September 19, 2025

Genna Montpetit, Authorized Agent Wild River Services Inc

1394 Jackson St

St Paul, MN 55117

License Number: 1090195 (245G)

Investigation Number: 202501641

Investigation Number: 202500287

Investigation Number: 202500492

CORRECTION ORDER

Dear Genna Montpetit:

On June 23 through June 27, 2025, a Department of Human Services (DHS) licensor conducted a licensing review and investigation at your facility, The Heights Jackson located at 1394 Jackson St., St. Paul, MN 55117. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under Minnesota Statute 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.

Policy, Procedures and Practices

1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for ASAM 3.5 level of care services provided. The license holder did not provide, at minimum, daily skilled treatment services seven days a week as required by Minnesota Statutes, section 254B.19 subdivision 1, clause (7), ASAM standards of care for the week beginning January 6, 2025 (client file numbered 2).

Statute Violated: Minnesota Statute, section 245A.167, paragraph (a).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that daily skilled treatment services are provided seven days a week. The noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program

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

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 grievance procedures. The license holder did not respond to a client’s grievance within three days of a staff members receipt of the grievance, on grievances dated:

a. November 20, 2024; and

b. January 17, 2025.

Statute Violated: Minnesota Statute, section 245G.15, subdivision 2, clause (3).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program’s grievance procedure meets all requirements.

3. Violation: The license holder did not monitor the implementation of their policies and procedures as follows:

a. The license holder had two conflicting versions of the treatment services description;

b. The license holders’ policy regarding reporting maltreatment of vulnerable adults referenced a program that is not affiliated with the license.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), clause (c), 245A.65, subdivision 1, paragraph (a), 245G.07 and 245G.12.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the programs policies and procedures manual meets all applicable requirements. Within 45 days of receipt of this order, submit an updated vulnerable adult reporting policy.

4. Violation: The license holders’ policy governing administration of medication did not meet requirements. The license holder’s policies and procedures did not include guidelines for when to inform a nurse of problems with self-administration of a medication, including a client’s failure to administer, refusal of a medication, adverse reaction or error.

Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c).

Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that policy regarding administration of medications meets all applicable requirements. Within 45 days of receipt of this order, submit a policy that meets all applicable requirements regarding administration of medication.

5. Violation: The license holder did not provide supervision on-site by a registered nurse as defined in Minnesota Statutes, section 148.171, subdivision 23, at minimum, monthly or more often as warranted by a client’s health needs. There was no documentation of monthly nursing supervision since October 2024.

Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c).

Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that supervision on-site by a registered nurse, is provided at least monthly. Within 45 days of receipt of this order, submit documentation of monthly on-site supervision provided by a registered nurse.

6. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. There was no documentation that the plan was reviewed and signed annually by a controlling individual for calendar year 2024.

Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements.

Personnel Files

7. Violation: Three of four personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following:

a. Annual trainings for:

i. Calendar year 2024 (personnel file numbered 1):

1. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E including specific training covering the license holder’s policies for obtaining a release of client information; and

2. HIV minimum standards; and

ii. Calendar year 2025 (personnel files numbered 1 and 4):

1. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E including specific training covering the license holder’s policies for obtaining a release of client information; and

2. HIV minimum standards;

b. Every two-year training for the calendar year 2025 for (personnel file numbered 1):

i. Client confidentiality rules and regulations and client ethical boundaries; and

ii. Emergency procedures and client rights; and

c. 12 hours of co-occurring disorder training within 6 months of hire (personnel file numbered 3).

Statute Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (b) through (f).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements.

8. Violation: Two of four personnel files reviewed for requirements governing personnel file content did not meet requirements. There was no written annual review for the following:

a. Calendar year 2024 (personnel file numbered 1); and

b. Calendar year 2025 (personnel file numbered 4).

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

9. Violation: One of five client files reviewed for requirements governing client orientation (client file numbered 2) did not meet requirements. There was no documentation of the following:

a. On day of service initiation:

i. A written statement of client rights and responsibilities and that the staff reviewed the statement with the client;

ii. Grievance procedure; and

iii. Opioid educational material approved by the commissioner;

b. Within 72 hours of admission, the HIV Minimum Standards;

c. Information on the programs personal electronic device policy and the clients right to refuse being photographed or recorded; and

d. Within 24 hours of admission, the maltreatment of vulnerable adults internal and external reporting policies.

Statute Violated: Minnesota Statute, sections 245A.19, 245A.65, subdivision 1, paragraph (c), 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1), and 245G.15.

Corrective Action Required: Immediately, and on an ongoing basis the license holder must ensure that client orientation meets all applicable requirements.

10. Violation: One of five client files reviewed for requirements governing client education (client file numbered 2) did not meet requirements. There was no documentation in the client record that the client received information on tuberculosis education on a form approved by the commissioner.

Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1, paragraph (a), clause (2), and 245G.09, subdivision 3, clause (1).

Corrective Action Required: Immediately, and on an ongoing basis the license holder must ensure that client education meets all applicable requirements.

11. Violation: Five of seven client files reviewed for requirements governing initial services plan (ISP) did not meet requirements. The ISP was not person centered and client specific (client files numbered 1 through 3, 6 and 7).

Statute Violated: Minnesota Statute, section 245G.04, subdivision 1.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. Within 45 days of receipt of this order, submit two initial service plans that meet all applicable requirements.

12. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 through 3) did not meet requirements. The IAPP did not include documentation of an individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and self-abuse.

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), 245G.04, subdivision 2, paragraph (b), and 245G.21 subdivision 6.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. Within 45 days of receipt of this order, submit one individual abuse prevention plan the meets all applicable requirements.

13. Violation: Four of four client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways:

a. The comprehensive assessment was not completed by the end of the fifth day on which a treatment service was provided and there was no documentation identifying the client-centered reason why the assessment was not completed within this timeframe (client files numbered 4 and 5); and

b. The comprehensive assessment did not document the following:

i. The client’s perception of the client’s condition (client file numbered 2);

ii. The client’s description of the client’s symptoms (client files numbered 2, 4 and 5);

iii. Periods of abstinence (client file numbered 5);

iv. Circumstances of relapse (client files numbered 4 and 5);

v. The client’s relationship with the client’s family and other significant personal relationships, including the client’s evaluations of the quality of each relationship (client file numbered 2);

vi. Important developmental incidents in the client’s life (client files numbered 2 through 5);

vii. The client’s history of or exposure to alcohol and drug usage (client files numbered 2 and 5);

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

ix. The client’s health history (client file numbered 3);

x. The client’s family health history (client files numbered 2 through 5);

xi. Diagnosis of a substance use disorder, or a finding that the client does not meet the criteria for a substance use disorder (client file numbered 3); and

xii. Determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (client files numbered 2 through 5).

Statute Violated: Minnesota Statute, section 245G.05.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 45 days of receipt of this order, submit two comprehensive assessments that meet all applicable requirements.

14. Violation: Four of seven client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows:

a. The ITP was not completed by the end of the tenth day on which a treatment session had been provided from the day of service initiation (client files numbered 4 and 5);

b. The ITP was not updated based on new information gathered about the client condition, level of participation, and whether methods identified have the intended effect (client file numbered 2);

c. An update to the ITP was not signed by the client (client file numbered 5);

d. The ITP was not based on the client’s comprehensive assessment (client file numbered 2); and

e. The ITP did not document the following:

i. A treatment strategy (client files 2 through 5);

ii. ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 2 through 5); and

iii. Active interventions to stabilize mental health symptoms (client file numbered 2).

Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 1 and 1a, clauses (1), (3), and (4), and 245G.20, clause (5).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Violation: Eight of eight client files reviewed for requirements governing client record documentation did not meet requirements in the following ways:

f. Documentation of a significant event that occurred at the program was not completed within 24 hours of an event occurring on:

i. December 29, 2024 (client file numbered 6); and

ii. December 10, 2024 (client file numbered 7);

g. Documentation was not accurate. A group note dated December 30, 2024, indicated that client attended group; however, documentation in the client file indicated they were hospitalized during this time (client file numbered 6);

h. Documentation was not completed within seven days of providing the treatment service on:

i. February 22, 2025 (client file numbered 1);

ii. December 12, 2024 (client file numbered 2);

iii. May 11 and June 26, 2025 (client file numbered 3); and

iv. May 8, 2025 (client file numbered 5); and

i. Client documentation did not record:

i. Type of treatment service for the following dates:

1. February 20 through 22, 2025 (client file numbered 1);

2. December 9 through 13, 2024 and January 6 through 10, 2025 (client file

numbered 2);

3. May 11, 19 through 21, and 23, and June 2, 3, and 6, 2025 (client file numbered

3);

4. May 12, 14, and 15, and June 9 through 12, 2025 (client file numbered 4); and

5. April 28 and 30, May 1, 5 and 7, and June 11 and 12, 2025 (client file numbered

5);

ii. Client response to each treatment service for the following dates:

1. December 11, 2024 (client file numbered 2); and

2. May 11, and 22 and June 2, 5, and 6, 2025 (client file numbered 3); and

iii. Job title of the staff person making the entry on the following:

1. February 19and 24, 2025, (client file numbered 1);

2. December 3 and 6, 2024 (client file numbered 2);

3. May 13, 22 and 23, 2025 (client file numbered 3);

4. April 28, May 14, 15, and June 20, 2025 (client file numbered 4);

5. March 18, 27, and April 17, 2025 (client file numbered 5);

6. November 27, December 11 and 26, 2024, January 13, and 27, February 10,

March 5, 10, 24 and 29, 2025 (client file numbered 7); and

7. December 6, 2024 and January 17, 2025 (client file numbered 8).

Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraphs (a) and (c).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all client records meet all applicable requirements.

15. Violation: Two of six client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows:

a. The treatment plan review did not document the following:

i. Participation of others involved in the individual’s treatment planning, including services offered to client’s family or significant others (client file numbered 2 and 5);

ii. Whether the client agrees with the staff recommended changes in the methods identified (client file numbered 5); and

iii. Collaboration with continuing care mental health providers and involvement of the providers in the treatment planning meetings (client file numbered 2); and

b. A treatment plan review was not completed every 30 days for a client receiving ASAM level

2.1 services. The treatment plan review was due on March 18, 2025, and was not completed until March 27, 2025 (client file numbered 5).

Statute Violated: Minnesota Statutes, sections 245G.06 subdivision 3, clauses (3) and (4), and 245G.20, clause (6).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all treatment plan reviews meet all applicable requirements.

16. Violation: Three of three client files reviewed for requirements governing medication administration did not meet requirements. There was no documentation of client’s use of medication including staff signatures with date and time for the following:

a. December 4, 8 17, 19, 20 22, 25, 28 through 31, 2024 and January 2 through 5, 9, 12, 17, 21

through 23, 2025 (client file numbered 2);

b. June 10, 13, 14, 20 through 22, 2025 (client file numbered 3); and

c. October 22, 23, 26, November 19 and 20, December 17 through 20, and 28 through 31,

2024; (client file numbered 6).

Statute Violated: Minnesota Statutes, sections 245G.08, subdivision 5, paragraph (c), clause (7) and 245G.21, subdivision 8.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all requirements governing medication administration are met.

17. Violation: Two of two client files reviewed for requirements governing discharge summaries did not meet requirements. The discharge summaries did not document the following:

a. Progress towards achieving each of the goals identified in the individual treatment plan (client file numbered 2); and

b. A risk rating and description for each of the ASAM six dimensions (client file numbered 1).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b), clauses (2) and (3).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements.

18. Violation: Two of three client files reviewed for requirements governing property management did not meet requirements as follows:

a. The license holder did not ensure that persons served by the program retained the use and availability of personal property. A note in the client record on January 10, 2025, indicated that the client’s cell phone would be confiscated; however, there was no justification for the restriction in the client’s individual plan (client file numbered 2); and

b. There was no documentation of the following:

i. Receipt of the client’s property, including the person’s signature (client file numbered 2); and

ii. Disbursement of the client’s property, including the person’s signature (client files numbered 1 and 2).

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 13, paragraphs (a) and (c), clause (1) and 245G.21 subdivision 3.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements governing client property management meet 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.eppel@ state.mn.us or by mail:

Commissioner, Department of Human Services ATTN: Jennifer Eppel

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 651-431-6698 or at jennifer.eppel@state.mn.us.

Sincerely,

Jennifer Eppel, 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/