December 11, 2025                    

Sophia Thompson, Authorized Agent

Ramsey County

License Number:   830635 (MHC)

      1065750 (245G)

CORRECTION ORDER

Dear Sophie Thompson,

On September 15 through September 17, 2025, Department of Human Services (DHS) licensor(s) conducted a licensing and certification review at your facility, Ramsey County Human Services Mental Health Center, located at 1919 University Ave, 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 under Minnesota Statutes, chapter 245G, and mental health clinic services under Minnesota Statutes, chapter 245I. 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 and certification rules and statutes, as described below.

Throughout this order, the programs reviewed will be referenced as follows:

· Ramsey County Mental Health Center – mental health clinic (MHC)

· Ramsey County Personalized Recovery Services (CoOccurringRecovery ORE) – substance use disorder treatment (245G)

· When citations are specific to both the MHC certification and the 245G license (ALL)

Postings

1. Violation: The license holder’s postings did not meet requirements (ALL). Two conflicting grievance procedures were posted.

Statute Violated: Minnesota Statutes, sections 245G.15, subdivision 2, and 245I.12, subdivision 5, paragraph (c).

Corrective Action Ordered: Correct immediately and maintain compliance.

Practices

2. Violation: The license holder did not notify the commissioner before making a change to the type of services the license holder is licensed to provide (245G). At the time of the licensing review, the license holder informed DHS Licensors that the program had not provided substance use disorder treatment services to adolescents for approximately 1.5 years.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance.

3. Violation: The license holder’s plan for the transfer of clients and records upon closure did not meet requirements (245G). There was no documentation to demonstrate a controlling individual annually reviewed and signed the plan. The plan stated it was reviewed in 2025, but there was no signature or indication of who completed the review.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance.

4. Violation: A controlling individual of the program (ALL) did not annually review and sign the transfer of clients and records upon closure plan for calendar year 2024.

Statute Violated: Minnesota Statute, section 245A.04, subdivision 13a, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance.

5. Violation: The license holder’s annual review of the quality assurance and improvement plan did not include the following required components, for calendar years 2024 and 2025 (MHC):

a. Documentation of the actions that the license holder will take as a result of information obtained from monitoring activities in the plan; and

b. Goals established for improved service delivery to clients for the next year.

Statute Violated: Minnesota Statutes, section 245I.20, subdivision 9, paragraph (b).

Corrective Action Ordered: Correct immediately and maintain compliance.

6. Violation: The license holder’s review of policies and procedures did not meet requirements (MHC). There was no documentation to demonstrate a review of policies and procedures were completed every two years.

Statute Violated: Minnesota Statutes, section 245I.03, subdivision 1.

Corrective Action Ordered: Correct immediately and maintain compliance.

Policies and Procedures

7. Violation: The license holder's grievance procedure did not meet requirements in the following ways:

a. The procedure did not describe how staff will explain the grievance procedure to clients on the day of admission (MHC);

b. The procedure did not include current contact information for the following entities (MHC):

i. The Department of Human Services, Licensing Division; and

ii. The Board of Nursing.

c. The procedure did not account for how former clients could submit a grievance (ALL); and

d. The grievance procedure did not require that clients be allowed to voice grievances and recommend changes in policies and services to staff and others of their choice, free from restraint, interference, coercion, discrimination, or reprisal, including threat of discharge; the procedure indicated the client has the right to no reprisal if they have a complaint (MHC).

Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, and 245I.12, subdivision 5, paragraphs (a), (b), and (d).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised grievance procedure that meets requirements (ALL).

8. Violation: The license holder’s service initiation policy did not identify titles of all staff members authorized to initiate services for clients (245G). The policy manual contained two conflicting service initiation policies.

Statute Violated: Minnesota Statutes, section 245G.14, subdivision 1.

Corrective Action Ordered: Correct immediately and maintain compliance.

9. Violation: The license holder’s service termination policy did not meet requirements in the following ways (245G):

a. The written protocols did not address the license holder’s responsibilities or procedures a staff must follow if a client poses a substantial likelihood of harm to themselves or others, or if their behavior is beyond the behavior management capabilities of the staff members; and

b. The policy did not require staff members to assist the client with assessing needs of care or other resources. The policy manual contained two conflicting policies.

Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 2, paragraph (a), and 3.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised protocol that meets requirements.

10. Violation: The license holder’s description of treatment services did not meet requirements in the following ways (245G):

a. The Treatment Services policy contained a list of required treatment services, but did not include a description of how the following services are provided:

i. A service to help the client integrate gains made during treatment into daily living and to reduce the client’s reliance on a staff member for support;

ii. A service to address issues related to co-occurring disorders; and

iii. Treatment coordination services;

b. The following additional treatment services offered by the license holder were not included:

i. Relationship counseling;

ii. Therapeutic recreation;

iii. Stress management and physical well-being;

iv. Living skills development;

v. Employment or educational services;

vi. Socialization skills development; and

vii. Peer recovery support services; and

c. The description of treatment services did not include the following required components:

i. The amount and type of services provided;

ii. Which services met the definition of group counseling; and

iii. Which groups and topics could be provided by a guest speaker.

Statute Violated: Minnesota Statutes, sections 245G.07, subdivisions 1 and 2, and 245G.12, clause (10).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised treatment services description that demonstrates compliance.

11. Violation: The license holder’s policy and procedure for tracking and recording client attendance at treatment activities did not meet requirements (245G). The policy stated attendance is recorded in an electronic health record system, but did not address the use of paper sign in sheets that were observed to be used in practice.

Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit a client attendance policy that meets all applicable requirements.

12. Violation: The license holder’s program abuse prevention plan did not meet requirements (245G). The assessment of the physical plant did not include an evaluation of the condition of the building as it relates to the safety of the clients.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit a revised program abuse prevention plan that demonstrates compliance.

13. Violation: The license holder did not maintain policies and procedures to ensure compliance with licensing requirements. The license holder provided services to a client with a developmental disability or related condition, and the policy manual did not include a screening process, or any procedures related to determining the applicability of Minnesota Rules, chapter 9544, the Positive Supports Rule.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy or procedure that addresses how the applicability of the Positive Supports Rule will be determined.

14. Violation: The license holder (245G) vulnerable adults maltreatment reporting policy and procedure did not meet requirements. The policy did not include the following:

a. The primary or secondary individual to whom internal reports may be made;

b. The primary and secondary person or position responsible for forwarding it to the common entry point when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and

c. The identification of the primary and secondary person or position who will ensure that, when required, internal reviews are completed.

Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (a) and (b), clause (2) and 245G.12, clause (9).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit a revised vulnerable adults maltreatment reporting policy and procedure that meets all applicable requirements.

Client Files

Client files identified below received services with the following certified and licensed programs:

· Client files numbered 1 through 7 (MHC)

· Client files numbered 8 through 10 (245G)

· Client files numbered 2 and 4 (MHC and 245G)

15. Violation: Seven of seven client files reviewed did not meet client orientation requirements in the following ways:

a. There was no documentation to demonstrate the client was oriented to the following required topics, for their admission to the substance use disorder program in 2023 (client file numbered 2):

i. Client rights;

ii. The grievance procedure;

iii. HIV minimum standards;

iv. Information on tuberculosis and tuberculosis screening;

v. Use of personal electronic devices;

vi. Maltreatment reporting policies and procedures;

vii. The program abuse prevention plan;

b. Documentation did not demonstrate the license holder gave a copy of the applicable client’s rights to the client on the day of admission (client files numbered 1 through 3, 5 and 7);

c. Documentation did not demonstrate the license holder explained the grievance procedure to the client (client files numbered 1 through 3, 5 and 7);

d. Opioid education material provided to the client on the day of service initiation was not the material approved by the commissioner, it was an outdated version (client files numbered 9 and 10).

Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 3, 245G.09, subdivision 3, paragraph (a), and 245I.12, subdivisions 3 and 5, paragraph (b).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit documentation for one client demonstrating compliance.

16. Violation: One of four client files reviewed for vulnerable adult determinations did not meet requirements (client file numbered 2). There was no documentation in the client file demonstrating a determination of the client’s vulnerable adult status was completed upon their admission to the substance use disorder program in 2023.

Statutes Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (a), and 245G.04, subdivision 2, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance.

17. Violation: Seven of seven client files reviewed did not meet comprehensive evaluation requirements as identified in Minnesota Statutes, section 245.735, subdivision 4b. Comprehensive evaluations (CE) completed by a Certified Community Behavioral Health Clinic meet the requirements of the diagnostic assessment (DA) required for a certified mental health clinic, as identified in Minnesota Statutes, section 245I.10, and the comprehensive assessment required for a substance use disorder treatment program, as identified in Minnesota Statutes, section 245G.05, subdivision 1.

Requirements were not met in the following ways:

a. The client file did not contain a CE or an update to an assessment (client files numbered 2 and 4);

b. The CE did not include the screening and assessment of the client for a substance use disorder (client file numbered 7);

c. The CE did not include the following required information about the client’s current life situation:

i. The client's current living situation, including the client's housing status and household members (client file numbered 2);

ii. The status of the client's basic needs (client file numbered 2);

iii. The client's current medications (client files numbered 1 and 7);

iv. Any immediate risks to the client's health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotional symptoms (client file numbered 2);

v. The client's description of the client's symptoms, including the reason for the client's referral (client file numbered 2);

vi. The client's history of mental health and substance use disorder treatment (client file numbered 2);

vii. Cultural influences on the client (client files numbered 1 and 5); and

viii. The client’s substance use history, including:

1. The amount of substances used (client file numbered 3 and 5 through 7);

2. Frequency of use (client files numbered 3, and 5 through 7);

3. The route of administration (client files numbered 3 and 7);

4. Periods of abstinence (client files numbered 2, 3, 6 and 7);

5. Circumstances of relapse (client files numbered 1, 3, and 5 through 7); and

6. The impact to functioning when under the influence of substances, including legal interventions (client files 5 through 7); and

d. The CE did not document information related to the following required topics:

i. The client's relationship with family and other significant personal relationships, including the client's evaluation of the quality of each relationship (client files numbered 3 and 6);

ii. The client's strengths and resources, including the extent and quality of the client's social networks (client files numbered 2 and 6);

iii. Important developmental incidents in the client's life (client files numbered 2, and 5 through 7);

iv. Maltreatment, trauma, potential brain injuries, and abuse that the client has suffered (client files numbered 2, 5 and 7);

v. The client's history of or exposure to alcohol and drug usage (client files numbered 3 and 5); and

vi. The client's family health history (client files numbered 2, 3 and 5);

e. The CE did not include the following required components of the assessment:

i. The client's baseline measurements (client files numbered 2, 3, and 5 through 7);

ii. The client's symptoms and behavior (client file numbered 2);

iii. The client's skills, abilities and vulnerabilities (client files numbered 5 and 6);

iv. The client's resources (client files numbered 2, 3, 5 and 6);

v. An explanation of:

1. How the assessor diagnosed the client using the information from the client's interview, assessment, psychological testing, and collateral information about the client (client files numbered 2, 3 and 5);

2. The client's strengths (client files numbered 5 and 6); and

3. The client's responsivity factors (client file numbered 3); and

f. The CE did not include a recommendation for the ASAM level of care identified in section 254B.19, subdivision 1 (client file numbered 2).

Statutes Violated: Minnesota Statutes, sections 245G.05, subdivision 1 and 245I.10, subdivision 4 through 6.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit two comprehensive evaluations that demonstrate compliance.

18. Violation: Seven of seven client files reviewed did not meet the following individual treatment plan (ITP) requirements:

a. The treatment plan was not completed after completing a client's diagnostic assessment or reviewing a client's diagnostic assessment received from a different provider (client files numbered 3, 4 and 7);

b. The ITP, completed by a practitioner, was not approved by a treatment supervisor within ten days of completion (client file numbered 3);

c. The ITP was not done within 60 days of initiating substance use disorder treatment services (client file numbered 1);

d. The ITP was not based on the client's diagnostic assessment and baseline measurements (client files numbered 2 and 4);

e. The client did not approve the ITP (client file numbered 3);

f. The ITP was not signed by the client when completed or when it was changed (client file numbered 4);

g. The ITP was not reviewed at least every 180 days (client files numbered 4 and 6);

h. The ITP was not updated based on new information gathered about the client’s condition, their level of participation, or whether methods identified have the intended effect (client files numbered 4 and 6);

i. For a child client, the license holder did not use a planning process that allows the client's parents and guardians to observe and participate in the child's individual and family treatment services, assessments, and treatment planning (client file numbered 3);

j. For an adult client, the license holder did not use a person-centered, culturally appropriate planning process (client file numbered 2);

k. The ITP did not include the following:

i. Measurable treatment objectives (client files numbered 3, 5 and 7);

ii. A schedule for accomplishing goals and objectives (client files numbered 2, 4 and 6); and

iii. The ASAM level of care identified in section 254B.19, subdivision 1, under which the client is receiving services (client file numbered 4); and

l. The ITP did not identify the client as a participant in their treatment planning (client file numbered 3).

Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 1a, paragraph (a), 245I.10, subdivision 8, paragraph (a), and 245I.08, subdivision 3.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit two individual treatment plans that demonstrate compliance.

19. Violation: Three of seven client files reviewed did not meet progress note requirements in the following ways:

a. The progress note did not include the following required components:

i. The start and stop time of service, for progress notes dated July 3 and 29, 2025, and August 28, 2025 (client file numbered 3);

ii. Documentation of the scope of the service, including the targeted goal and objective, for progress notes dated July 3 and 29, 2025, and August 28, 2025 (client file numbered 3);

iii. The client’s response to each treatment service, for group notes dated August 22 and 24, 2024, and September 26, 2024 (client file numbered 2); and

iv. The type of service provided, for notes dated January 29 and 31, 2024 (client file numbered 1). The progress note was categorized as individual psychotherapy, but the narrative referenced the client presenting to a group; and

b. Documentation was not completed within 7 days of providing the treatment service (client file numbered 1):

i. Treatment services provided on January 29 and 31, 2024, were documented on February 18, 2024; and

ii. A treatment service provided on March 5, 2024, was documented on March 16, 2024.

Statute Violated: Minnesota Statutes, sections 245I.08, subdivision 4, and 245G.06, subdivision 2a.

Corrective Action Ordered: Correct immediately and maintain compliance.

20. Violation: Five of six client files reviewed for discharge summaries did not meet requirements in the following ways:

a. The client file did not contain a discharge summary (client file numbered 1);

b. The discharge summary did not include the following required components:

i. The following information about the client while they participated in treatment:

1. The client’s needs (client files numbered 2, 4, 9 and 10);

2. The client’s strengths (client files numbered 4, 9 and 10); and

3. The services provided (client files numbered 10);

ii. The client’s progress toward achieving each of the goals identified in the individual treatment plan (client files numbered 9 and 10);

iii. A risk rating and description for each of the ASAM six dimensions (client file numbered 2); and

iv. The reasons for and circumstances of service termination (client files numbered 9 and 10).

Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days of this order, submit two discharge summaries that demonstrate compliance.

Personnel Files

· Personnel Files numbered (ALL)

· Personnel Files numbered (MHC)

21. Violation: Two of four personnel files reviewed for requirements governing background study documentation did not meet requirements (personnel files numbered 3 and 4). The first date that a background study subject had direct contact was not documented in the personnel file.

Statute Violated: Minnesota Statutes, section 245A.041, subdivision 6.

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit documentation for one staff person to demonstrate compliance.

22. Violation: Six of eight personnel files reviewed for requirements governing the contents of a personnel file did not meet requirements. The file did not contain the following:

a. Verification of the staff person's qualifications (personnel files numbered 2 and 8);

b. Documentation of the alcohol and drug counselor’s license (personnel files numbered 3 and 9);

c. The hiring date of the staff person (personnel files numbered 2 and 8);

d. The date the staff person's duties and responsibilities became effective (personnel file numbered 2);

e. Inquiries 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 files numbered 1 and 9); and

f. An annual job performance evaluation for:

i. 2023 (personnel files numbered 4 and 5);

ii. 2024 (personnel files numbered 1, 2, 4, 5 and 9); and

iii. 2025 (personnel files numbered 4 and 9).

Statute Violated: Minnesota Statutes, section 245I.07, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance.

23. Violation: Four of four personnel files reviewed for training documentation did not meet requirements. Documentation of training did not include the following required components:

a. The name and credentials of the trainer (personnel files numbered 1, 2, 6 and 7);

b. The license holder's method of evaluating the trainee's competency upon completion of training (personnel files numbered 1, 2, 6 and 7); and

c. The length of training in hours and minutes (personnel files numbered 1, 2, 6 and 7).

Statute Violated: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a).

Corrective Action Ordered: Correct immediately and maintain compliance. Within 30 days receipt of this order, submit documentation of training for one staff person that demonstrates compliance.

24. Violation: Two of two personnel files reviewed for treatment supervision plans did not meet requirements in the following ways:

a. The treatment supervision plan was not developed within 30 days of the staff person's first day of employment (personnel files numbered 2 and 8);

b. The treatment supervision plan was not updated at least annually in 2024 (personnel file numbered 2); and

c. The treatment supervision plan did not identify the qualifications of the staff person receiving supervision (personnel file numbered 2).

Statute Violated: Minnesota Statutes, section 245I.06, subdivision 2, paragraphs (a) and (b).

Corrective Action Ordered: Correct immediately and maintain compliance.

25. Violation: Six of six personnel files reviewed for requirements governing training did not meet requirements. There was no documentation to demonstrate the staff person received orientation and ongoing training as required:

a. To the Minnesota Health Records Act, including family engagement under Minnesota Statutes, section 144.294, prior to providing direct contact services (personnel files numbered 6 and 7);

b. To client confidentiality, within 24 hours of starting their position (personnel file numbered 1);

c. Annually to the following required topics:

i. Vulnerable adult maltreatment reporting requirements, the program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment, for calendar years:

1. 2023 and 2025 (personnel file numbered 4); and

2. 2024 (personnel files numbered 1 and 9);

ii. Maltreatment of minors reporting requirements, for:

1. 2023 and 2025 (personnel files numbered 4 and 9); and

2. 2024 (personnel file numbered 1);

iii. Client rights and protections under section 245I.12, for 2024 (personnel files numbered 1 and 2);

iv. Minnesota Health Records Act, including family engagement (personnel files numbered 1 and 2) and client privacy (personnel file numbered 2) for 2024;

v. Emergency procedures, including fire and inclement weather, responding to a report of a missing person, behavioral and medical emergencies, for 2024 (personnel files numbered 1 and 2); and

vi. HIV minimum standards, for 2024 (personnel file numbered 1) and 2025 (personnel files numbered 1 and 9);

d. Every two years, to the following required topics:

i. Client confidentiality rules and regulations in 2024 (personnel file numbered 4); and

ii. Client ethical boundaries in 2024 (personnel files numbered 4 and 9); and

e. 12 additional hours of training in co-occurring disorders (personnel files numbered 4 and 9).

Statute Violated: Minnesota Statutes, sections 245A.19; 245A.65, subdivision 3; 245G.13, subdivisions 1 and 2; and 245I.05, subdivision 3, paragraph (b).

Corrective Action Ordered: Correct immediately and maintain compliance.

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 by email at to Char Hanson at Charlene.M.Hanson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Char Hanson

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.McGarry@state.mn.us

Sincerely,

Maura McGarry, SUD Licensing Supervisor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/