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December 2, 2025 Ahmed Eid, Authorized Agent Hazelden Betty Ford Foundation PO Box 11, RE 11 Center City, MN 55012 License Number: 1059811 License Number: 1062516 CORRECTION ORDER Dear Ahmed: On August 11, 12, 13, 14, 15, and 18, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facilities located at the following: · 7001 E Fish Lake Rd Ste 120, Maple Grove, MN 55311, license number 1059811 · 1107 Hazeltine Boulevard Ste 300 MD 67, Chaska, MN 55318, license number 1062516 This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under MN 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 Policies, Procedures, and Practices DHS determined that your program did not follow licensing rules and statutes, as described below. 1. Violation: The license holder (1059811 and 1062516) did not meet requirements governing grievance procedures. The license holder’s grievance procedure did not include: a. The current address of the Office of Ombudsman for Mental Health and Developmental Disabilities; and b. The highest level of authority in the program the client may bring the grievance to. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clauses (2) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 60 days of receipt of this order, submit an updated grievance procedure that meets all applicable requirements. 2. Violation: The license holder (1059811 and 1062516) did not meet requirements governing photographs of clients. The license holder’s personal electronic device policy did not include the client’s right to refuse being photographed or recorded. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personal electronic devices policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated personal electronic device policy that meets all applicable requirements. 3. Violation: The license holder (1059811 and 1062516) did not meet requirements regarding the provision of telehealth according to Minnesota Statutes, section 256B.0625, subdivision 3b. The license holder did not identify the categories or types of services the health care provider 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 the telehealth policies meet all applicable requirements. Within 60 days of receipt of this order, submit an updated telehealth policy that meets all applicable requirements. 4. Violation: The license holder’s (1059811 and 1062516) medical services policy did not meet requirements. The license holder did not have a policy that describes the program’s procedures for administering opiate antagonist medications in the license holder’s description of health care services under Minnesota Statutes, section 245G.08, subdivision 1. Statute Violated: Minnesota Statutes, sections 245A.242, subdivision 2, paragraph (b), clause (3), and 245G.08, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the medical services policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated medical services policy that meets all applicable requirements. 5. Violation: The license holder’s (1059811 and 1062516) policies and procedures regarding HIV according to Minnesota Statutes, section 245A.19 did not meet requirements. The policies and procedures were not consistent with the HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (a) and 245G.12, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the HIV minimum standards policy meets all applicable requirements. 6. Violation: The license holder’s (1059811 and 1062516) program abuse prevention plan did not meet requirements. The program abuse prevention plan (PAPP) policy did not include an evaluation the following factors: a. Gender; b. Need for specialized programs of care for clients; c. Need for training of staff to meet identified individual needs; and d. The type of internal programming. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan policy meets all applicable requirements. Within 60 days of receipt of this order, submit an updated PAPP that meets all applicable requirements. 7. Violation: The license holder (1059811 and 1062516) did not meet requirements governing vulnerable adult maltreatment reporting. The vulnerable adult maltreatment reporting policy did not identify the secondary person or position responsible for forwarding internal reports to the common entry point. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (a), clause (2) and 245G.12, clause (9). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the vulnerable adult maltreatment reporting policy meet all applicable requirements. Within 60 days of receipt of this order, submit documentation of a vulnerable adult maltreatment reporting policy that demonstrates compliance. 8. Violation: The license holder’s (1059811 and 1062516) personnel policies and procedures did not meet requirements. The personnel policies and procedures did not contain: a. Job descriptions for each staff member position specifying responsibilities, the degree of authority to execute job responsibilities, and qualification requirements; and b. Policies prohibiting client abuse as described in Minnesota statutes, sections 245A.65, 260E, 626.557, and 626.5572. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clauses (2) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies and procedures meets all applicable requirements. Within 60 days of receipt of this order, submit an updated personnel policies and procedure that meets all applicable requirements. Personnel Files Personnel files reviewed are identified in the following manner: · Personnel files numbered 1 through 3, license number 1059811 (Maple Grove) · Personnel file numbered 4 through 6, license number 1062516 (Chaska) 9. Violation: One of six personnel files reviewed for requirements governing background studies (personnel files numbered 6) did not meet requirements. Staff Person (SP) 6 began a position allowing direct contact with persons served by the program on August 4, 2025. A BGS was submitted under license numbers 800997 and 1033807, however, SP6 was also working under license number 1062516. The license holder did not affiliate SP6 to all required rosters. Statute Violated: Minnesota statutes, section 245C.07, paragraph (f). Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. 10. Violation: Three of four personnel files reviewed for requirements governing personnel orientation did not meet requirements. There was no documentation of orientation to the following: a. Within 24 working hours of starting: 1) Staff members specific job responsibilities (personnel files numbered 4, 5, and 6); 2) Policies and procedures (personnel files numbered 4 and 6); 3) Client confidentiality (personnel file numbered 6); and 4) Client needs (personnel file numbered 6); and b. Within 72 hours of first providing direct contact services: 1) HIV minimum standards (personnel files numbered 4 and 6); 2) Reporting requirements and definitions in Minnesota statutes, sections 245A.65, 626.557, and 626.5572 (personnel file numbered 6); 3) Program abuse prevention plan (personnel files numbered 4, 5, and 6); and 4) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 4, 5, and 6); c. Before the mandatory reporter had direct contact, reporting requirements and definitions in Minnesota Statutes, chapter 260E (personnel files numbered 5 and 6); and d. 12 hours of training in co-occurring disorders within six months of employment (personnel file numbered 3). Statute Violated: Minnesota statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.13, subdivisions 1, clause (7), and 2, paragraphs (d), (e), and (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel orientation meets all applicable requirements. 11. Violation: Three of three personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of annual trainings to the following: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of information for the calendar year 2025 (personnel file numbered 4); and b. HIV Minimum Standards for the calendar years 2023, 2024, and 2025 (personnel files numbered 2 through 4). Statute Violated: Minnesota statutes, 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (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 personnel above received the required training. 12. Violation: Three of six personnel files reviewed for requirements governing personnel contents did not meet requirements. There was no documentation of the following: a. A completed application for employment signed by the staff member (personnel file numbered 6); b. An inquiry of required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel file numbered 4 and 6); and c. The first date that a background study subject has direct contact, as defined in Minnesota Statutes, section 245C.02, subdivision 11, with a person served by the license holder’s program (personnel file numbered 1). Statute Violated: Minnesota statutes, sections 245A.041, subdivision 6 and 245G.13, subdivision 3, clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure personnel file contents meet all applicable requirements. Client Files Client files reviewed are identified in the following manner: · Client files numbered 1 through 5, license number 1059811 (Maple Grove) · Client files numbered 6 through 10, license number 1062516 (Chaska) 13. Violation: Ten of ten client files reviewed for requirements governing client orientation (client files numbered 1 through 10) did not meet requirements. There was no documentation of orientation to the following: a. HIV minimum standards within 72 hours of admission; and b. Opioid education material approved by the commissioner on the day of service initiation. Statute Violated: Minnesota statues, sections 245A.19, paragraph (b) and 245G.04, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 14. Violation: Six of ten client files reviewed for requirements governing initial service plans (ISP) and vulnerable adult determinations did not meet requirements in the following ways: a. The ISP was not completed within 24 hours of the day of service initiation (client files numbered 5 and 6); b. The vulnerable adult determination was not completed within 24 hours of the day of service initiation (client file numbered 5); and c. The ISP was not person centered and client specific (client files numbered 1, 3, 9, and 10). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1a, paragraph (a), and 245G.04, subdivisions 1 and 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans and vulnerable adult assessment meet all applicable requirements. Within 60 days of receipt of this order and submit an initial service plan from two recently admitted clients that demonstrates compliance. 15. Violation: Four of ten client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not include the following information: a. Maltreatment and abuse the client has suffered (client files numbered 1, 3, and 4); and b. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to section Minnesota Statutes, section 245.4863 (client file numbered 9). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 16. Violation: Ten of ten client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not signed by the client (client files numbered 1 through 10); b. A change to the ITP was not signed by the client (client file numbered 8); c. The ITP was not updated based on new information gathered about the client’s condition (client file numbered 6); and d. There was no documentation of the following: 1) How the family or others will be involved in the client’s treatment and did not include 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 6, 7, 9, and 10); 2) A treatment strategy (client files numbered 1 through 10); and 3) The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 through 10). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 1a, clauses (2) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order, submit an individual treatment plan that meets requirements. 17. Violation: Ten of ten client files reviewed for requirements governing treatment plan reviews (TPR) and did not meet requirements as follows: a. There was no documentation of the following: a. Whether the identified methods continue to be effective (client files numbered 1 through 10); b. Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 10); c. Referrals made since the previous treatment plan review (client files numbered 6, 8, and 9); and d. Collaboration with continuing care mental health providers, and involvement of the providers in treatment planning meetings (client files numbered 8 through 10); and b. Treatment plan reviews were not completed once every: a. 14 days (client file numbered 7); and b. 30 days (client file numbered 5). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 3, clauses (1), (4), and (6), 3a, paragraphs (d) and (e), and 245G.20, clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 18. Violation: One of five client files reviewed for requirements governing service discharge summaries (client file numbered 7) did not meet requirements. The discharge summary was not completed within five days of service termination. Statute Violated: Minnesota statute, section 245G.06, subdivision 4, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure 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 david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely, David Her, Licensor Licensing Division Office of Inspector General
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