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December 3, 2025 Amy Morgan, Authorized Agent The Wayside House, Inc. 3705 Park Center Blvd St. Louis Park, MN 55416-2504 License Number: 802632 Report Numbers: 202404610, 202500717 CORRECTION ORDER Dear Amy Morgan: On September 22 through 26, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigations at your facility, Wayside Women’s Treatment Center, located at 3705 Park Center Blvd, St. Louis Park, MN 55416-2504. 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 corrective 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 as follows: 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. There was no documentation of the following: i. Diagnostic assessment completed within 10 days of admission (client files numbered 1 through 3); ii. Monthly multidisciplinary case review for February and April, 2024 (client file numbered 1); and iii. Co-occurring counseling staff receiving 8 hours of co-occurring disorder training annually for calendar years: 1. 2023 (personnel file numbered 4); and 2. 2025 (personnel files numbered 1 and 3); and b. The license holder did not meet requirements in Minnesota Statutes, section 254B.19, subdivision 1, paragraph (a), clause (7) for receiving public funding reimbursement from the commissioner for high intensity residential clients. Daily skilled treatment services were not documented on November 23 and 24, 2024 (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245A.167 and 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services provided meet the requirements for payment from the behavioral health fund. 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 meet requirements governing provider policies and procedures. The policy and procedure manual did not contain the following: a. Assessment and treatment planning policies that meet current Minnesota Statute, chapter 245G requirements; and b. Policies and procedures regarding HIV according to Minnesota Statute, section 245A.19. Statute Violated: Minnesota Statutes, sections 245A.19, and 245G.12, clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that assessment and treatment planning and HIV policies meet all requirements. Within 45 days of receipt of this order, submit assessment and treatment planning and HIV policies that meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing service termination policies. The service termination policy did not include 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. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the service termination policy meets all requirements. Within 45 days of receipt of this order, submit a service termination policy that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing grievance procedures. Two of four 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. January 23, 2025; and b. February 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. 5. Violation: The license holder did not meet requirements governing descriptions of treatment services. The description of treatment services did not include the following: a. Types of required treatment services provided including client education; and b. Which groups and topics a guest speaker could provide services under the direct observation of an alcohol and drug counselor. 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 program’s treatment services description meets all requirements. Within 45 days of receipt of this order, submit a description of treatment services that meets all applicable requirements. 6. Violation: The license holder did not meet requirements governing license holders serving persons with co-occurring disorders. There policies and procedures did not include: a. Continuing access to a medical provider with appropriate expertise in prescribing psychotropic medication; and b. Flexibility for a client who may lapse in treatment or may have difficulty adhering to established treatment rules as a result of a mental illness. Statute Violated: Minnesota Statutes, section 245G.20, clauses (2) and (8). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program’s policies for license holders serving persons with co-occurring disorders meet all requirements. Within 45 days of receipt of this order, submit policies that meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing behavioral emergency procedures. The procedure did not include the following information: a. Person-centered planning and trauma informed care; b. A plan designed to prevent a client from hurting themselves or others; c. Contact information for emergency resources that staff must consult when a client's behavior cannot be controlled by the behavioral emergency procedures; d. Types of procedures that may be used; and e. Circumstances under which behavioral emergency procedures may be used. Statute Violated: Minnesota Statutes, section 245G.16, paragraph (a), clauses (1) through (4). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the behavioral emergency procedures meet all requirements. Within 45 days of receipt of this order, submit a behavioral emergency procedure that meets all applicable requirements. 8. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults as follows: a. The policies and procedures did not include: i. Primary and secondary person who will ensure that, when required, internal reviews are completed; and ii. The secondary person shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and b. An internal review was not 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. November 15, 2023; and ii. November 21, 2024. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (b), clauses (1) and (2). 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 vulnerable adult maltreatment reporting procedures that meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing maltreatment of minors reporting. The policy did not identify the following: a. The primary and secondary person who will ensure that, when required, internal reviews are completed; and b. The secondary person shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that maltreatment of minors policies and procedures meet all applicable requirements. Within 45 days of receipt of this order, submit a maltreatment of minors reporting procedure that meets all applicable requirements. 10. Violation: The license holder did not meet requirements governing provider personnel policies. The personnel policies did not include: a. A written plan that includes orientation within 24 working hours of starting for each new staff member that, at a minimum, includes training related to the staff member's specific job responsibilities, policies and procedures, client confidentiality, HIV minimum standards, and client needs; and b. Policies outlining the license holder's response to a staff member with a behavior problem that interferes with the provision of treatment service. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clauses (7) and (8). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that personnel policies meet all applicable requirements. Within 45 days of receipt of this order, submit personnel policies that meet all applicable requirements. 11. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure in the following ways: a. There was no documentation that the plan was reviewed and signed annually by a controlling individual for calendar years 2024 and 2025; and b. The plan did not specify arrangements the program will make to transfer clients to another provider or county agency for continuation of services and to transfer the case record with the client. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraphs (a) and (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements. Within 45 days of receipt of this order, submit a plan for transfer of clients and records that meets all applicable requirements. Personnel Files 12. Violation: One personnel file reviewed for requirements governing staff qualifications for individuals with a temporary permit (personnel file numbered 1) did not meet requirements. There was no documentation of the amount and type of supervision provided to an individual with a temporary permit on at least a weekly basis for January 9, 17, 24, and 31, February 7, 11, 18, and 27, March 6, 13, 20, and 27, April 2, May 7, 14, and 21, June 11 and 25, and July 16, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder will ensure that staff qualifications for individuals with a temporary permit meet all applicable requirements. 13. Violation: Five of five personnel files 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: i. The staff member’s specific job responsibilities (personnel file numbered 5); ii. Policies and procedures (personnel file numbered 5); and iii. Client needs (personnel files numbered 1, 2, 5, 6, and 8); b. Within 72 working hours of first having direct contact (personnel files numbered 1, 2, 5, 6, and 8): i. Program abuse prevention plan; and ii. All internal policies and procedures related to the prevention and reporting of maltreatment; and c. Twelve hours of co-occurring disorders training within six months of hire (personnel files numbered 2 and 5). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivisions 1, clause (7), and 2, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. Within 45 days of receipt of this order, submit documentation which demonstrates that the above personnel meet all applicable orientation requirements. 14. Violation: Six of six personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual training on: i. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E for calendar years: 1. 2024 (personnel files numbered 1, 3, 4, and 7); and 2. 2025 (personnel files numbered 3 and 8); ii. Program abuse prevention plan for calendar years: 1. 2024 (personnel files numbered 1, 3, 4, and 7); and 2. 2025 (personnel files numbered 1, 3, 4, 5, 7, and 8); iii. Training on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: 1. 2024 (personnel files numbered 1, 3, 4, and 7); and 2. 2025 (personnel files numbered 1, 3, 7, and 8); and iv. HIV minimum standards for calendar years: 1. 2024 (personnel files numbered 4 and 7); and 2. 2025 (personnel files numbered 4, 5, and 8). Statute Violated: Minnesota Statutes, sections 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 staff development meets all applicable requirements. Within 45 days of receipt of this order, submit documentation that the staff identified above have completed all required annual trainings for calendar year 2025. 15. Violation: Five of eight personnel files reviewed for requirements governing personnel file contents did not meet requirements. The personnel file did not contain: a. The first date that a background study subject had direct contact with a person served (personnel file numbered 6); b. An inquiry 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 employer names and addresses for the past five years for which the staff member provided psychotherapy services (personnel file numbered 4); c. Documentation that the staff member meets the requirements in Minnesota Statute, section 245G.11 (personnel files numbered 2 and 4); and d. A written annual review for calendar year: i. 2024 (personnel files numbered 4 and 7); and ii. 2025 (personnel file numbered 8). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clause (3). Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files 16. Violation: Three of three client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation that the client received a written statement of client rights and responsibilities from Minnesota Statutes, section 144.651 on the day of service initiation (client files numbered 1 through 3); Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, paragraph (a), clause (1) and 245G.15, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. Within 45 days of receipt of this order, submit orientation documentation for one client that meets all applicable requirements. 17. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 through 3) did not meet requirements. There was no documentation of an assessment of the person’s risk of abusing other vulnerable adults. Statute Violated: Minnesota Statutes, sections 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. 18. Violation: Three of three 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 through 3); b. The client’s current medications (client files numbered 1 and 2); c. Immediate risks to the client's health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotional symptoms (client file numbered 1); d. The client's perceptions of the client's condition (client files numbered 1 and 3); e. The client’s description of the client’s symptoms, including the reason for the client’s referral (client file numbered 3); f. Substance use history, including: i. Duration of use (client files numbered 1 through 3); and ii. Route of administration (client file numbered 1); g. 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 files numbered 2 and 3); h. The client's strengths and resources (client files numbered 1 through 3); and i. Important developmental incidents in the client's life (client files numbered 1 through 3). 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. Within 45 days of receipt of this order, submit one comprehensive assessment that meets all applicable requirements. 19. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. The ITP was not updated based on new information about the client’s level of participation (client files numbered 1 and 2); and b. The ITP did not document the following: i. A treatment strategy (client files numbered 1 through 3); ii. A schedule for accomplishing the client’s treatment goals and objectives (client file numbered 2); and iii. The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 and 2). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (3) 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. 20. Violation: Three of three 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 December 30, 2024 (client file numbered 2); b. Documentation of concerns related to attendance for treatment services, including the reason for any client absence from a treatment service was not completed on the date that each occurs for the following dates: i. November 21 and 26, 2024 (client file numbered 2); and ii. June 23, 24, and 29, and July 8 through 10, 2025 (client file numbered 3); c. Concerns related to medications were not completed on the day that they occurred for an event on December 22, 2024 (client files numbered 2 and 4); and d. Documentation of treatment services did not include: i. Client response for: 1. November 25 and 27, 2024, and January 2, 28, and 31, 2025 (client file numbered 2); 2. February 6 and 9 and March 11, 2025 (client file numbered 1); and 3. July 9, 2025 (client file numbered 3); ii. Signature of the staff person making the entry for: 1. November 25 and 27, 2024, and January 2, 2025 (client file numbered 2); and 2. February 5, 6, 8, and 9, March 13, and April 2, 2025 (client file numbered 1); and iii. Job title of the staff person making the entry for February 5 through 9, 26, March 1, 11 and 15, and April 2 through 4, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraphs (b), clauses (2) and (3), and (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 21. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan review did not document: a. The accurate span of time covered by the review for the following dates: i. December 2, 10, and 17, 2024 (client file numbered 2); ii. March 29, 2025 (client file numbered 1); and iii. July 3 and 10, 2025 (client file numbered 3) b. Client goals addressed since the last treatment plan review and whether identified methods continue to be effective for December 2, 2024 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3, clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 22. Violation: Two of three client files reviewed for requirements governing administration of medications did not meet requirements. The client’s use of medication was not recorded, including staff signatures with date and time on the following dates: a. November 23, 2024, January 5 through 19 and 24 through 26, and February 5 and 15, 2025 (client file numbered 2); and b. January 31 and April 1 through 11, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.08, subdivision 6, clause (3) and 245G.21, subdivision 8. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that administration of medication documentation meets all applicable requirements. 23. Violation: Two of three client files reviewed for requirements governing service discharge summaries did not meet requirements. a. The discharge summary was not completed within five days of service termination (client file numbered 1); and b. The discharge summary did not include the following information: i. The services provided (client files numbered 1 and 2); and ii. Continuing care recommendations (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (1) and (6). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that 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 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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