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January 12, 2026 Eric Vagle, Authorized Agent Minnesota Adult & Teen Challenge 740 E 24th St Minneapolis, MN 55404-3862 License Number: 1066304 (245G) License Number: 1088843 (245G)
CORRECTION ORDER Dear Eric Vagle: On September 22 through 26, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facilities, Minnesota Adult & Teen Challenge located at: · 1530 Assisi Drive NW Rochester, MN 55901, license number 1066304 · 1542 Assisi Drive NW Rochester, MN 55901, license number 1088843 This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under Statute 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. Policy, Procedure and Practices 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. 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: a. Diagnostic assessment completed within 10 days of admission (client files numbered 1 and 3); b. Monthly multidisciplinary case review for the following: i. July 30, 2025, to September 4, 2025 (client files numbered 2); ii. May 16, 2025, to August 4, 2025 (client file numbered 3); and iii. August 8, 2025, to September 22, 2025 (client file numbered 4); and c. Annual 8 hours of co-occurring disorder training for calendar years: i. 2023 (personnel file numbered 2); ii. 2024 (personnel files numbered 1, 2, 7 and 9); and iii. 2025 (personnel file numbered 2, 3, 6, 7 and 9). Statute Violated: Minnesota Statute, sections 245A.191 and 245A.167. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services are provided in accordance with 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. 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 grievance procedures as follows: a. The grievance procedure did not include the current telephone number and address for the Department of Health Facilities Complaints (license number 1066304 and 1088843); and b. Two of seven grievances reviewed did not meet requirements. There was no documentation of a response to a client’s grievance within three days of a staff members receipt for grievances received on August 11 and 13, 2025 (license number 1088843). Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 60 days of receipt of this order the license holder will submit an updated grievance procedure that meets all applicable requirements. 3. Violation: The license holder policy governing services initiation did not meet requirements. The service initiation criteria did not contain specific service initiation criteria (license number 1066304 and 1088843). Statute Violated: Minnesota Statutes, section 245G.14, subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis the license holder must ensure that requirements governing service initiation meets all applicable requirements. Within 60 days of receipt of this order the license holder will submit an updated services initiation policy that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing visitors for licensed residential treatment (license number 1066304 and 1088843). The program’s practice was to restrict a client’s ability to receive visitors for rule infractions. The program has a form titled ‘Short Term Privileges and Consequences’ which identifies a list of rule infractions that will restrict a client’s ability to receive visitors; however, through staff interview it was identified that these infractions are not always necessary for the welfare of the client. Statute Violated: Minnesota Statutes, section 245G.21, subdivision 2. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements governing visiting meet all applicable requirements. 5. Violation: The license holders policy governing photographs of clients did not meet requirements (license number 1066304 and 1088843). The license holder did not have a written policy regarding the use of any personal electronic device that can record, transmit, or make images of another client. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements governing photographs of clients meets all applicable requirements. Within 60 days of receipt of this order the license holder will submit a policy that meets all applicable requirements. 6. Violation: The license holders (license number 1066304 and 1088843) treatment service descriptions did not meet requirements. The treatment services description did not include: a. Amount and type of services provided; b. Which groups and topics on which a guest speaker could provide under the direct observation of an alcohol and drug counselor; and c. The programs treatment week. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3a, and 245G.12, clause (10). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment service description meet all applicable requirements. Within 60 days of receipt of this order the license holder will submit treatment service descriptions that meet all applicable requirements. 7. Violation: The license holder did not meet requirements governing program abuse prevention plans. The plan did not contain an assessment and evaluation of the following factors: a. Gender (license numbers 1066304 and 1088843); b. The condition and design of the building as it related to the safety of the clients (license number 1066304); and c. The location of the program in a particular neighborhood or community (license numbers 1066304 and 1088843). Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a), clause (1), (2) and (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all requirements. Within 60 days of receipt of this order, submit a program abuse prevention plan for license number 1066304 and 1088843 that meets all applicable requirements. 8. Violation: The license holder did not meet requirements governing internal reviews of alleged or suspected maltreatment of vulnerable adults as follows (license number 1066304): a. Through staff interviews, it was determined that written notice stating whether the facility reported the incident to the common entry point was not given to the reporter within two working days for a report received on February 26, 2025; and b. Internal reviews dated October 23, 2023, and February 26, 2025, did not document the following: i. If the reported event is similar to past events with the vulnerable adults, or the services involved; and ii. There is a need for any corrective action to be taken by the license holder to protect the health and safety of vulnerable adults. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraphs (a), clause (1) and (b), clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the vulnerable adult internal review requirements meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing the administration of medication and assistance with self-medication (license numbers 1066304 and 1088843). The license holder did not provide supervision as defined in Minnesota Statutes, section 148.171, subdivision 23, by a registered nurse at minimum, monthly on-site supervision or more often if warranted by a client’s health needs. Through staff interviews it was determined that at minimum monthly onsite supervision is being completed by an RN, however the license holder did not document the supervision as evidence by no supervision log for the time period of March 2024 through August 2025. Statute Violated: Minnesota Statutes, section 245G.08 subdivision 5, paragraph (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure medical services meets all applicable requirements. Within 60 days of receipt of this order the license holder (license numbers 1088843 and 1066304) will submit updated policies for on-site supervision by a registered nurse, and the documentation of the supervision provided by a registered nurse for 2 months. 10. Violation: The license holders policy governing the plan for transfer of clients and records upon closure did not meet requirements (license numbers 1088843 and 1066304). The plan did not provide for notifying affected client of the closure at least 25 days prior to closure. Statute Violated: Minnesota Statute, section 245A.04 subdivision 15a, paragraph (a). 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 60 days of receipt of this order the license holder will submit a plan for transfer of clients and records upon closure that meets all applicable requirements. Personnel Files Personnel files reviewed are identified in the following manner: · License Number: 1066304 Personnel files 1 through 6 · License number: 1088843 personnel files 7 through 10 11. Violation: One of ten personnel files reviewed for requirements governing background studies (personnel file numbered 1) did not meet requirements. Staff person 1 (SP1) began a position allowing direct contact with persons served by the program on March 31, 2014. A background study was submitted under license number 1066304, however SP1 was also working under license number 1088843. The license holder did not affiliate SP1 to all required rosters. Statute Violated: Minnesota Statute, section 245C.07 paragraph (f). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with background study requirements. The license holder corrected this onsite. 12. Violation: Two of three personnel files for requirements governing individuals with temporary permits did not meet requirements. There was no documentation of weekly supervision for an individual with a temporary permit for the weeks beginning: a. June 2, 9, 16, 23, July 14, August 4, and September 1, 2025 (personnel file numbered 8); and b. May 20, 27, June 3, 10, 17, 24, July 1, 8, and 15, 2024 (personnel file numbered 9). Statute Violated: Minnesota Statute, section 245G.11, subdivision 11. Corrective Action Required: Immediately and on an ongoing basis the license holder must meet all applicable requirements for individuals with temporary permits. 13. Violation: Three of three personnel files reviewed for requirements governing staff orientation (personnel files numbered 3, 8, and 10) did not meet requirements. There was no documentation of orientation to HIV minimum standards within 24 working hours of employment. Statute Violated: Minnesota Statutes, sections 245A.19, clause (b), and 245G.13, subdivisions 1, clause (7) and 2, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure all applicable requirements governing orientation are met. 14. Violation: Nine of nine personnel files reviewed for annual trainings did not meet requirements. There was no documentation of annual training for: a. Program abuse prevention plan for the calendar years: i. 2024 (personnel file numbered 2); and ii. 2025 (personnel file numbered 8); b. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for the calendar years: i. 2023 (personnel file numbered 2); and ii. 2025 (personnel file numbered 8); c. Reporting of maltreatment of minors for the calendar year 2024 (personnel file numbered 2); d. HIV minimum standards for the calendar years: i. 2024 (personnel file numbered 1 through 9); and ii. 2025 (personnel file numbered 1 through 9); and e. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of client information for the calendar years: i. 2023 (personnel file numbered 5); and ii. 2025 (personnel file numbered 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 all applicable requirements governing annual training is met. 15. Violation: One of seven personnel files reviewed for requirements governing two-year training (personnel file numbered 2) did not meet requirements. There was no documentation of training on client confidentiality, rules, regulations and client ethical boundaries for the calendar year 2024. Statute Violated: Minnesota Statutes, sections 245G.13, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure all applicable requirements governing two-year training is met. 16. Violation: One of one personnel file reviewed for requirements governing administration of medication training for unlicensed staff did not meet requirements (personnel file numbered 8). There was no documentation of training according to a formalized training program that is taught by a registered nurse and offered by the license holder. Statute Violated: Minnesota Statutes, 245G.08 subdivision 5, paragraph (b), clause (2). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure staff qualifications meets all requirements. Within 60 days of receipt of this order the license holder will submit documentation of administration of medication training for unlicensed staff that meets all applicable statute requirements. Client Files Client files reviewed are identified in the following manner: · License Number: 1066304 client files 1 through 3 · License number: 1088843 client files 4 through 6 17. Violation: Six of six client files reviewed for requirements governing client orientation (client files numbered 1 through 6) did not meet requirements. There was no documentation on the day of service initiation of the following: a. Staff reviewed the written statement of client rights and responsibilities with the client; and b. An explanation of the grievance procedure. Statute Violated: Minnesota Statutes, sections 245G.09, subdivision 3, clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meets all applicable requirements. 18. Violation: Six of six client files reviewed for requirements governing initial services plans (client files numbered 1 through 6) did not meet requirements. The initial services plan was not person-centered and client specific. 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 services plans meet all applicable requirements. Within 60 days of receipt of this order the license holder will submit two initial services plans that meet all applicable statute requirements. 19. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. The IAPP did not contain an individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults (client files numbered 1 through 5). Statute Violated: Minnesota Statutes, Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), 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 60 days of receipt of this order the license holder will submit two individual abuse prevention plans that meet all applicable statute requirements. 20. Violation: Six of six client files reviewed for requirements governing comprehensive assessments did not meet requirements as follows: a. A comprehensive assessment was not completed by the end of the fifth day on which a service was provided in a nonresidential program and did not contain the person-centered reason for the delay and the planned completion date was not documented in the clients file (client file numbered 3); b. The comprehensive assessment did not include: i. The clients age (client files numbered 1 through 4); ii. The client’s perception of the client’s condition (client file numbered 4); iii. The client’s description of the client’s symptoms (client file numbered 5); iv. Substance use history, including: 1. Amounts and types of substances (client files numbered 1, 4, and 5); v. Duration (client file and 4); and 1. Route of administration (client files numbered 4 and 6); vi. Client’s evaluation of the quality of client’s relationship with family and other significant personal relationships (client files 1 through 6); vii. Client’s resources (client files numbers 1, 4, and 5); viii. Important developmental incidents in the client’s life (client files numbered 1, 2, 4 and 6); ix. Client’s history of or exposure to alcohol and drug use (client files numbered 1 through 6); and x. The client’s family health history (client files 1 through 6). Statute Violated: Minnesota Statutes, section 245G.05. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the comprehensive assessment meets all applicable requirements. Within 60 days of receipt of this order submit one comprehensive assessment that meets all applicable requirements. 21. Violation: Six of six client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. a. The ITP was not: i. Completed within ten days from the day of service initiation (client file numbered 5); ii. Signed by the client and did not document the client’s involvement in the development of the plan (client file numbered 6); iii. Signed or dated by an alcohol or drug counselor or qualified staff member (client file numbered 1); iv. Updated based on new information gathered about client’s participation (client file numbered 2); v. Based on the client’s comprehensive assessment (client files numbered 1 through 6); and vi. Person centered (client files numbered 1 through 6); and b. There was no documentation of the following: i. A treatment strategy (client files numbered 1 through 6); ii. How family or others will be involved in the client’s treatment or the reason that the client’s family or other natural supports were not involved (client files numbered 3 and 5); iii. Maintenance strategy goals and methods designed to address relapse prevention and to strengthen the client’s protective factors (client file numbered 6); and iv. Active interventions to stabilize mental health symptoms present (client files numbered 2 and 3). Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 1 and 1a, clauses (1), (2), (3), (5), and (7), and 245G.20, clause (5). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order submit 2 individual treatment plans that meet all applicable requirements. 22. Violation: Six of six client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Client documentation did not record: i. Type of treatment service for the following dates: 1. June 21, 23, 24, 25, 26, and 27, 2025 (client file numbered 1); 2. August 19, 21, and 23, 2025 (client file numbered 2); 3. June 11, 14, and July 24, 2025 (client file numbered 3); 4. September 19, 2025 (client file numbered 4); 5. May 19, 20, 22, 23, June 9, 10, and 12, 2025 (client file numbered 5); and 6. May 13, 14, June 23, 25, 26, 27, August 18 and 20, 2025 (client file numbered 6); ii. Clients’ response to the treatment service on August 21, 2025 (client file numbered 2); and iii. Job title or position of the staff person making the entry on the following dates: 1. August 8 and 13, 2025 (client file numbered 4); and 2. April 28,, May 12, 27, June 9 , 23,July 7, and 21, 2025 (client file numbered 6); and b. For services provided via telehealth the license holder did not document the following (client file numbered 4): i. Determination that telehealth is an appropriate and effective means for delivering the treatment service on August 8 and 29, 2025; ii. The mode of transmission used to deliver the service through telehealth on August 8, 2025; and iii. The location of the originating site and distance site on August 8, and 29, 2025. Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 2a and 2b, paragraphs (a) and (c), 245G.07, subdivision 4, paragraph (c), clause (2). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all client records meet all applicable requirements. 23. Violation: Four of five client files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. There was no documentation of client’s use of medication including staff signatures with date and time for the following: i. July 1 through 3, 2025 (client file numbered 1); ii. August 1 through 3, 6 through 8, 13, 22, 23 and 25, 2025 (client file numbered 2); iii. August 10, 13 and 30, 2025 (client file numbered 4); and iv. May 1 through 31, 2025 (client file numbered 5). Statute Violated: Minnesota Statutes, sections 245G.08, subdivision 5, paragraph (c), clause (7) and 245G.21, subdivision 8. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all requirements governing medication administration are met. 24. Violation: Five of five client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The service discharge summary was not completed within five days of the client’s service termination (client file numbered 6); and b. The service discharge summary did not include the following: i. Services provided (client files 4 through 6); and ii. Risk rating descriptions for each of the ASAM six dimensions (client files 2 through 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (1) and (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements. Within 60 days of receipt of this order the license holder will submit one discharge summary that meets all applicable requirements. 25. Violation: Five of six client files reviewed for requirements governing property management did not meet requirements. There was no documentation of the following: a. Receipt of the client’s property, including the person’s signature (client file numbered 1, 2 and 4); and b. Disbursement of the client’s property, including the person’s signature (client files numbered 1 through 4 and 6). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 13, paragraph (c), clause (1) and 245G.21 subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that requirements governing client property management 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.eppel@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Jennifer Eppel 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 651-431-66998 or at jennifer.eppel@state.mn.us. Sincerely, Jennifer Eppel, Licensor Licensing Division Office of Inspector General
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