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October 30, 2025 Michelle Kellum, Authorized Agent Juel Fairbanks Chemical Dependency Services 806 N. Albert St. St. Paul, MN 55104 License Number: 803854 CORRECTION ORDER Dear Michelle Kellum: On August 12 through 14, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Juel Fairbanks Chemical Dependency Services located at 806-804 N. Albert St., St. Paul, MN, 55104. 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 governing service termination policies. The service termination policy did not include: a. A requirement that before discharging a client from a residential setting, for not reaching treatment plan goals, the license holder must confer with other interested persons to review the issues involved in the decision; and b. Procedures consistent with Minnesota Statutes, Section 253B.16, subdivision 2, that staff members must follow when a client admitted under Minnesota Statutes, chapter 253B is to have services terminated. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3, clauses (3) and (4). Correction Action Required: Immediately, and on ongoing basis, the license holder must ensure that service termination policies meet all applicable requirements. Within 45 days of receipt of this order, submit a service termination policy that meets all applicable requirements. 2. Violation: The license holder did not meet the requirements governing client rights protections. The license hold did not have policies and procedures that protect client rights as identified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03, as applicable. Statute Violated: Minnesota Statutes, sections 245G.12, clause (5) and 245G.15, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures are followed and meet all requirements. Within 45 days of receipt of this order, submit client rights that meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing grievance procedures. Three of six grievances reviewed did not have documentation that the license holder responded to client’s grievance within three days of a staff member’s receipt of the grievance on the following dates: a. August 15, 2023; b. May 4, 2024; and c. May 6, 2025. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. 4. Violation: The license holder did not meet requirements governing the description of treatment services. The description of treatment services did not: a. Include the amount and type of services provided; b. Identify which services meet the definition of group counseling; c. Identify which groups and topics on which a guest speaker could provide; and d. Define the program’s treatment week. 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 applicable requirements. 5. Violation: The license holder did not meet requirements governing health services. The health services policy did not include: a. Written procedures for obtaining a medical intervention for a client, that are approved in writing by a physician who is licensed under Minnesota Statutes, chapter 147, advanced practice registered nurse who is licensed under Minnesota Statutes, chapter 148, or physician assistant who is licensed under Minnesota Statutes, chapter 147A; b. Written procedures for assessing and monitoring a client's health approved and signed by an RN; c. A provision that a client may carry emergency medication as instructed by the client’s physician, advanced practice registered nurse, or physician assistant; and d. A provision for the client to self-administer medication when a client is scheduled to be away from the facility. Statute Violated: Minnesota Statutes, sections 245G.08, subdivisions 2 and 5, paragraph (c), clauses (3) and (4) and 245G.21, subdivisions 7 and 8. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies regarding administration of medication and assistance with self-medication meet all applicable requirements. Within 45 days of receipt of this order, submit a health services policy that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing program abuse prevention plans. There was no documentation that the license holder’s governing body or the governing body’s delegated representative reviewed the program abuse prevention plan for calendar year 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that program abuse prevention plans meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing the reporting of maltreatment of vulnerable adults in the following ways: a. The policies and procedures did not: i. Identify the primary and secondary person or position to whom internal reports may be made; ii. State that the secondary person must be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and iii. Identify the primary and secondary person or position who will ensure that internal reviews are completed; and b. There was no documentation that an internal review was completed within 30 days when the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made for the following dates: i. August 10, 2023; and ii. December 19, 2024. Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraphs (a), clause (2) and paragraph (b), clauses (1) and (2) and 245G.12, clause (9). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adult policies and procedures meet all applicable requirements. Within 45 days of receipt of this order, submit a maltreatment of vulnerable adults reporting policy that meets all applicable requirements. Personnel Files 8. Violation: One personnel file (personnel file numbered 3) reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation: a. Within 24 working hours related to client needs; b. Program abuse prevention plan within 72 hours of direct contact; and c. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E before a mandatory reporter has direct contact. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivisions 1, clause (7), and 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 9. Violation: Four of five personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual training on HIV minimum standards for calendar year: i. 2023 (personnel files numbered 1, 2, 4, and 5); and ii. 2025 (personnel files numbered 4 and 5); and b. Every two year training on client ethical boundaries for calendar year 2023 (personnel files numbered 4 and 5). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b) and 245G.13, subdivision 2, paragraphs (b), clause (1), and (d). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with staff development requirements. 10. Violation: Four of five personnel files reviewed for requirements governing personnel files did not meet requirements. There was no documentation of the following: a. The date that the employee first had direct contact with a person served by the program (personnel file numbered 3); and b. A written evaluation completed for calendar year: i. 2023 (personnel files numbered 2 and 4); and ii. 2024 (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6, and 245G.13, subdivision 1, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with all personnel file requirements. Client Files 11. Violation: Five of five client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation that the client received: a. A written statement of client rights and responsibilities from Minnesota Statutes, sections 144.651 and 148F.165 on the day of service initiation (client files numbered 1, 3, 4, and 5); b. A staff member review of the client rights and responsibilities from Minnesota Statutes, sections 144.651 and 148F.165 (client file numbered 1); c. An explanation of the grievance procedure on the day of service initiation (client files numbered 1 through 5); d. A grievance procedure containing the current address and phone number for the Minnesota Board of Behavioral Health and Therapy (client files numbered 1 through 5); e. Orientation to HIV minimum standards within 72 hours of admission to the program (client file numbered 1); f. Policy regarding the use of any personal electronic device and the client’s right to refuse being photographed or recorded (client file numbered 1); g. Orientation to maltreatment of vulnerable adult internal and external reporting procedure within 72 hours of admission to the program (client file numbered 1); and h. Opioid educational material approved by the commissioner on the day of service initiation (client files numbered 1, 3, and 5). 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), and 245G.15, subdivisions 1, 2, and 3, paragraph (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 12. Violation: One of five client files (client file numbered 1) reviewed for requirements governing maltreatment of vulnerable adults did not meet requirements. There was no documentation that the program sought consent to the disclosure of suspected maltreatment upon a patient’s admission as required in Minnesota Statutes, section 626.557, subdivision 3a, clause (1). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1a, paragraph (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements governing maltreatment of vulnerable adults meet all applicable requirements. 13. Violation: One of five client files (client file numbered 1) reviewed for requirements governing initial service plans (ISP) did not meet requirements. The ISP was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, 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. 14. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 through 5) did not meet requirements. There was no documentation of the following: a. An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults; and b. An assessment of the person’s risk of abusing other vulnerable adults. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), clause (1), 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 individual abuse prevention plans meet all applicable requirements. Within 45 days of receipt of this order, submit one IAPP that meets all applicable requirements. 15. Violation: Five of five client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include the following: a. The status of the client’s basic needs (client files numbered 1 and 2); b. The client’s description of the client’s symptoms, including the reason for the client’s referral (client files numbered 1 and 2); c. Substance use history, including duration of use (client file numbered 5); d. The client's resources, including the extent and quality of the client's social networks (client files numbered 1 through 3); e. Important developmental incidents in the client's life (client files numbered 1 through 3); f. Potential brain injuries (client file numbered 2); and g. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 through 5). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 16. Violation: Five 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 within ten days from the day of service initiation (client file numbered 1); b. The ITP was not based on the client’s comprehensive assessment (client file numbered 1); c. The ITP was not updated based on new information about the client’s level of participation (client file numbered 3); and d. The ITP did not document the following (client files numbered 1 through 5): i. A treatment strategy; and ii. The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services. Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (1) and (4). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 45 days of receipt of this order, submit one individual treatment plans that meet all requirements. 17. Violation: Five of five client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Documentation was not completed within seven days of providing a treatment service on January 22, 2025 (client file numbered 1); b. Documentation within 24 hours of a significant event that occurred on October 19, 2024 (client file numbered 5); and c. Documentation of treatment services did not include: i. Type of treatment service for the following dates: 1. August 5, 6, 8, 9, 12 through 16, 2024 (client file numbered 4); 2. October 7 through 10 and 15 through 17, 2024 (client file numbered 5); 3. January 21 through 24, February 3-7, and March 17-21, 2025 (client file numbered 1); 4. April 28 through 30, May 5 through 8, and July 7 through 10, 2025 (client file numbered 2); and 5. July 1 through 3, 7 through 11, 14, and 15, 2025 (client file numbered 3); ii. Amount of treatment service provided on March 17, 2025 (client file numbered 1); and iii. Client response for March 21, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 18. Violation: Five of five client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review did not document: i. Client goals addressed since the last treatment plan review on May 6 and June 17, 2025 (client file numbered 2); ii. Whether identified methods continue to be effective on February 13, March 5, and April 8, 2025 (client file numbered 1); and iii. Monitoring of any physical and mental health problems and include toxicology results on: 1. July 25, August 7 and 29, and September 28, 2024 (client file numbered 4); 2. October 15, 2024 (client file numbered 5); and 3. May 30, June 18, July 3, 18 and 31, 2025 (client file numbered 3); and b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1 intensive outpatient. The treatment plan review was due on April 08, 2025; however, was not completed until April 08, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3, clauses (1) and (2) 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. 19. Violation: One of three client files (client file numbered 4) reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of service termination; and b. The discharge summary did not include the client’s living arrangements at service termination. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clause (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements. 20. Violation: Three of five client files reviewed for requirements governing the contents of client records did not meet requirements. There was no documentation that the client was given information about tuberculosis on the form approved by the commissioner (client files numbered 1, 4, and 5). 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 contents of client records meet all 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 L. White, LADC, MBA, Licensor II Licensing Division Office of Inspector General
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