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October 7, 2025 October Allen, Authorized Agent Grace Place LLC 414 W Superior St Duluth, MN 55802-1512 License Number: 1120840 (245G) Licensing Investigation: 202411111 Licensing Investigation: 202503531 CORRECTION ORDER Dear October Allen: On July 9 and 10, 2025, a Department of Human Services (DHS) licensor conducted a licensing review and investigation at your facility, located at 412 W Superior St Duluth, MN 55802-1512. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under 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, Practices and Procedures 1. Violation: The license holder did not meet requirements governing treatment services. Treatment services were provided by a staff member that was not a qualified professional (personnel file numbered 3). The staff member provided group counseling and individual counseling on November 18, 19, and 26, 2024; however, did not meet the qualifications of an alcohol and drug counselor until December 6, 2024. Statute Violated: Minnesota Statute, sections 245G.07, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that all treatment services are provided by qualified professionals. PO Box 64242 * Saint Paul, Minnesota * 55164-0242 * An Equal Opportunity Employer https://mn.gov/dhs/general-public/licensing/ 2. Violation: The license holder did not meet requirements governing emergency overdose treatment. The license holder did not maintain a supply of opiate antagonist as defined in Minnesota Statutes, section 604A.04, subdivision 1 available for emergency treatment of opioid overdose. Statute Violated: Minnesota Statute, sections 245G.08, subdivision 3 and 245A.242, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program maintains a supply of opiate antagonist. Personnel Files 3. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not meet requirements. The license holder did not have record of the date of first direct contact with persons served by the program (personnel files numbered 1 through 3). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure compliance with personnel file documents. 4. Violation: One of one personnel file reviewed for requirements governing an individual with a temporary permit from the Board of Behavioral Health and Therapy (BBHT) (personnel file numbered 3) did not meet requirements. There was no documentation of weekly supervision for an individual with a temporary permit for the week beginning May 12, 2025. Statute Violated: Minnesota Statutes, section 245G.11 subdivision 11, paragraph (b), 245G.13, subdivision 3, paragraph (5). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure compliance with requirements governing individuals with temporary permits. 5. Violation: One of three personnel files reviewed for requirements governing staff orientation (personnel file numbered 1) did not meet requirements. There was no documentation of orientation to HIV minimum within 72 hours of employment. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), and 245G.13, subdivision 1, clause (7). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure compliance with orientation requirements. Client Files 6. Violation: Three of three client files reviewed for requirements governing orientation did not meet requirements. There was no documentation of the following: a. On the day of service initiation: i. A written statement of client rights and responsibilities as identified in Minnesota Statutes, sections 144.651 and that the staff reviewed the statement with the client (client file numbered 3); and ii. Opioid educational material approved by the commissioner (client files 1 through 3); b. HIV Minimum Standards within 72 hours of admission (client file numbered 3); c. Information on the programs personal electronic device policy and the clients right to refuse being photographed or recorded (client files numbered 1 and 3); and d. Maltreatment of Vulnerable Adults internal and external reporting policies within 24 hours of admission (client files numbered 1 through 3). Statute Violated: Minnesota statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 1, paragraph (c), 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1), 245G.15, subdivisions 1 and 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 45 days of receipt of this order, submit client orientation documents that meet all applicable requirements. 7. Violation: One of three client files reviewed for requirements governing client education (client file numbered 3) 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. 8. Violation: Two of three client files reviewed for requirements governing initial services plan (ISP) (client files numbered 1 and 2) did not meet requirements. The ISP was not person centered and client specific. 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 the license holder will submit two initial services plans that meet all applicable requirements. 9. Violation: Three of three client files reviewed for requirements governing comprehensive assessment did not meet requirements in the following ways: a. The comprehensive assessment was not completed by an alcohol and drug counselor (client file numbered 3); b. The comprehensive assessment did not document the following: i. The client’s relationship with the client’s family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client files numbered1 and 2); and ii. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client file numbered 2). 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. 10. Violation: One of two client files reviewed for requirements governing individual treatment plans (ITP) (client file numbered 3) did not meet requirements. The ITP was not developed and signed by an alcohol and drug counselor. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Client documentation did not record a client response to a treatment service on: i. February 6 and 13, 2025 (client file numbered 1); ii. May 8, 2025 (client file numbered 2); and iii. November 26, 2024 (client file numbered 3); b. Documentation did not accurately record amount of treatment service on December 16, 2024 (client file numbered 3); and c. Documentation was not completed within seven days of providing the treatment service on November 19, 2024, and December 3, 2024 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all client records meet all applicable requirements. 12. Violation: Two of two client files reviewed for requirements governing treatment plan reviews did not meet requirements. A treatment plan review was not completed every 30 days for a client receiving nonresidential ASAM level 2.1 services for the timeframes: a. Treatment plan review was due on: i. April 17, 2025; however, was not completed until May 28, 2025 (client file numbered 2); ii. June 28, 2025; however, was not completed until July 7, 2025 (client file numbered 2); and iii. March 21, 2025; however, was not completed until April 7, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3a, paragraph (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all treatment plan reviews meet all applicable requirements. 13. Violation: One of two client files reviewed for requirements governing discharge summaries (client file numbered 3) did not meet requirements in the following ways: a. The service discharge summary was not completed within five days of service termination; and b. The service discharge summary did not document the clients’ issues and needs addressed while participating in treatment. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries 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: Jen 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 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, Jen Eppel, Licensor Licensing Division Office of Inspector General
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