September 17, 2025

Jihan Ali, Authorized Agent

Hennepin County Mental Health Center

License Number:  801020 (MHC)

1116952 (245G)

AMENDED CORRECTION ORDER

NOTICE: This Amended Correction Order supersedes a Correction Order issued September 10, 2025, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) is amending the correction order to revise violation number 7. This amended order is to accurately reflect the number of client files reviewed and client files in non-compliance.

Dear Jihan Ali,

On July 8 through 10, 2025, a Department of Human Services (DHS) licensor(s) conducted a licensing and certification review at your facility, Hennepin County Mental Health Center, located at 2215 East Lake Street. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance use disorder treatment under Minnesota Statutes, Chapter 245G and mental health clinics under Minnesota Statutes, Chapter 245I. 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 and certification rules and statutes, as described below.

Throughout this order, the licensed programs will be referenced as follows:

· Hennepin County Mental Health Center – mental health clinic (MHC)

· Hennepin County Mental Health Center- substance use disorder treatment (245G)

· When citations are specific to both licensed and certified programs (ALL)

Policies, Procedures and Practices

1. Violation: The license holder (245G) did not have a procedure that will track and record client attendance at treatment activities, including duration and nature of each treatment service provided to the client.

Statute Violated: Minnesota Statute, section 245G.09, subdivision 1.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit a client attendance policy that meets all applicable requirements.

2. Violation: The license holder (245G) did not meet requirements governing the program abuse prevention plan for the following:

a. The plan did not include the following factors:

i. Adolescent age;

ii. Need for specialized programs of care for clients;

iii. Need for training of staff to meet identified individual needs;

iv. Knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients;

v. Assessment of the physical plant where the licensed services are provided did not include the fifth floor description; and

vi. The areas difficult to supervise; and

b. The governing body or the governing body’s delegated representative did not review the plan at

least annually for calendar year 2024.

Statutes Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a) clause (1), (2) and (5).

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit a revised program abuse prevention plan that meets all applicable requirements.

3. Violation: The license holder (245G) vulnerable adults maltreatment reporting policy and procedure did not meet requirements. The policy did not include the following:

a. The primary or secondary individual to whom internal reports may be made, and

b. The primary and secondary person or position responsible for forwarding it to the common entry point when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and

c. The identification of the primary and secondary person or position who will ensure that, when required, internal reviews are completed.

Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (a) and (b), clause (2) and 245G.12, clause (9).

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit a revised vulnerable adults maltreatment reporting policy and procedure that meets all applicable requirements.

4. Violation: A controlling individual of the program (ALL) did not annually review and sign the transfer of clients and records upon closure plan for calendar year 2024.

Statute Violated: Minnesota Statute, section 245A.04, subdivision 13a, paragraph (a).

Corrective Action Required: Correct immediately and maintain compliance.

Client Files

· Client files 2, 3, 6 through 8, and 11 through 37 (MHC)

· Client files 1, 4, 5, 9 through 12 (MHC and 245G)

5. Violation: Three out of three client files reviewed (245G) (client files numbered 1, 4 and 5) did not meet requirements for client record content and orientation: No documentation in the client record for the following:

a. The client being given a written statement of the client rights and responsibilities upon service initiation, as identified in section 148F.165 or the staff reviewed the statement with the client;

b. The client received information on tuberculosis and tuberculosis screening;

c. The license holder provided opioid education material to the client on the day of service initiation; and

d. Upon admission, the license holder sought consent to the disclosure of suspected maltreatment according to MN statute, section 626.557, subdivision 3a, clause (1).

Statute Violated: Minnesota Statutes, section 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1) and 245G.15, subdivision 1.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit two client files demonstrating compliance with paragraphs (a) through (d) above.

6. Violation: Seven of seven client files reviewed (ALL) did not meet requirements according to Minnesota Statutes 245.735, subdivision 4b, as a comprehensive evaluation. A comprehensive evaluation performed by a Certified Community Behavioral Health Clinic meets the requirements in Minnesota Statutes 245I.10 subdivision 4 to 6 (Diagnostic Assessment in a Mental Health Clinic) and 245G.05, subdivision 1 (Comprehensive Assessment in a Substance Use Disorder Treatment program).

a. The comprehensive evaluation was not completed within 60 days (client files numbered 4 and 5)

b. The comprehensive evaluation did not include the following components:

i. The client’s current living situation, including the client’s housing status and household members (client file numbered 4);

ii. The client’s education level (client file numbered 5);

iii. The client’s perception of their condition (client file numbered 2); and

iv. Substance use history, if applicable, including:

1. Amounts and types of substances (client files numbered 4 and 5);

2. Frequency and duration of use (client files numbered 4 and 5);

3. Route of administration (client files numbered 4 and 5); and

4. Periods of abstinence (client file numbered 4).

v. The client’s relationship with family and other significant personal relationships,

including the client’s evaluation of the quality of each relationship (client files numbered 2, 3, and 6);

vi. The client’s strengths and resources, including the extent and quality of the client’s

social networks (client file numbered 3);

vii. Potential brain injuries (client files numbered 4 and 5);

viii. The client’s history of or exposure to alcohol and drug usage (client file numbered 5);

ix. The client’s mental status examination (client file numbered 8);

x. An explanation of:

1. How the assessor diagnosed the client using the information from the client’s interview, assessment, psychological testing, and collateral information about the client (client files numbered 2 and 5 through 7); and

2. The client’s responsivity factors (client files numbered 2, 3, and 5).

Statute Violated: Minnesota Statutes, section 245G.05, subdivision 1 and 245I.10, subdivision 4 through 6.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit two current comprehensive evaluations that meets all applicable requirements.

7. Violation: Twenty-seven of thirty-two client files reviewed did not meet requirements for individual treatment plans (ITP) in the following ways:

a. The client file did not contain an ITP (client files numbered 2 through 5, 7 and 13, 14, 17 through 22, and 24 through 37)

b. The ITP was not reviewed at least every 180 days (client file numbered 5)

c. The ITP did not include measurable treatment objectives (client file numbered 5)

d. The ITP did not document the reason that the license holder did not involve the client’s family or

other natural supports (client file numbered 5)

e. The ITP review (245G) (client file numbered 5) did not document the following:

i. The client goals addressed since the last treatment plan review and whether the identified methods continue to be effective; and

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit two ITP’s from two clients that meets all applicable requirements.

8. Violation: Six of eight client files reviewed did not meet progress note requirements (MHC). The progress note did not include the following components:

a. The targeted goal and objective for the following:

i. For progress note(s) dated May 29, 2025, April 16, 2025, March 17, 2025. (Client file

numbered 3);

ii. For progress note(s) dated June 26, 2025, May 30, 2025, May 16, 2025. (Client file

numbered 6);

iii. For progress note(s) dated June 26, 2025, June 12, 2025, May 29, 2025. (Client file

numbered 7);

iv. For progress note(s) dated 5/19/25, 6/16/25 (Client file numbered 4);

v. For progress note(s) dated 9/5/24 and 11/6/24 (Client file numbered 5);

vi. For progress note(s) dated 4/17/25, 5/1/25, and 5/9/25 (Client file numbered 8); and

b. The methods the staff person used:

i. For progress note(s) dated May 29, 2025. (Client file numbered 3);

ii. For progress note(s) dated June 26, 2025, May 30, 2025, May 16, 2025. (Client file

numbered 6);

iii. For progress note(s) dated June 26, 2025, June 12, 2025, May 29, 2025. (Client file

numbered 7); and

c. The staff person’s plan to take future actions, including changes in treatment that the staff person will implement if the intervention was ineffective for progress notes date May 19, 2025, and June 16, 2025 (client file numbered 4); and

d. Documentation of significant observations by staff of the client’s current risk factors for progress

note dated June 26, 2025 (client file numbered 6).

Statute Violated: Minnesota Statutes, section 245I.08, subdivision 4

Corrective Action Required: Correct immediately and maintain compliance.

9. Violation: Four of four client files (245G) reviewed for discharge summaries did not meet requirements for the following:

a. No documentation of a discharge summary in the client record (client files numbered 9 through 11);

b. No identified risk rated for dimension 3 (client file numbered 12), and

c. No documentation of a discharge summary within five days of the client’s service termination,

completed late (client file numbered 12).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit two discharge summaries that meet all applicable requirements.

Personnel Files

· Personnel Files numbered 1, 4, 5, and 6 (ALL)

· Personnel Files numbered 2, 3, 7, 9 (MHC)

10. Violation: One of four personnel files (personnel file numbered 5) did not meet Minnesota Statutes, chapter 245C background study requirements (245G). The license holder did not initiate a new background study for an individual following a legal name change or did not notify the background studies division of the legal name change.

Statute Violated: Minnesota Statutes, section 245C.04, subdivision 7.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, submit written documentation to your licensor detaining how compliance has been achieved and how compliance will be maintained in the future.

11. Violation: Seven of eight personnel files were not readily accessible for the commissioner’s review (personnel files numbered 1 through 7). The program did not have one cohesive personnel record or system to determine where required personnel documents were filed (MHC).

Statute Violated: Minnesota Statutes, section 245I.07, subdivision (b).

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days, submit a personnel file plan identifying where required documents will be located and staff or department that is responsible.

12. Violation: Eight of eight personnel files reviewed for requirements governing the contents of a personnel file did not meet requirements (ALL). The file did not contain the following:

a. A description of the staff person’s job responsibilities (personnel files numbered 5 and 8);

b. The date the staff person’s duties and responsibilities became effective (personnel numbered 1

through 8);

c. The date the staff person began having direct contact with clients (personnel files numbered 1 through 8);

d. A verification copy of license renewals that the staff person completed during the staff person’s

employment (personnel files numbered 2 and 3);

e. For a staff member who provides psychotherapy services, 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 (personnel file numbered 5)

f. An annual job performance evaluation

i. For calendar year 2024 (personnel file number 3);

ii. For calendar year 2025, annual performance conducted late (personnel file number 5); and

iii. For Calendar year 2025, annual performance conducted late (personnel file number 8).

Statutes Violated: Minnesota Statutes, section 245A.041, subdivision 6, 245G.13, subdivision 1, clause

(2) and (3), subdivision 3, clause (3) and (5), 245I.07, paragraph (a), clauses (4), (5), (7) and (8) Corrective Action Required: Correct immediately and maintain compliance.

13. Violation: Seven of seven personnel files reviewed for training documentation did not meet requirements (MHC). Documentation of training did not include the following required components:

a. The name and credentials of the trainer (personnel files numbered 1,2, 4, and 5 through 8);

b. The license holder’s method of evaluating the trainee’s competency upon completion of training

(personnel files numbered 1, 2 4, and 5 through 8); and

c. The length of training in hours and minutes (personnel files numbered 1,2, 4, and 5 through 8).

Statute Violated: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a).

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of the order, you must submit a training plan and/or tracking document that outlines the requirements in the above paragraph (a) through (c).

14. Violation: Five of five personnel files reviewed for treatment supervision plans did not meet requirements (MHC) in the following ways:

a. A written treatment supervision plan was not developed (personnel file numbered 7);

b. The treatment supervision plan was not developed within 30 days of the staff person's first day of employment (personnel file numbered 3);

c. The treatment supervision plan was not updated at least annually;

i. For calendar year 2024. (personnel file numbered 1)

ii. For calendar year 2024 and 2025. (personnel file numbered 3)

d. The staff person's treatment supervision plan did not include the following required components:

i. How frequently the treatment supervisors must provide treatment supervision to the staff person (personnel files numbered 1 through 3, and 9); and

ii. The staff person's authorized scope of practice (personnel files numbered 1 through 3 and 9).

Statute Violated: Minnesota Statutes, section 245I.06, subdivision 2, paragraphs (a) and (b)

Corrective Action Required: Correct immediately and maintain compliance.

15. Violation: Three of three personnel files reviewed for requirements governing initial training did not meet requirements in the following ways:

a. Documentation did not demonstrate the staff person was orientated to the following required topics, prior to providing direct contact services (MHC) or within 24 working hours of starting (245G):

i. Client rights and protections under section 245I.12 (MHC) (personnel file numbered 5);

ii. The Minnesota Health Records Act, including

1. Client confidentiality (ALL) (personnel file numbered 5)

2. Family engagement under section 144.294 (MHC) (personnel files numbered 2, 5, and 8); and

3. Client privacy (MHC) (personnel file numbered 5); and

iii. Specific activities and job functions for which the staff person is responsible (ALL) (personnel files numbered 2, 5 and 8);

iv. The license holder’s program policies and procedures applicable to the staff person’s

position; including drug and alcohol policy (ALL) (personnel file numbered 5);

v. Client needs (ALL) (personnel file numbered 2 and 5); and

b. No documentation to demonstrate the staff person was orientated to HIV minimum standards, within 72 hours of employment (245G) (personnel file numbered 5): and

c. No documentation to demonstrate the staff person was orientated to the program abuse prevention plan within 72 hours of first providing direct contact services (245G) (personnel file numbered 5).

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, 245G.13, subdivision 1, clause (7), and 245I.05, subdivision 3, paragraph (b)

Corrective Action Required: Correct immediately and maintain compliance.

16. Violation: Five of five personnel files reviewed for requirements governing ongoing training did not meet requirements. Documentation did not demonstrate the staff person received annual training on the following required topics:

a. Vulnerable adult maltreatment reporting and maltreatment of minor reporting requirements for calendar year 2025 (ALL) (personnel file numbered 1);

b. The license holder’s program abuse prevention plan (245G) (personnel files numbered 1 and 4 through 6);

c. HIV minimum standards including (245G) (personnel files numbered 1 and 4 through 6):

i. HIV basics;

ii. HIV transmission and prevention;

iii. substance use and HIV;

iv. Opioid overdose prevention;

v. Resources for support with HIV or SUD; and

vi. Program policies and procedures for working with HIV-infected clients and referring clients to individual HIV counseling and services when needed; and

d. Client rights and protections under section 245I.12 (MHC) for calendar year 2023 (personnel file numbered 4) and calendar year 2025 (personnel files numbered 1, 4 through 6, and 8);

e. Minnesota Health Records Act, including family engagement under section Minnesota Statutes

144.294 (MHC):

i. For calendar year 2023 (personnel file numbered 1 and 4);

ii. For calendar year 2024 (personnel files numbered 1, 4 through 6, and 8);

iii. For calendar year 2025 (personnel files numbered 1, 4 through 6 and 8); and

f. Emergency procedures, including fire and inclement weather, responding to a report of a missing person, behavioral emergencies, and medical emergencies (MHC) (personnel files numbered 1 and 4 through 6).

Statutes Violated: Minnesota Statutes, section 245A.19, 245A.65, subdivision 3, 245G.13, subdivision 2, paragraph (c) and (d), and 245I.05, subdivision 4, paragraph (a).

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, staff (personnel files numbered and 1, 4, 5, and 6) must receive training on HIV minimum standards and the license holder must submit verification of completion to their DHS licensor.

17. Violation: Four of four personnel files (personnel files numbered 1, 4, 5, and 6) did not meet requirements for emergency overdose treatment (245G). No documentation of staff training in the specific mode of administration of emergency overdose treatment (Narcan/Naloxone) used at the program, which may include intranasal administration, intramuscular injection, or both.

Statutes Violated: Minnesota Statutes, section 245A.242, subdivision 2, paragraph (a) and 245G.08, subdivision 5.

Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of this order, staff (personnel files numbered and 1, 4, 5, and 6) must receive training emergency overdose treatment and the license holder must submit verification of completion to their DHS licensor.

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 Maddy. Moore@state.mn.us or by mail:

Commissioner, Department of Human Services ATTN: Maddy Moore

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 651-431-4585 or at Maddy.Moore@state.mn.us

Sincerely,

Maddy Moore, Licensor Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/