screening document that demonstrates compliance. 10. Violation: Three of three patient files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements in the following ways: a. The CA was not completed within 72 hours following admission including the reason why it was late (patient file numbered 2); and b. There was no documentation of: i. The patient’s employment status (patient files numbered 1 and 2); ii. The reason for the patient’s referral (patient file numbered 3); and iii. Mental health symptoms and the effect on the patient’s ability to function (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 11. Violation: One of three patient files reviewed for requirements governing individualized stabilization plans (patient file numbered 2) did not meet requirements. The stabilization plan was not updated based on new information gathered about the patient condition. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization plans meet all applicable requirements. 12. Violation: Three of three patient files reviewed for requirements governing progress notes (patient files numbered 1, 2, and 3) did not meet requirements. There was no progress note documentation of the following: a. The patient’s involvement in the stabilization services, including the type and amount of each stabilization service; and b. The participation of others. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit two patient progress note documentation that meets all applicable requirements. 13. Violation: Two of two patient files reviewed for requirements governing discharge plans (patient files numbered 1 and 2) did not meet requirements. The discharge plan was not completed before the patient left the facility and the patient was not provided with a copy of a completed discharge plan. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of the discharge plans from two clients that meet all requirements. 14. Violation: Two of three patient files reviewed for requirements governing care coordination did not meet requirements. Care coordination documentation did not include the following: a. Referral to mental health services as identified in the comprehensive assessment (patient file numbered 2); and b. Socioeconomic factors affecting the patient’s access to services (patient files numbered 1 and 2). _ Statute Violated: Minnesota Statutes, section 245F.08, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure care coordination meet all applicable requirements. 15. Violation: One of four patient files reviewed for requirements governing patient confidentiality (patient file numbered 1) did not meet requirements. The license holder did not obtain a release of information as required per Code of Federal Regulations, title 42, sections 2.1 to 2.67, before disclosing information to an outside agency. Statute Violated: Minnesota Statutes, section 245F.19, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient confidentiality practices meet all applicable requirements. 16. Violation: One of four patient files reviewed for requirements governing medication administration (patient file numbered 4) did not meet requirements. The patient’s use of medication was not recorded, including staff signatures with date and time for the following: a. Gabapentin on May 25, 2025, June 2, 2025, and June 9, 2025; b. Olanzapine on June 2, 2025, June 7, 2025, and June 9, 2025; c. Benztropine on June 9, 2025; d. Cetirizine on June 1, 2025, June 2, 2025, June 7, 2025, and June 9, 2025; and e. Lithium, Oxybutynin Senna, Multi-vitamin on June 9, 2025. Rule Violated: Minnesota Rules, 9530.6555, subpart 2, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that 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 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 withdrawal management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F and Minnesota Rules, parts 9530.6590 (Rule 32) · 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 Char Hanson, Licensor, at 651-431-6617. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
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