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January 12, 2026
Rebecca Rosenthal, Authorized Agent Hennepin Healthcare System Inc DBA HC Medical Center 701 Park Ave Minneapolis, MN 55415 License Number: 1062260 CORRECTION ORDER Dear Rebecca: On November 3, 4, 5, and 6, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, HCMC Addiction Medicine Program located at 914 S 8th St. Minneapolis, MN 55404. As a result of this visit, DHS determined that you are in violation of the Substance Use Disorder 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 did not follow licensing rules and statutes, as described below. Throughout the correction order, references to the statute or rule requirement will be identified as follows: Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements governing specific measures to reduce the possibility of diversion. The license holder contacted less than five percent of clients who had unsupervised use of medication to require the clients to physically return to the program in January, February, March, April, and September of 2025. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (c), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that diversion control measures are followed and meet all applicable requirements. 2. Violation: The license holder did not meet requirements governing quality improvement plans. The quality improvement plan for calendar year 2025 did not include a goal concerning oversight and monitoring of the premises around and near the exterior of the program to reduce the possibility of medication used for the treatment of opioid use disorder being inappropriately used by a client, including but not limited to the sale or transfer of the medication to others. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 18, clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the quality improvement plan goal areas meet all applicable requirements. Within 30 days of receipt of this order, submit a quality improvement plan that meets all applicable requirements. 3. Violation: The license holder’s service initiation and termination policy did not meet requirements. There was no documentation of the following: a. Service initiation preferences to pregnant persons as required by the Code of Federal Relations, title 45, part 96.131; b. Procedures the staff members must follow when a client is admitted under Minnesota Statutes, chapter 253B, is to have services terminated; and c. Procedures for communicating staff approved service termination criteria to a client, including the expectation in the client’s individual treatment plan. Statute Violated: Minnesota Statutes, section 245G.14, subdivisions 1 and 3, clauses (4) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation and termination policies meet all applicable requirements. Within 30 days of receipt of this order, submit the policies identified above that meet all applicable requirements. 4. Violation: The license holder did not meet requirements governing client rights protection, as follows: a. The license holder’s client’s right policy did not include client rights as identified in Minnesota Statutes, sections 148F.165 and 253B.16; and b. There was no documentation that the response to the client’s grievance occurred within three days of the staff members’ receipt of the grievance for the following dates: 1) January 19, 2024; 2) July 27, 2024; 3) December 27, 2024; 4) February 14, 2025; 5) February 14, 2025; 6) July 16, 2025; and 7) September 22, 2025. Statute Violated: Minnesota Statutes, section 245G.15, subdivisions 1 and 2, clauses (2) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights protection meets all applicable requirements. Within 30 days of receipt of this order, submit the policies identified above that meet all applicable requirements. 5. Violation: The license holder’s client attendance policy and procedure did not meet requirements. The policy did not identify how the program will track and record the nature of each treatment service provided to the client. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client attendance policy and procedures meet all applicable requirements. 6. Violation: The license holder’s tuberculosis policy and procedure did not include written methods and resources to provide information of tuberculosis and tuberculosis screening to each client according to section 144.4804. Statute Violated: Minnesota Statutes, section 245G.12, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that tuberculosis policies meet all applicable requirements. Within 30 days of receipt of this order, submit a tuberculosis policy that meets all applicable requirements. 7. Violation: The license holder did not meet requirements governing program abuse prevention plans (PAPP). The PAPP did not include the type of grounds and terrain surrounding the building in the assessment of the environment. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 8. Violation: The license holder did not notify the commissioner within 24 hours of receiving knowledge of the death of an individual served by the program on January 23, April 9, September 24, 25, 2024, March 27, and August 25, 2025. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that death reporting meets all applicable requirements. Personnel files 9. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of orientation to the following within 24 working hours of starting: a. The staff members specific job responsibilities (personnel files numbered 1, 3, and 5); and b. Client needs (personnel files numbered 1, 3, 5, and 6). Statute Violated: Minnesota statutes, 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. 10. Violation: Two of five personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Annual trainings on: 1) Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572 and chapter 260E for calendar years: i. 2024 (personnel file numbered 2); and ii. 2023 and 2024 (personnel file numbered 4); 2) HIV minimum standards for calendar years: i. 2024 (personnel file numbered 2); and ii. 2023 and 2024 (personnel file numbered 4); b. Every two year trainings for calendar year 2024 (personnel file numbered 4); 1) Client confidentiality and ethical boundaries; and 2) Emergency procedures including behavioral and client rights. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (a) through (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff development meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that personnel file numbered 4 has completed the trainings. 11. Violation: One of five personnel files reviewed for requirements governing personnel file contents (personnel file numbered 4) did not meet requirements. There was no documentation of a written annual review for calendar year 2025. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client files 12. Violation: Two of eight client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation as follows: a. On the day of service initiation: 1) A written statement of client rights and responsibilities and that staff reviewed the statement with the client (client files numbered 5 and 9); 2) Grievance procedure (client files numbered 5 and 9); b. HIV minimum standards within 72 hours of admission (client file numbered 5); and c. Within 24 hours of admission or 72 hours for persons who would benefit more from a later orientation: 1) The internal and external maltreatment of vulnerable adults reporting policies (client files numbered 5 and 9); and 2) Program abuse prevention plan (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a), clause (4), 245G.09, subdivision 3, paragraph (a), clause (1), and 245G.15, subdivisions 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meet all applicable requirements. 13. Violation: Two of eight client files reviewed for requirements governing initial services plan (ISP) did not meet requirements. There was no documentation the ISP was completed within 24 hours of the day of service initiation (client files numbered 5 and 9). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. 14. Violation: Three of eight client files reviewed for requirements governing vulnerable adult (VA) assessment and determination did not meet requirements. There was no documentation the VA assessment and determination was completed within 24 hours of the day of service initiation (client files numbered 5, 8, and 9). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1a, paragraph (a), clause (1) and 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that VA assessment and determination meets all applicable requirements. 15. Violation: Eight of eight client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. There was no documentation of: a. The client’s perceptions of the client’s condition (client files numbered 8 and 9); b. The client’s description of the client’s symptoms (client files numbered 8 and 9); c. The client’s history of mental health treatment (client files numbered 5 and 9); and d. Substance use history, including: 1) Amounts of substances (client file numbered 2); 2) Frequency (client file numbered 2); and 3) Duration (client files numbered 3, 4, 5, and 9); e. The client’s evaluation of the quality of each relationship (client files 1, 2, 3, 5, and 9); f. Important developmental incidents in the client’s file (client files numbered 1, 2, 3, 4, 5, 6, 8, and 9); g. A diagnosis of a substance use disorder (client file numbered 2); and h. A risk rating and summary to support the risk ratings within each of the dimensions listed in Minnesota Statutes, section 254B.04, subdivision 4, paragraphs (b) through (g) (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, 245G.05. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that meet requirements. 16. Violation: Eight of eight client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. There was no documentation of the following: a. An updated ITP based on new information gathered about the client’s condition (client file numbered 1); b. 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, 2, 3, 4, 5, 6, 8, and 9); c. The participants involved in the client’s treatment planning (client files 1, 2, and 3); and d. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1a, paragraph (a) clauses (3) through (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan that demonstrates compliance. 17. Violation: Seven of seven client files reviewed for requirements governing treatment service documentation did not meet requirements. The following treatment service documentation did not include: a. The date: 1) May 1, 9, and June 13, 2025 (client file numbered 3); 2) April 11, 25, May 9, June 30, August 28, and September 18, 2025 (client file numbered 4); 3) August 29, September 8, and October 10, 2025 (client file numbered 5); and 4) July 18, August 15, September 19, and October 31, 2025 (client file numbered 6); b. The type: 1) July 18, August 15, September 19, and October 31, 2025 (client file numbered 6); and 2) August 7, 15, 22, 25, and 28, 2025 (client file numbered 2); c. The amount on August 7,15, 22, 25, and28, 2025 (client file numbered 2); d. The client’s response: 1) June 13, 18, 24, July 3, 8, 16, 22, July 28, August 7, 11, September 24, and October 8, 2025 (client file numbered 1); 2) August 7, 15, 22, 25, and 28, 2025 (client file numbered 2); 3) April 22, May 1, 9, 15, 22, June 3, 13, July 25, and September 4, 2025 (client file numbered 3); 4) April 11, 25, May 9, June 30, August 28, and September 18, 2025 (client file numbered 4); 5) August 29, September 8, and October 10, 2025 (client file numbered 5); 6) July 18, August 15, September 19, and October 31, 2025 (client file numbered 6); and 7) July 25, September 25, and October 23, 2025 (client file numbered 8). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment service documentation meets all applicable requirements. Within 30 days of receipt of this order, submit treatment service documentation from two clients that demonstrates compliance. 18. Violation: Seven of seven client files reviewed for requirements governing treatment plan reviews and their frequency did not meet requirements. There was no documentation of: a. The span of time covered by the review (client files numbered 1, 2, 3, 4, 5, 6, and 8); b. Whether the identified methods continue to be effective (client files 1, 2, 3, 4, 5, 6, and 8); c. Monitoring of physical and mental health problems (client files numbered 4, 5, 6, and 8); d. Referrals made since the previous treatment plan review (client files 2 and 3); and e. Non-residential opioid treatment plan review completed: 1) Weekly for ten weeks: i. September 17, 25, and October 2, 2025 (client file numbered 2); ii. April 15 and April 29, 2025 (client file numbered 3); iii. March 4, 11, 18, 25, April 1, 8, 18, 25, and May 2, 2025 (client file numbered 4); and iv. September 20, 2025 (client file numbered 6); 2) Monthly thereafter: i. August 2025 and October 2025 (client file numbered 3); and ii. July 2025 and October 2025 (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3, clauses (1), (2), and (6) and 3a, paragraph (f), clauses (1) and (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews and their frequency meet all applicable requirements. Within 30 days of receipt of this order, submit treatment plan reviews from two clients that meet all requirements. 19. Violation: Three of eight client files reviewed for requirements governing record keeping (client files numbered 1, 2, and 3) did not meet requirements. The GAIN-SS was not signed and dated by the staff member making the entry. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure record keeping meets all applicable requirements. 20. Violation: Three of three client files reviewed for requirements governing discharge summaries did not meet requirements as follows: There was no documentation of: a. The service discharge summary recorded in the six dimensions (client file numbered 2); and b. There was no documentation of: a. The client’s issues and needs while participating in treatment (client files numbered 2 and 7); b. The client’s progress towards achieving each of the goals identified in the individual treatment plan (client file numbered 2); c. The client’s living arrangements at service termination (client file numbered 2); and d. Service termination diagnosis (client file numbered 9). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b), clauses (1), (2), (5) and (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. 21. Violation: Three of six client files reviewed for requirements governing opioid treatment programs central registry did not meet requirements. There was no documentation of the following: a. Date of admission (client file numbered 1); and b. Current or previous enrollment status in another opioid treatment program (client files numbered 1, 5, and 6). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, clauses (2) and (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that central registry documentation meet all applicable requirements. 22. Violation: Three of six client files reviewed for requirements governing opioid treatment programs prescription monitoring program (PMP) did not meet requirements. There was no documentation of: a. The medical director or designee reviewing the prescription monitoring program data before the client was ordered medications for the use of the treatment of opioid addiction on: 1) August 21, 2025 (client file numbered 5); and 2) June 2, 2025 (client file numbered 1); and b. The physician reviewing the data within 72 hours when the PMP contained a recent history of multiple prescribers on June 5, 2025 (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b), clauses (2) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that prescription medication monitoring meets all applicable requirements. 23. Violation: Four of six client files reviewed for requirements governing opioid treatment programs non-medication treatment services did not meet requirements. There was no documentation that the program offered at least 50 consecutive minutes of individual or group therapy treatment services on: a. March 4, 11, 18, 25, April 1, 8, 18, 25, and May 2, 2025 (client file numbered 4); b. April 15 and 29, 2025 (client file numbered 3); c. September 17, 25, and October 2, 2025 (client file numbered 2); and d. June 13, 18, 24, July 3, 8, 16, 22, 28, August 7, 11, September 24, and October 8, 2025 (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 15, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that non-medication treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit treatment service documentation from two clients that meets all 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 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 651-431-6617. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
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