|
October 24, 2025
Terri Senkow, Authorized Agent Metro Treatment of MN LP 2500 Maitland Center Pkwy Ste 250 Maitland, FL 32751-0000 License Number 830320 CORRECTION ORDER Dear Terri: On September 9, 10, 11, and 12, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility located at 2311 Woodbridge St, Roseville, MN 55113. As a result of this visit, DHS determined that you are in violation of the Substance Use Disorder statutes under Minnesota Statutes, 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 did not follow licensing rules and statutes, as described below. Throughout the correction order, references to the statute or rule requirement will be identified as follows: Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements governing specific measures to reduce the possibility of diversion. The license holder contacted less than five percent of clients who had unsupervised use of medication to require the clients to physically return to the program in March 2025. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (c), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that diversion control measures are followed and meet all applicable requirements. 2. Violation: The license holder did not develop written policies and procedures necessary to maintain compliance with licensing requirements for opioid treatment programs. The policy did not reflect the current criteria in the Code of Federal Regulations, title 42, part 8.12 (i) (2), when determining whether dispensing medication for a client’s unsupervised use is safe and appropriate to implement, increase, or extend the amount of time between visits to the program. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), clause (3), and 245G.22, subdivision 6, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that provider policy and procedures meets all applicable requirements. Within 30 days of receipt of this order, submit the revised policies and procedures that meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing the provision of telehealth services in accordance with Minnesota Statutes, section 256B.065, subdivision 5, paragraph (f). The license holder did not identify the categories or types of services the license holder will provide 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 telehealth policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. There was no documentation that a controlling individual reviewed the plan for calendar year 2025. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the transfer of clients and records meets all applicable requirements. Personnel Files 5. Violation: Two of two personnel files reviewed for requirements governing staff orientation (personnel files numbered 2 and 5) did not meet requirements. There was no documentation of orientation training on internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services. Rule and Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivision 1, clause (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that staff orientation meets all applicable requirements. Client Files 6. Violation: Seven of seven client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. There was no documentation of: a. The status of the client’s basic needs (client file numbered 2); b. The client’s employment status (client file numbered 3); c. The client’s perception of the client’s condition (client files numbered 6, 8, and 10); d. The client’s description of the client’s symptoms, including the reason for the client’s referral (client files numbered 6, 8, and 10); e. Substance use history, including: 1) Duration (client file numbered 2); and 2) Route of administration (client file numbered 8); f. 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 file numbered 10); g. Important developmental incidents in the client’s life (client files numbered 1, 2, 3, 6, 8, 9, and 10); h. Potential brain injuries (client files numbered 1, 2, 3, 6, 8, 9, and 10); i. The client’s family health history (client files numbered 8 and 10); j. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner (client files numbered 1, 2, 3, 6, 8, 9, and 10); k. A risk summary to support risk rating within each of the dimensions (client file numbered 8); and l. ASAM level of care recommendation as identified in Minnesota Statutes, section 254B.019, subdivision 1 (client files numbered 1, 2, 3, 6, 8, 9, And 10). Statute Violated: Minnesota Statutes, 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 30 days of receipt of this order, submit two comprehensive assessments that meet requirements. 7. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans did not meet requirements. There was no documentation of: a. A treatment strategy (client file numbered 2); b. ASAM level of care identified in Minnesota Statutes, section 245B.19, subdivision 1, under which the client is receiving services (client files numbered 1, 2, 3, and 6 through 10); and c. Participants involved in the client’s treatment planning (client files numbered 3and 6 through 10). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1a, clauses (3) through (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan that demonstrates compliance. 8. Violation: Two of ten patient files reviewed for requirements governing client record and treatment service documentation did not meet requirements. Treatment services provided via telehealth did not include the location of the originating site and the distance site (patient file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 2b, and 245G.07, subdivision 4, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record and treatment service documentation meets all applicable requirements. 9. Violation: Eight of eight client files reviewed for requirements governing treatment plan reviews and their frequency did not meet requirements. There was no documentation of: a. The span of time covered by the review (client files numbered 1, 2, 3, and 6 through 10); b. Client goals addressed since the last treatment plan review (client files numbered 1 and 7); c. Whether the identified methods continue to be effective (client files numbered 3, 6, 9, and 10); d. Nonresidential opioid treatment plan review completed: 1) Weekly for ten weeks: i. September 22-28, 2024, October 13-19, 2024, and October 20-26, 2024 (client file numbered 1); ii. May 11-17, 2025, May 18-24, 2025, and June 1-7, 2025 (client file numbered 2); iii. May 18-24, 2025 (client file numbered 6); and iv. August 3-9, 2025 (client file numbered 8); 2) Monthly thereafter: i. January 30, 2024 completed late (client file numbered 7); and ii. July and August 2025 (client file numbered 9). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3, clause (1) and 3a, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews and their frequency meet all applicable requirements. Within 30 days of receipt of this order, submit treatment plan reviews from two clients that meet all requirements. 10. Violation: Two of four client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. Service discharge summary was not completed within five days of the client’s service termination (client file numbered 7); and b. There was no documentation of the following (client file numbered 1): 1) The client’s issues, strengths, and needs while participating in treatment; 2) The client’s progress toward achieving each of the goals identified in the individual treatment plan; and 3) A risk rating and description for each of the ASAM six dimensions. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (1) through (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. 11. Violation: One of seven client files reviewed for requirements governing opioid treatment programs central registry (client file numbered 10) did not meet requirements. The current or previous enrollment status in another opioid treatment program was not listed. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a), clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that central registry documentation 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 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 in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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: Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This withdrawal management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F and Minnesota Rules, parts 9530.6590 (Rule 32) · 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 Char Hanson, Licensor, at 651-431-6617. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
|
