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October 2, 2025 Lewis Zeidner, Authorized Agent Lake Shore Treatment Center LLC dba EOSIS Lake Shore 550 Main St Suite 230 New Brighton, MN 55112 License Number 1067244 CORRECTION ORDER Dear Lewis: On August 13, 14, 15, and 18, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Lake Shore Treatment Center LLC dba EOSIS Lake Shore located at 140 Quail St, Mahtomedi, MN 55115. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder 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 did not meet requirements for receiving public funding reimbursement from the commissioner under Minnesota statutes, section 254BG.05, subdivision 5, paragraph (c) for higher rates for service provided to individuals with co-occurring mental health and substance use disorder problems as follows: a. The monthly multidisciplinary case review for June 2025 did not document the inclusion of a licensed mental health professional; and b. There was no documentation of eight hours of co-occurring disorders training annually for the 2024 calendar year (personnel file numbered 6). Statute Violated: Minnesota statutes, sections 245A.191. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that monthly multidisciplinary case reviews includes a licensed mental health professional. Additionally, 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 service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. 2. Violation: The license holder did not meet requirements governing client rights protection. The license holder’s policies and procedures did not include all client rights identified in Minnesota Statutes, section 144.651. Statute Violated: Minnesota statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that client rights meet all applicable requirements. Within 30 days of receipt of this order, submit client rights that meet requirements. 3. Violation: The license holder did not monitor the implementation of policies and procedures necessary to maintain compliance with licensing requirements. The license holder did not ensure that procedures for acceptance, documentation, and implementation of a prescription were followed: a. May 27, 2025 order for Trazadone 50mg as needed was transcribed incorrectly on the medication record (client file numbered 3); and b. Thiamine 100mg for 30 days was ordered on June 11, 2025, and was not transcribed on the medication record (client file numbered 3). Statute Violated: Minnesota statutes, section 245A.04, subdivision 14, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that provider policy and procedures meet all applicable requirements. 4. Violation: The license holder did not meet staff requirements in the following ways: a. The treatment director did not designate a staff member who, when present in the facility, is responsible for the delivery of treatment services during all hours of operation; and b. There was no documentation that at least one staff person on the premises, when a client was present, had a current American Red Cross standard first aid certificate or an equivalent certificate from July 13, 2025 through July 26, 2025. Statute Violated: Minnesota statutes, section 245G.10, subdivisions 3 and 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that staff requirements meet all applicable requirements. Personnel Files 5. Violation: One of seven personnel files reviewed for requirements governing background studies (personnel file numbered 3) did not meet requirements. Staff person began a position allowing direct contact with persons served by the program on May 27, 2025. A background study (BGS) was submitted under license number 802564; however, staff person was also working under license number 1067244. The license holder failed to affiliate staff person to all required rosters. Statute Violated: Minnesota statutes, section 245C.07, paragraph (a). Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Violation corrected on August 18, 2025 with a cleared BGS affiliated with license number 1057244. 6. Violation: Five of five personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of training on the program abuse prevention plan (PAPP) for calendar year 2025 (personnel file numbered 1, 2, 3, 4, and 6). Statute Violated: Minnesota statutes, section 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure annual training meets all applicable requirements. 7. Violation: One of seven personnel files reviewed for requirements governing staff qualifications (personnel file numbered 1) did not meet requirements. There was no documentation of the amount and type of supervision provided at least weekly from June 5, 2025, through June 30, 2025, for an individual with a temporary permit. Statute Violated: Minnesota statutes, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure that staff qualifications meet all applicable requirements. Client Files 8. Violation: Two of three client files reviewed for requirements governing client orientation (client files numbered 1 and 3) did not meet requirements. There was no documentation that the client was orientated to the PAPP within 24 hours of admission to the program. Statute Violated: Minnesota statutes, section 245A.65, subdivision 2, paragraph (a), clause (4), and 245G.09, subdivision 3, clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client rights protection meets all applicable requirements. 9. Violation: Three of three client files reviewed for requirements governing initial services plan (ISP) (did not meet requirements as follows: a) The ISP was not person-centered and client specific (client files numbered 1, 2, and 3); and b) There was no documentation of immediate health and safety concerns (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. Within 30 days of receipt of this order, submit two ISP that meet all applicable requirements. 10. Violation: Two of three client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not document the following: a. Client’s description of the client’s symptoms (client file numbered 3); b. Client’s evaluation of the quality of each relationship (client file numbered 3); c. The client’s resources (client file numbered 3); d. Important developmental incidents in the client’s life (client file numbered 2); and e. A risk rating within each of the dimensions listed in Minnesota Statutes, section 254B.04, subdivision 4 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. The ITP did not include a treatment strategy (client files numbered 1, 2, and 3). Statute Violated: Minnesota statutes, section 245G.06, subdivision 1a, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan that meets all applicable requirements. 12. Violation: Two of three client files reviewed for requirements governing client record keeping did not meet requirements in the following ways: a. May 16, 2025 individual note did not include the staff member’s signature (client file numbered 2); and b. The comprehensive assessment contained inaccurate information about the client’s history of substance use disorder treatment (client file numbered 1). 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 meets all applicable requirements. 13. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency did not meet requirements in the following ways: a. TPR did not include staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 3); and b. TPR was not completed once every 14 days as follows: 1) A TPR was due on 7/15/2025; however, not completed until July 23, 2025(client file numbered 1); 2) A TPR was due on July 30, 2025; however, not completed until August 1, 2025 (client file numbered 1); and 3) A TPR was due on May 14, 2025; however, not completed until May 29, 2025 (client file numbered 2). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3, clause (4) and 3a, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 14. Violation: One of three client files reviewed for requirements governing medication administration did not meet requirements. The client’s use of medication was not recorded, including staff signatures with date and time on July 5, 2025 (client file numbered 1). Statute Violated: Minnesota statutes, sections 245G.08, subdivisions 5, paragraph (c), clause (7), 6, clause (3), and 245G.21, subdivision 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure 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 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 651-431-6617 or at Charlene.m.hanson@state.mn.us. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
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