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August 18, 2025 Jessica Johnson, Authorized Agent RS Eden 1025 Portland Avenue Minneapolis, MN 55404 License Number 1003334 License Number 1078488 Report Number 202403047, 202500269 CORRECTION ORDER Dear Jessica Johnson: On June 23 through June 27, June 30, and July 1, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigations at your facilities located at the following: · 1025 Portland Avenue, Minneapolis, MN 55404-1449, license 1003334 · 614 Grant Street, Minneapolis, MN 55404, license 1078488 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 (1003334) did not meet requirements in Minnesota Statutes, section 254B.19, subdivision 1, paragraph (a) for receiving public funding reimbursement from the commissioner for low intensity residential clients. Low intensity residential services were not provided at 15 hours or more of skilled treatment services per week for the following weeks starting: a. March 3 and 10, 2025 (client file numbered 4); and b. January 6, 13, and 20, 2025 (client file numbered 5). 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 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 client rights. The license holder did not protect client’s rights according to Minnesota Statutes, section 144.651, subdivision 23. The license holder required residents to perform labor for the facility and those activities were not included for therapeutic purposes and appropriately goal-related in the client’s individual medical records. Through staff and client interviews and review of the program’s policy entitled Therapeutic Community, the program’s practice was to require all clients to clean the communal areas, ensure that other clients complete their cleaning tasks, stock cleaning supplies, set up meals and snacks, work in the kitchen, and coordinate clients to take their medications. If assigned tasks were not completed, clients might not earn privileges like being allowed to leave the facility independently. 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 30 days of receipt of this order, submit updated client rights policies that meet all applicable requirements. 3. Violation: The license holder (1003334) did not meet requirements governing visitors for residential treatment. Visiting hours did not include evening times. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Correction Action Required: Immediately, and on ongoing basis, the license holder must ensure that visitor hours meet all applicable requirements. 4. Violation: The license holder did not meet requirements governing grievance procedures. Three of eight grievances reviewed did not have documentation that the license holder responded to client’s grievance within three days of a staff member’s receipt of the grievance on the following dates: a. January 24, 2025 (license 1003334); and b. June 15, 2025 (license 1078488). Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. 5. Violation: The license holder (1078488) did not meet requirements governing personal electronic devices. The program did not have a written policy regarding the use of any personal electronic device that can record, transmit, or make images of another client. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that personal electronic device policies meet all applicable requirements. Within 30 days of receipt of this order, submit a personal electronic device policy that meets all applicable requirements. 6. Violation: The license holder (100334 and 1078488) did not meet requirements governing provider policies and procedures. The manual did not contain the following: a. Policies and procedures regarding HIV according to Minnesota Statute, section 245A.19; and b. Resources to provide education on tuberculosis. Statute Violated: Minnesota Statutes, section 245G.12, clauses (2) and (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures meet all applicable requirements. 7. Violation: The license holder (1003334 and 1078488) did not meet requirements governing maltreatment of vulnerable adults. There was no documentation that an internal review was completed within 30 days when the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made for the following dates: a. October 27, 2023; and b. April 10, 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b), clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adult policies and procedures meet all applicable requirements. 8. Violation: The license holder (1003334 and 1078488) did not meet requirements governing program abuse prevention plans. The program abuse prevention plan did not document the following: a. There was no evaluation of the program’s staffing patterns; and b. The license holder’s governing body or the governing body’s delegated representative did not review the program abuse prevention plan for calendar years 2024 and 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (3) and (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adult policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. Personnel Files Personnel files reviewed worked for both licenses reviewed (1003334 and 1078488). 9. Violation: Twenty-six of thirty-one personnel files reviewed for requirements governing background studies (BGS) did not meet requirements. The license holder failed to affiliate staff to all required rosters before allowing direct contact with persons served by the program for the following: a. Staff (personnel files numbered 6, 8, 10, 14, 16, 17, 18, 26, 27, 29) were not affiliated to license 1003334; and b. Staff (personnel files numbered 3, 4, 8, 9, 10, 12 through 15, 17, 19 through 25, 28, 30, and 31) were not affiliated to license 1078488. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure background studies meet all applicable requirements. 10. Violation: Two of eight personnel files reviewed for requirements governing staff qualifications did not meet requirements. There was no documentation of the following: a. The treatment director knows and understands the implications of Minnesota Statute, chapter 245A (personnel file numbered 2); and b. A treatment coordinator successfully completed 30 hours of classroom instruction on treatment coordination for an individual with substance use disorder (personnel file numbered 6). Statute Violated: Minnesota Statutes, section 245G.11, subdivisions 3, clause (3), and 7, paragraph (a), clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder will ensure that staff qualifications meet all applicable requirements. Within 30 days of receipt of this order, submit documentation which demonstrates that the above personnel meet all applicable qualification requirements. 11. Violation: One personnel file reviewed for requirements governing staff qualifications for individuals with a temporary permit (personnel file numbered 3) did not meet requirements. There was no documentation of the amount and type of supervision provided to an individual with a temporary permit on at least a weekly basis from April 10, 2024, through June 16, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder will ensure that staff qualifications for individuals with a temporary permit meet all applicable requirements. Within 30 days of receipt of this order, submit three weeks of supervision notes that meet all applicable requirements. 12. Violation: Five of five personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation: a. Within 24 working hours related to: i. The staff member’s specific job responsibilities (personnel files numbered 2, 3, 6, 7, and 8); ii. Policies and procedures (personnel file numbered 6); iii. Client confidentiality (personnel file numbered 6); and iv. Client needs (personnel files numbered 2, 3, 6, 7, and 8); and b. Within 72 working hours on HIV minimum standards (personnel files numbered 2, 3, 6, 7, and 8); and c. Maltreatment of minors reporting requirements and definitions in Minnesota Statute, chapter 260E before a mandatory reporter has direct contact (personnel file numbered 6). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b) and 245G.13, subdivisions 1, clause (7), and 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation which demonstrates that the above personnel meet all applicable orientation requirements. 13. Violation: Five of five 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 the calendar years: i. 2023 (personnel file numbered 1); and ii. 2025 (personnel file numbered 7); and b. HIV minimum standards for calendar years: i. 2023 (personnel files numbered 1, 4, and 5); ii. 2024 (personnel files numbered 1, 3, 4, and 5); and iii. 2025 (personnel file numbered 7). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 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. 14. Violation: Two of eight personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of a written annual review of the staff member’s job performance for calendar year 2024 (personnel file numbered 1) and 2025 (personnel file numbered 7). Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files Client files reviewed are identified in the following manner: · License Number 1003334: Client files numbered 1 through 5 · License Number 1078488: Client files numbered 6 through 9 15. Violation: Six of six client files reviewed for requirements governing initial service plans (ISP) did not meet requirements. The ISP was not person-centered and client specific (client files numbered 3 through 7 and 9). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation meets all applicable requirements. Within 30 days of receipt of this order, submit two initial service plans which meet all applicable requirements. 16. Violation: Six of six client files reviewed for requirements governing opioid educational material did not meet requirements. The license holder did not provide opioid education material approved by the commissioner on the day of service initiation (client files numbered 3 through 7 and 9). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that opioid educational material meets all applicable requirements. 17. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 3 through 5) did not meet requirements. There was no documentation of the following): a. An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults; and b. An assessment of the person’s risk of abusing other vulnerable adults. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, 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. Within 30 days of receipt of this order, submit two IAPP that meet all applicable requirements. 18. Violation: Five of five client files reviewed for requirements governing comprehensive assessments did not meet requirements. There was no documentation of a review and update of the comprehensive assessment 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 files numbered 3 through 5, 7, and 9). Statute Violated: Minnesota Statute, section 245G.05, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 19. Violation: Seven of seven client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed by the end of the tenth day on which a treatment session was provided from the day of service initiation (client files numbered 2 and 7); b. The ITP was not person-centered (client files numbered 3, 4, and 9); c. The ITP was not updated based on new information about the client’s level of participation (client file numbered 7); d. The ITP was not based on the client’s comprehensive assessment (client file numbered 6); and e. The ITP did not document the following: i. A treatment strategy (client files numbered 2 through 7 and 9); and ii. The participants involved in the client's treatment planning (client files numbered 2 through 7 and 9). Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (1) through (3), and (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit two individual treatment plans that meet all requirements. 20. Violation: Five of six 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 a treatment service on September 6, 2024 (client file numbered 3) and June 10, 2025 (client file numbered 7); b. Document concerns related to medications that are not documented in the medication administration record was not completed on the day that it occurred for an event on January 5, 2025 (client file numbered 1); c. Documentation of treatment services did not include: i. Client response for March 24, 2025 (client file numbered 7); ii. Signature of the staff person making the entry for the following dates: 1. July 31, 2024 (client file numbered 3); and 2. December 27, 2024, and January 30, 2025 (client file numbered 5); iii. Job title of the staff person making the entry for the following dates: 1. August 21, 2024 (client file numbered 3); 2. February 14 and 17, 2025 (client file numbered 9); and 3. February 6 and 26, March 5 and 6, 2025 (client file numbered 5); and Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (b), clause (2) and paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 21. Violation: Three of four client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan review did not document a review and evaluation of the IAPP for the following dates: a. August 12, August 15, and September 5, 2024 (client file numbered 3); b. January 3, January 15, and March 5, 2025 (client file numbered 5); and c. April 25 and June 27, 2025 (client file numbered 9). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3, clause (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 22. Violation: Three of three client files reviewed for requirements governing administration of medications did not meet requirements. The client’s use of medication was not recorded, including staff signatures with date and time as follows: a. August 16 through September 9, 2024 (client file numbered 3); b. March 10, 2025 (client file numbered 4); c. January 22, February 6, and March 10 and 11, 2025 (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.08, subdivision 6, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that administration of medication documentation 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.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 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) 431-6282 or at Jennifer.White@state.mn.us Sincerely,
Jennifer White, MBA, LADC Licensor 2 Licensing Division Office of Inspector General
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