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December 15, 2025 Emma Fernandez, Authorized Agent Community Medical Services Minneapolis on Broadway 8444 N 90th Street, Suite 100 Scottsdale, AZ 85258 License Number: 1118288 CORRECTION ORDER Dear Emma: On October 1, 2, and 3, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Community Medical Services Minneapolis on Broadway located at 1020 W Broadway Ave, Minneapolis, MN 55411This 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 DHS determined that your program failed to follow licensing rules and statutes, as described below. Personnel Files 1. Violation: One personnel file was reviewed for requirements governing individuals with temporary permit (personnel file numbered 3) and did not meet requirements as follows: a. There was no documentation of supervision for the following weeks: 1) March 3, 24, and 31, 2025; 2) April 14, 21 and 28, 2025; 3) May 5, 2025; 4) July 7, 21, and 28, 2025; 5) August 11, 18, and 25, 2025; and 6) September 1, 15, and 22, 2025; and b. Documentation of supervision did not meet the requirements of Minnesota Statutes, section 148F.04 for the following weeks starting on: 1) March 10 and 17, 2025; 2) June 16 and 30, 2025; and 3) August 4, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the documentation governing individuals with temporary permit meet all applicable requirements. 2. Violation: One personnel file was reviewed for requirements governing staff orientation (personnel file numbered 5) and did not meet requirements. There was no documentation of orientation to the following: a. Within 24 working hours to the following: 1) Staff members specific job responsibilities; and 2) Client confidentiality; b. Within 72 hours of first providing direct contact services to the program abuse prevention plan; c. Before the mandatory reporter had direct contact, reporting requirements and definitions in Minnesota statutes, chapter 260E; and d. Within six months of employment, 12 hours of training in co-occurring disorders within six months of employment. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245G.13, subdivisions 1, clause (7), and 2, paragraphs (e) and (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the staff orientation meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above staff received the required orientation. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. 3. Violation: Three of three personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual trainings for the calendar year 2025 for the following: 1) The license holder’s specific policies for obtaining a release of client information (personnel file numbered 3); 2) Program abuse prevention plan (personnel files numbered 1 and 3); and 3) HIV minimum standards (personnel files numbered 1 and 3); b. Every 2 year training for calendar year 2025 (personnel file numbered 4): 1) Client confidentiality rules and regulations and client ethical boundaries; and 2) Emergency procedures and client rights. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (b) through (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual, every 2 year, and additional personnel trainings meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the above staff received the required trainings. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. 4. Violation: Four of four personnel files reviewed for requirements governing personnel file contents (personnel files numbered 1 through 3) did not meet requirements as follows: a. There was no documentation of job performance evaluation for calendar year 2025 (personnel files numbered 1 through 3); and b. There was no documentation of date of first direct contact (personnel file numbered 5). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivision 1, clause (3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure personnel file contents meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. Client Files 5. Violation: One of four client files reviewed for requirements governing client orientation (client file numbered 1) did not meet requirements. There was no documentation of orientation to the following: a. Internal and external maltreatment of vulnerable adults reporting policies within 24 hours of admission; and b. Opioid education material approved by the commissioner on the day of service initiation. Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1, paragraph (c) 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. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. 7. Violation: One of four client files reviewed for requirements governing vulnerable adult determinations (client file numbered 1) did not meet requirements. The vulnerable adult determination was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1a, paragraph (a) and 245G.04, subdivision 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. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. 8. Violation: Four of four client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not include documentation of the following: a. Status of the client’s basic needs (client files numbered 1, 2, 4, and 5); b. Client’s resources (client file numbered 5); and c. Client’s history of potential brain injuries (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. 9. Violation: Six of six client files reviewed for requirements governing documentation of treatment services and client records did not meet requirements in the following ways: a. There was no documentation of telehealth originating and distance site (client file numbered 5); and b. Entries did not include the job titles or position of the staff that made the entry for the following dates: 1) June 27, July 3, 7, 8, 14, 17, 23, and 31, August 6, 12, and 28, and September 4, 13, 22, and 29, 2025 (client file numbered 1); 2) July 25, August 5, 20, and 28, and September 3, 11, 17, and 26, 2025 (client file numbered 2); 3) March 22, April 2, May 8, June 12, July 14, August 27, and September 16, 2025 (client file numbered 3); 4) March 25, 26, and 31, April 17 and 30, May 20 and 27, June 3, 6, 24, 27, and 30, July 9 and 23, and August 4, 2025 (client file numbered 4); and 5) April 9, 24, and 25, May 5, June 6, 25, and 26, July 1 and 24, and August 6, 8, and 22, 2025 (client file numbered 5). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 2a, 2b, paragraph (c) and 245G.07, subdivision 4, paragraph (c), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 6. Violation: Five of five client files reviewed for requirements governing treatment plan reviews did not meet requirements. The treatment plan reviews did not meet requirements in the following ways: a. There was no documentation of the following: 1) The span of time covered by the review for the review period starting: i. July 1, 14, 21, August 1, 11, and September 1, 2025 (client file numbered 1); ii. August 24, 31, and September 11, 2025 (client file numbered 2); iii. April 1, May 1, June 1, July 1, and August 1, 2025 (client file numbered 3); and iv. July 21 and August 2, 2025 (client filed numbered 4); and b. Treatment plans were not completed weekly for ten weeks following the completion of the treatment plan (client files numbered 1, 2, 4, and 5); and c. Treatment plans were not completed monthly following the first ten weeks following the completion of the treatment plan (client file numbered 3). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 3 and 3a, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit two treatment plan reviews that meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 11, 2024. 7. Violation: Three of three client files reviewed for requirements governing service discharge summaries did not meet requirements. The discharge summary did not include documentation of the following: 1) Client’s issues (client files numbered 3, 4, and 5); 2) Client’s strengths (client files numbered 3 and 4); 3) Client’s needs (client files numbered 3 and 4); 4) Progress toward achieving each goal identified in the treatment plan (client files numbered 3 and 4); 5) Risk rating and description for each of the ASAM six dimensions (client files numbered 3 and 4); and 6) Reasons for and circumstances of service termination (client file numbered 4). Statute Violated: Minnesota statute, section 245G.06, subdivision 4, paragraph (b), clauses (1) through (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service discharge summaries meet all applicable requirements. 8. Violation: One of five client files reviewed for requirements governing criteria for unsupervised medication use did not meet requirements. There was no documentation that a practitioner reviewed and documented the criteria in the Code of Federal Regulations, title 42, part 8.12 (2) when determining whether dispensing medication for a client’s unsupervised use is appropriate to implement (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 6, paragraphs (b) and (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure criteria for unsupervised medication use meets 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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