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November 3, 2025 Fartun Wardere, Authorized Agent Serenity Recovery LLC 1821 University Avenue W, Suite S298 Saint Paul, MN 55104 License Number: 1114345 CORRECTION ORDER Dear Fartun Wardere: On July 28, 29, 30, 31, and August 1, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Serenity Recovery LLC located at 1821 University Avenue W, Suite S298, Saint 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 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 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. Group counseling was billed for services not provided as follows: a. Five hours were billed for on March 18, 2025; however, there was no supporting documentation (client file numbered 1); b. Five hours were billed for on March 19 and 20, 2025; however, only four hours were documented (client file numbered 1); c. Five hours were billed for on May 12, 2025; however, only four hours were documented (client file numbered 3); d. Six hours were billed for on June 4, 5, 9, 12, 16, and 17, 2025; however, only four hours were documented (client file numbered 4); e. Six hours were billed for on June 10, 2025; however, only five hours were documented (client file numbered 4); and f. Six hours were billed for on June 11, 2025; however, only three hours were documented (client file numbered 4). Statute Violated: Minnesota Statutes, section 245A.167. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they are billed. 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 grievance procedures in the following ways: a. The grievance procedure did not require that a staff member help the client develop and process a grievance; and b. The grievance procedure did not identify the current address of the Office of Ombudsman for Mental Health and Developmental Disabilities. Statute Violated: Minnesota Statutes, sections 245G.15, subdivision 2 and 245G.12, clause (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. Within 60 days of receipt of this order, submit a grievance procedure that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults reporting. The procedures for reporting the maltreatment of vulnerable adults did not include the secondary person or position responsible for forwarding internal reports to the common entry point as defined in Minnesota Statutes, section 626.5572, subdivision 5. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (a), clause (2) and paragraph (d) and 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of vulnerable adults reporting policy meets all applicable requirements. Within 60 days of receipt of this order, submit a maltreatment of vulnerable adults reporting policy that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing client rights protection. The client rights protection policy did not include rights according to Minnesota Statutes, section 253B.03. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client rights meet all applicable requirements. Within 60 days of receipt of this order, submit a client rights protection policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing HIV policies and procedures. The policies and procedures were not consistent with the HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (d) and 245G.12, clause (2). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that HIV minimum standards meet all applicable requirements. Within 60 days of receipt of this order, submit HIV minimum standards that meet all applicable requirements. 6. Violation: The license holder did not meet requirements governing maltreatment of minors reporting. The procedures for reporting the maltreatment of minors were not consistent with Minnesota Statutes, chapter 260E. Statute Violated: Minnesota Statutes, section 245G.12, clause (9). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of minors reporting of meet all applicable requirements. Within 30 days of receipt of this order, submit a maltreatment of minors reporting policy that meets all applicable requirements. 7. Violation: The license holder did not meet requirements for physical plant postings. A copy of the internal and external reporting policies and procedures was not posted in a prominent location in the program. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraphs (a) and (b), clause (3), 245A.65, subdivision 1, 245G.13, subdivision 1, clause (6), and 245G.14. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that physical plant postings meet all applicable requirements. 8. Violation: The license holder did not meet requirements governing medical emergencies. The license holder did not ensure that at least one staff member on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate on July 28, 29, 30, 31, and August 1, 2025 from 9:00 AM to 5:00 PM. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that medical emergency staff requirements are met. Client Files 9. Violation: Three of three client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation: a. Opioid education material on a form approved by the commissioner on the day of service initiation (client files numbered 1 through 3); b. HIV minimum standards within 72 hours of admission (client file numbered 3); and c. The personal electronic device policy (client files numbered 1 through 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1), and 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 60 days of receipt of this order, submit documentation of one client orientation that meets all applicable requirements. 10. Violation: Two of three client files reviewed for requirements governing tuberculosis education (client files numbered 1 and 2) did not meet requirements. There was no documentation that the client was provided tuberculosis education on a form approved by the commissioner. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1, paragraph (a), clause (2) and245G.09, subdivision 3, clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that tuberculosis education meets all applicable requirements. 11. Violation: Two of three client files reviewed for requirements governing initial services plans (client files numbered 1 and 2) did not meet requirements. The initial services plan was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1 and 245G.09, subdivision 3, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements. 12. Violation: Two of three client files reviewed for requirements governing vulnerable adult determinations (client files numbered 1 and 2) did not meet requirements. The vulnerable adult status was not determined within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult status meets all applicable requirements. 13. Violation: Two of three client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed by the end of the fifth day on which a treatment service was provided and did not include the person-centered reason for the delay and the planned completion date (client file numbered 1); b. There was no documentation that a compressive assessment that authorized the treatment service was not reviewed and updated as clinically necessary by the end of the fifth day on which a treatment service was provided (client file numbered 3); and c. The comprehensive assessment did not include the following information: i. The reason for the client’s referral client file numbered 1); ii. Substance use history, including rout of administration (client file numbered 2); iii. 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 2); iv. Important developmental incidents in the client’s life (client files numbered 1 and 2); and v. The client’s family health history (client file numbered 2). 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. 14. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) (client files numbered 1 through 3) did not meet requirements as follows: 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; and b. An alcohol and drug counselor did not review and sign an ITP prepared by a student intern (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 1 and 245G.11, subdivision 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 15. Violation: Three of four client files reviewed for requirements governing client record documentation did not meet requirements as follows: a. Entries in the client’s record were not accurate. The amount of group counseling identified in the documentation of treatment services was inconsistent with group sign-in sheets for services provided on: i. March 19, 2025 (client file numbered 1); and ii. June 10 and 16, 2025 (client file numbered 4); and b. Entries in the client record did not document the amount of treatment service provided and the client’s response to the treatment service on: i. March 17, 19, and June 10, 2025 (client file numbered 1); ii. April 30, May 1, 6, and 13, 2025 (client file numbered 3); and iii. June 3, 2025 (client file numbered 4). 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 client record documentation meets all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. The TPR did not document 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. The TPR was not completed once every 30 days as follows: i. TPR was due on June 8, 2025; however, was not completed (client file numbered 1); ii. A TPR was due on February 9, 2025; however, was not completed until March 21, 2025 (client file numbered 2); and iii. A TPR was due on July 4, 2025; however, was not completed until July 6, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 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. 17. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements. The discharge summary did not include: a. The treatment services provided (client files numbered 1 through 3); and b. Continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b), clauses (1) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meet all applicable requirements. Within 60 days of receipt of this order, submit documentation of two client discharge plans that meet all applicable requirements. Personnel Files 18. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not contain documentation that orientation was received on the following topics: a. Within 24 working hours: i. The staff member’s specific job responsibilities (personnel file numbered 1; ii. Policies and procedures (personnel files numbered 2 and 4); and iii. Client needs (personnel files numbered 2 and 4); b. Within 72 hours of first providing direct contact services, vulnerable adults’ maltreatment reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557 and 626.5572 (personnel file numbered 3); and c. Drug and alcohol policy (personnel files numbered 2 and 4). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 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 staff orientation meets all applicable requirements. 19. Violation: Three of three personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following annual trainings: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E, including specific training covering the license holder's policies for obtaining a release of client information for calendar years: i. 2024 (personnel file numbered 1); and ii. 2025 (personnel files numbered 1 and 3); b. Program abuse prevention plan for calendar year 2025 (personnel file numbered 2); c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services and reporting as specified for the reporting of maltreatment of minors for calendar year 2025 (personnel file numbered 2); and d. HIV minimum standards for calendar years: i. 2024 (personnel file numbered 1); and ii. 2025 (personnel files numbered 1 through 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (d), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual trainings meet all applicable requirements. Within 60 days of receipt of this order, submit documentation that the staff mentioned above have completed the trainings identified above. 20. Violation: Two of two personnel files reviewed for requirements governing every two-year trainings (personnel files numbered 1 and 2) did not meet requirements. There was no documentation of training on client confidentiality and client ethical boundaries for calendar year 2025. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that every two-year trainings meet all applicable requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed timelines 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 Kayla.Northrop@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Kayla Northrop 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 651-431-6671 or at Maura.McGarrry@state.mn.us. Sincerely, Maura McGarry, Licensing Supervisor Licensing Division Office of Inspector General
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