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September 11, 2025 Emma Fernandez, Authorized Agent Community Medical Services Montana Private LLC 8444 N 90th Street, Suite 100 Scottsdale, AZ 85258 License Number: 1116865 CORRECTION ORDER Dear Emma: On June 9, 10, 11, 12, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Community Medical Services Roseville on Cleavland located at 2350 Cleveland Ave N, Roseville, MN 55113. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under MN 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, Procedures, and Practices 1. Violation: The license holder did not meet requirements governing program abuse prevention plans. There was no documentation that the license holder’s governing body or delegated representative reviewed the plan for calendar year 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. 2. Violation: The license holder did not meet requirements governing the monitoring of implementation of the program’s policies and procedures as follows: a. There were two conflicting grievance procedures. The grievance procedure that clients were being oriented to was not the same as the grievance procedure in the policy manual and did not include that a client may bring a grievance to the program’s highest level of authority; and b. The policy manual contained incorrect hours of operation. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), clause (3), 245G.12, clause (12), and 245G.15, subdivision 2, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policies and procedures meets all applicable requirements. Within 30 days of receipt of this order, submit a policy with accurate hours of operation that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing the provision of telehealth, pursuant to Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c). The license holder did not have a policy that adequately addressed patient safety before and after the service is delivered through telehealth. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the provision of telehealth meets all applicable requirements. Within 30 days of receipt of this order, submit a telehealth policy that demonstrates compliance. 4. Violation: The license holder did not meet requirements governing vulnerable adult maltreatment reporting. The vulnerable adult maltreatment reporting policy did not identify the secondary person or position responsible for forwarding internal reports to the common entry point and completing internal reviews. Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraphs (a), clause (2), and (b), clause (2), and 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the vulnerable adult maltreatment reporting policy meet all applicable requirements. Within 30 days of receipt of this order, submit a vulnerable adult maltreatment reporting policy that demonstrates compliance. 5. Violation: The program did not follow the terms of a variance which was granted on October 31, 2023 to allow clients to be admitted to the license holder's opiate treatment program and begin receiving services without a government issued identification: a. The program did not document what the barriers were to the client obtaining a government issued ID, and the action steps and resources provided to the client to address the barriers (client files numbered 6 and 10); and b. The program did not develop and maintain a central log that documents all clients that fell under the terms of the variance, as confirmed through staff interview. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 9. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the license holder is following the terms of the granted variance. Personnel Files 6. Violation: Four of four personnel files did not meet requirements governing staff orientation (personnel files numbered 1 through 4). There was no documentation of orientation to the following: a. Within 24 working hours of starting: 1) Staff members specific job responsibilities; 2) Policies and procedures; 3) Client confidentiality; 4) Client needs; and 5) HIV minimum standards; b. Within 72 hours of first providing direct contact services: 1) Reporting requirements and definitions in Minnesota statutes, sections 245A.65, 626.557 and 626.5572; and 2) Program abuse prevention plan; and 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and c. Before the mandatory reporter had direct contact, reporting requirements and definitions in Minnesota statutes, chapter 260E before the mandatory reporter has direct contact. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 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 the documentation of personnel orientation meet all applicable requirements. 7. Violation: Two of two personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of an inquiry required by Minnesota Statutes, 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). Statute Violated: Minnesota Statutes, 245G.13, subdivision 3, clause (3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure personnel file contents meet all applicable requirements. Client Files 8. Violation: Three of nine client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation orientation to the following: a. Within 24 hours of admission: 1) Program abuse prevention plan (client file numbered 3); and 2) Internal and external maltreatment of vulnerable adult reporting policies (client files numbered 8 and 9); b. Personal electronic device policy (client files numbered 3 and 8); and c. Opioid education material on the day of service initiation (client files numbered 3, 8 and 9). Statute Violated: Minnesota statutes, sections 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a), clause (4), 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1), and 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 9. Violation: Three of nine client files reviewed for requirements governing initial service plans (ISP) and vulnerable adult determinations did not meet requirements in the following ways: a. The ISP and vulnerable adult determination were not completed within 24 hours of the day of service initiation (client files numbered 4, 5, and 8); b. The ISP was not person centered and client specific (client file numbered 4); and c. The ISP did not identify treatment needs to be addressed between day of service initiation and development of the individual treatment plan (client file numbered 5). Statute Violated: Minnesota statutes, sections 245G.04, subdivisions 1 and 2, paragraph (a) and 245G.09, subdivision 3, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans and vulnerable adult assessment meet all applicable requirements. 10. Violation: Nine of nine client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements as follows: a. CA was not completed within 21 calendar days from day of service initiation, and there was no documentation of the person-centered reason for the delay and planned completion date (client file numbered 6); b. There was no documentation that the CA was reviewed and updated as clinically necessary to ensure compliance with Minnesota Statutes, section 245G.05, subdivision 1 when the client received a CA that authorized the treatment service (client file numbered 5); and c. CA did not include documentation of the following: 1. Status of the client’s basic needs (client files numbered 4 through 7, 9, and 10); 2. Client’s substance use history, including: a. Frequency of substance use (client file numbered 5); b. Duration of substance use (client files numbered 4, 5, and 10); and c. Route of administration (client file numbered 5 and 10); 3. Client’s evaluation of the quality of significant personal relationships (client file numbered 4, 7 and 9); 4. Client’s strengths (client files numbered 1 and 3 through 10); 5. Client’s resources (client files numbered 4 through 10); 6. Client’s important developmental incidents (client file numbered 3); 7. Client’s history of potential brain injuries (client files numbered 4, 5, and 10); and 8. Recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 4, 6, 8 and 10). Statute Violated: Minnesota Statutes, section 245G.05. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 11. Violation: Nine of nine client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not based on the client’s comprehensive assessment (client file numbered 7); and b. There was no documentation of the following: 1) A treatment strategy (client file numbered 5); and 2) The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1, 3, 4, 5, 6, and 7 through 10). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1a, paragraph (a), clauses (1), (4), . Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. 12. Violation: Two of ten client files reviewed for requirements governing documentation of treatment services did not meet requirements. Documentation of treatment services were not completed within seven days of providing the treatment service as follows: a. Treatment service was provided on May 12, 2025; however, documentation was not completed until June 2, 2025 (client files numbered 4); and b. Treatment service was provided on May 9, 2025; however, documentation was not completed until June 2, 2025 (client file numbered 10). Statute Violated: Minnesota statutes, sections 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of treatment services meet all applicable requirements. 13. Violation: Seven of seven client files reviewed for requirements governing telehealth services, pursuant to Minnesota Statutes 256B.0625, subdivision 3b, paragraph (c) (client files numbered 1, 2, 4 through 7, and 9) did not meet requirements as follows: a. There was no documentation of the health care provider’s basis for determining that telehealth is an appropriate and effective means for delivering the treatment service; and b. There was no documentation of the location of the originating and the distance site. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the provision of telehealth meets all applicable requirements. 14. Violation: Nine of ten client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Entries in the client record were not accurate as follows: 1) Inconsistent information on take-home doses in a case management note dated May 7, 2025 (client file numbered 6); 2) Treatment plan review dated June 6, 2025, contained the incorrect methadone dose (client file numbered 7); and 3) Comprehensive assessment indicated client was court ordered for treatment; however, other documents in chart indicate client was voluntarily admitted (client file numbered 8); and b. Entries did not include the job titles or position of the staff that made the entry: 1) May 1, 2, 7, 21, 28, and June 3, 2025 (client file numbered 1); 2) December 12, 2024, February 20, May 28, June 3 and 4, 2025 (client file numbered 2); 3) January 7, 21, 23, and 27, 2025 (client file numbered 3); 4) April 11, May 7, 12, and 27, 2025 (client file numbered 4); 5) December 17 and 23, 2024, January 21, 23, 29, 31, February 11, 14, and 18, 2025 (client file numbered 5); 6) April 29, May 2, and June 4, 2025 (client file numbered 6); 7) May 29 and June 6, 2025 (client file numbered 7); 8) May 12, 27, 28, 29, 30, and June 2, 2025 (client file numbered 8); and 9) May 9, 12, 20, 22, 23, 27, June 2, 5, 6 and 10, 2025 (client file numbered 10). 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 documentation meets all applicable requirements. 15. Violation: Ten of ten client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan reviews did not meet requirements in the following ways: a. The treatment plan review did not include documentation of the following: 1) The span of time covered by the review for the treatment plan reviews signed: i. May 14, 20, and 28, 2025 (client file numbered 1); ii. January 22, and May 28, 2025 (client file numbered 2); iii. June 6, 2025 (client file numbered 4); and iv. May 7, 14, 21, and June 3, 2025 (client filed numbered 6); and v. June 4, 2025 (client file numbered 9); 2) Client goals addressed since the last treatment plan review and whether the identified methods continue to be effective for treatment plan reviews signed May 20, 2025 (client file numbered 8); 3) Monitoring of any physical and mental health problems including toxicology results for alcohol and substance use for treatment plan reviews dated: i. June 6, 2025 (client file numbered 7); and ii. May 30, 2025 (client file numbered 8); and 4) Participation of others involved in the individual’s treatment planning for treatment plan reviews dated: i. April 25 and May9, 2025 (client file numbered 4); and ii. May 30, 2025 (client file numbered 8); and 5) Collaboration with continuing care mental health providers, and involvement of the providers in treatment planning meetings for treatment plan reviews dated: i. April 11, 25, May 9, 16, June 6, 2025 (client file numbered 4); ii. May 7, 14, 21, and June 3, 2025 (client file numbered 6); and iii. March 14 and May 23, 2025 (client file numbered 10); and b. Treatment plan reviews were not completed weekly for ten weeks following the completion of the treatment plan: 1) Treatment plan reviews were due on January 14, 21, and 28, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 3); 2) Treatment plan reviews were due on April 4, 18, May 2, 23, and 30, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 4); 3) Treatment plan reviews were due on December 24and 31, 2024 and January 7, 14, 21, and 28, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 5); 4) Treatment plan review was due on May 30, 2025; however, the treatment plan review was not completed until June 3, 2025 (client file numbered 6); 5) Treatment plan review was due on May 23, 2025; however; the treatment plan review was not completed until May 30, 2025 (client file numbered 8); and 6) Treatment plan reviews were due February 14, 21, 28, March 7, 21, 28, April 4 and 11, 2025 however; there was no treatment plan review documentation in the chart (client file numbered 10). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 3, clauses (1), (2), and (3), and 3a, , paragraph (f), clause (1), and 245G.20, clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of service termination (client file numbered 5); and b. The discharge summary did not include documentation of the following: 1) Client’s issues (client files numbered 3 and 8); 2) Client’s strengths and needs while participating in treatment (client files numbered 3); 3) Progress toward achieving each goal identified in the treatment plan (client files numbered 3 and 8); 4) Risk rating and description for each of the ASAM six dimensions (client file numbered 5); and 5) Continuing care recommendations (client files numbered 5 and 8). Statute Violated: Minnesota statute, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (1), (2), (3), and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service discharge summaries meet all applicable requirements. 17. Violation: Six of nine client files reviewed for requirements governing central registry requirements did not meet requirements, as follows: a. A central registry form was not submitted to the state central registry upon admission (client file numbered 5); and b. The information submitted to the state central registry did not include the following: 1) Current or previous enrollment status in another opioid treatment program (client files numbered 4, 6, 7, and 9); and 2) Government-issued photo identification card number (client files numbered 4 and 5). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a), clauses (5) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure central registry meets all applicable requirements. 18. Violation: Ten of ten client files reviewed for requirements governing the prescription monitoring program (PMP) did not meet requirements as follows: a. PMP was not reviewed by the medical director or delegate before the client was ordered a controlled substance used for the treatment of opioid addiction (client file numbered 5); b. There was no documentation of the licensed practitioner’s decision for the frequency of ongoing PMP checks (client files numbered 1 through 10); c. A copy of the PMP data reviewed was not maintained in the client file for the following dates: 1) April 25 and 29, 2025 (client file numbered 4); 2) January 31, 2025 (client file numbered 5); 3) May 12, 2025 (client file numbered 8); and 4) June 2, 2025 (client file numbered 9); and d. There was no documentation of the licensed practitioner’s determination of whether or not prescriptions place the client at risk of harm and the actions to be taken in response to the PMP findings that contained a recent history of multiple prescriptions for controlled substances in the client’s file within 72 hours of PMP data review (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b), clauses (2), (3), and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the prescription monitoring program meets all applicable requirements. 21) Violation: Ten of ten client files reviewed for requirements governing criteria for unsupervised medication use did not meet requirements. There was no documentation that a practitioner reviewed and documented the criteria in the Code of Federal Regulations, title 42, part 8.12 (2) when determining whether dispensing medication for a client’s unsupervised use is appropriate to implement (client files numbered 1 through 10). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 6, paragraphs (b) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure criteria for unsupervised medication use 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 david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely, David Her, Licensor Licensing Division Office of Inspector General
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