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October 24, 2025 Elizabeth Rezek, Authorized Agent Elizabeth Rezek PO Box 142 Cottage Grove, MN 55106-0142 License Number: 1100939 CORRECTION ORDER Dear Elizabeth Rezek: On July 23 through 25, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Frazier Recovery Services DBA Frazier Wellness Services located at 621 Marie Avenue, South St. Paul, MN 55075-2039. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment services 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 for services provided. a. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c) for services provided to individuals with co-occurring mental health and substance use disorder problems: i. No diagnostic assessment completed within 10 days of admission (client files numbered 3 and 4); and ii. No documentation of co-occurring counseling staff receiving 8 hours of co-occurring disorder training annually for calendar year 2024 (personnel file numbered 1); b. The license holder did not provide peer recovery services in accordance with Minnesota Statute, section 254B.052. Peer recovery services were not offered face-to-face. On June 9, 2025 (client file numbered 1), a recovery treatment plan was developed without the client present; and c. The license holder did not provide treatment coordination services in accordance with Minnesota Statute, section 245G.07, subdivision 1, paragraph (a), clause (5). Documentation shows that treatment coordination services were billed for an internal case review on April 16, May 16, and June 13, 2025 (client file numbered 4). Statute Violated: Minnesota Statute, sections 245A.167 and 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services are provided in the amount for which they are billed. 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 services; disenrollment in the public payment program; or other administrative, civil, or criminal penalties provided by law. 2. Violation: The license holder did not follow requirements governing grievance procedures. The grievance procedure did not have the current telephone number and address for the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statute, section 245G.15, subdivision 2, clause (2). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 45 days of receipt of this order, submit a grievance procedure that meets all requirements. 3. Violation: The license holder did not meet requirements governing the description of treatment services. The description of treatment services did not identify which groups and topics on which a guest speaker could provide services. Statute Violated: Minnesota Statutes, section 245G.12, clause (10). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the treatment service description meets all requirements. Within 45 days of receipt of this order, submit a treatment services description that meets all requirements. 4. Violation: The license holder did not meet requirements governing provider policies and procedures. The policy and procedure manual did not contain resources to provide education on tuberculosis to each client on a form approved by the commissioner of the Department of Human Services. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1, paragraph (a), clause (2), and 245G.12, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures meet all applicable requirements. Personnel Files 5. Violation: One of seven personnel files reviewed for requirements governing staff qualifications did not meet requirements (personnel file numbered 6). An alcohol and drug counselor providing treatment services to adolescents did not have an additional 45 hours of coursework in adolescent development. Statute Violated: Minnesota Statutes, chapter 245G.18, subdivision 2, clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff qualifications meet all applicable requirements. Within 45 days of receipt of this order, submit documentation which demonstrates that the above personnel meet all applicable qualification requirements. 6. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit did not meet requirements (personnel file numbered 4). There was no documentation of the amount and type of supervision provided on at least a weekly basis for the weeks beginning January 6, 13, 20, and 27, February 3, 10, and 24, March 3, 10, 17, 24, and 31, April 21 and 28, May 5 and 19, June 9, 23, and 45, and July 14, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements regarding individuals with a temporary permit meet all applicable requirements. Within 45 days of receipt of this order, submit 3 weeks of supervision documents that meet all applicable requirements. 7. Violation: Two of two personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual trainings for calendar year 2025 (personnel files numbered 1 and 3) as follows: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E; ii. Program Abuse Prevention Plan; iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and iv. HIV minimum standards; and b. Every 2 year training for calendar year: i. 2024: 1. Client ethical boundaries (personnel files numbered 1 and 3); 2. Emergency procedures (personnel files numbered 1 and 3); and 3. Client rights (personnel file numbered 3); and ii. 2025: 1. Client rights (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (b), (c), and (d). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements. Within 45 days of receipt of this order, submit documentation that above mentioned staff have completed the required staff development in client ethical boundaries and emergency procedures. 8. Violation: One of four personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of a written annual review for calendar year 2025 (personnel file numbered 3). 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: Five of five client files reviewed for requirements governing client orientation did not meet requirements in the following ways: a. There was no documentation that each new person receiving services from the program received orientation to the internal and external maltreatment of vulnerable adults reporting procedures within 24 hours of admission (client files numbered 1 through 4); and b. The license holder did not provide opioid education material approved by the commissioner on the day of service initiation (client files numbered 1 through 5). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (c), and 245G.04, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 10. Violation: Three of five client files reviewed for requirements governing initial service plans (ISP) did not meet requirements in the following ways: a. The ISP was not person-centered and client-specific (client files numbered 2, 3, and 5); and b. The ISP did not identify the treatment needs of the client to be addressed during the time between the day of service initiation and the development of the individual treatment plan (client file numbered 5). Statute Violated: Minnesota Statutes, chapter 245G.04, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual service plans meet all applicable requirements. Within 45 days of receipt of this order, submit documentation of two initial service plans that meet all applicable requirements. 11. Violation: Three of five client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment did not include a review of the comprehensive assessment and update to the comprehensive assessment as clinically necessary to ensure compliance with Minnesota Statutes, section 245G.05, subdivision 1 when the client received a comprehensive assessment that authorized the treatment service (client files numbered 1 through 3); and b. The comprehensive assessment did not include: i. Substance use history, including duration of use (client file numbered 5); ii. Resources, including the extent and quality of the client’s social networks (client files numbered 4 and 5); and iii. Important developmental incidents in the client’s life (client file numbered 5). Statute Violated: Minnesota Statutes, chapter 245G.05. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 12. Violation: Four of five client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not completed by the end of the tenth day on which a treatment session was provided from the day of service initiation (client file numbered 3); b. The ITP was not person-centered (client files numbered 1 and 2); c. The ITP did not include how the family or others will be involved in the client's treatment and the reasons that the license holder did not involve the client’s family or other natural supports in the client’s treatment planning (client files numbered 2 and 3); and d. There was no documentation of the following (client file numbered 5): i. A treatment strategy; and ii. The ASAM level of care identified in section 254B.19, subdivision 1, under which the client is receiving services; iii. Coordination with the school system to address the adolescent client’s academic needs; and iv. A plan that addresses family involvement in the adolescent’s treatment. Statute Violated: Minnesota Statutes, chapter 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (1) and (3) through (5) and 245G.18, subdivision 5, clauses (1) and (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 13. Violation: Two of five client files reviewed for requirements governing documentation of treatment services did not meet requirements. The entries in the client’s record did not document the client’s response to the treatment service on: a. January 16 and March 12, 2025 (client file numbered 3); and b. June 2 and July 21, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, chapter 245G.06, subdivision 2a. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that documentation of treatment services meets all applicable requirements. 14. Violation: Four of five client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a. The treatment plan review did not document: i. Whether the identified treatment goal methods continue to be effective on: 1. January 21, February 18, March 18, and April 16, 2025 (client file numbered 4); 2. May 5, June 2, and June 30, 2025 (client file numbered 5); and 3. June 26, 2025 (client file numbered 1); b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1 intensive outpatient. There was no documentation of a treatment plan review due on the following dates: i. May 5, 2025 (client file numbered 5); and ii. July 7, 2025 (client file numbered 2). Statute Violated: Minnesota Statutes, chapter 245G.06, subdivisions 3, clause (1) and 3a, paragraph (e). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews 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.White@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer White 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) 431-6282 or at Jennifer.White@state.mn.us Sincerely,
Jennifer White, MBA, LADC Licensor 2 Licensing Division Office of Inspector General
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