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January 23, 2026 CERTIFIED MAIL Terri Senkow, Authorized Agent Metro Treatment of Minnesota LP 2500 Maitland Center Pkwy Ste 250 Maitland, FL 32751 License Number: 1036502 (245G) ORDER OF CONDITIONAL LICENSE Dear Terri Senkow: The Department of Human Services (DHS) is placing your license to provide at Rochester Metro Treatment Center, 2360 N Broadway, Rochester, MN 55901, on conditional status for two years, beginning January 23, 2026. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Substance Use Disorder Treatment licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On November 05 through 07 and 11, 2025, DHS licensors conducted a licensing review at your facility located at 2360 N Broadway, Rochester, MN 55901. As a result of this licensing visit, the DHS licensors determined that your program did not comply with the laws and rules that apply to licensed substance use disorder treatment programs, citing 28 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of the persons served by the program. · Nature and Severity: The license holder did not follow requirements which affected the health, safety, and rights of persons served: o The program did not provide treatment services according to the individual treatment plan and special needs of the client (violation numbered 1) o The program did not offer all required treatment services (violations numbered 2 and 13) o The program did not ensure monthly supervision was provided by a registered nurse (violation numbered 3) o The program did not have a qualified treatment director (violation numbered 5) o The program did not complete comprehensive assessments as required (violation numbered 9) o The program did not complete individual treatment plans as required (violation numbered 10) o The program did not comply with the requirements of the Code of Federal Regulations, title 42, part 8 (violation numbered 8) o The program did not complete treatment plan reviews as required (violation numbered 11) o The program did not complete discharge summaries as required (violation numbered 12) o The program did not comply with background study requirements (violation numbered 15) o The program did not provide staff orientation and annual training as required (violations numbered 16 and 17) o The program did not comply with specific measures to reduce the possibility of diversion (violation numbered 6) o The program did not ensure staffing ratios were maintained (violation numbered 7) o The program did not comply with the unsupervised use of methadone hydrochloride (violated numbered 14) Due to the serious nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder treatment is placed on a conditional status. Licensing Violations DHS determined that your program did not to follow licensing rules and statutes, as described below. 1. Violation: The license holder did not provide treatment services to a client with consideration to the special needs of the client (client file numbered 2). The client received treatment services through telehealth and was assigned to a telehealth only counselor on October 21, 2025; however, documentation in the client record and client interview indicated this was not appropriate as follows: a. Group note from September 10, 2025, stated that this service was provided through telehealth, and the client was asked to leave the group due to not having a secure space to participate in the service from; b. Note dated October 21, 2025, stated that client did not want telehealth services as they do not have the technology to participate; and c. In an interview with DHS Licensor on October 23, 2025, the client indicated that they did not want telehealth services and did not have the technology to participate. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 1, paragraph (b). 2. Violation: The license holder did not offer all treatment services in Minnesota Statutes, 245G.07, subdivision 1, paragraph (a), clauses (1) to (4), physically in-person to each client. Through staff interviews, it was identified there was no counseling staff physically present at the licensed location to provide treatment services from October 12 through 22, 2025. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c). 3. Violation: The license holder did not to meet the requirements governing the administration of medication and assistance with self-medication. Through staff interviews, it was determined that a registered nurse had not provided, at a minimum, monthly on-site supervision. A registered nurse had not been on site to provide supervision since May 2025. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). 4. Violation: One of nine client files reviewed for requirements governing medication orders (client file numbered 11) did not meet requirements. A client-specific medication order was not received from a practitioner prior to the program dispensing a mediation used for the treatment of opioid use disorder. The client’s first dose was received on June 17, 2025; however, there was no medication order in the chart. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 3. 5. Violation: The license holder did not meet requirements governing treatment directors as follows: a. Through staff interviews, it confirmed that the program had not had a treatment director since November 2, 2025; b. Through staff interviews and as evidenced by the number and nature of citations in this order, it was evident that the treatment director employed from June 14 through August 04 and October 11 through November 01, 2025, did not know and understand the requirements of Minnesota Statutes, chapters 245A and 245G (personnel file numbered 1); and c. There was no documentation in the personnel record that the treatment director employed from August 04 through October 10, 2025, knew and understood the implications of Minnesota Statutes, chapters 245A, 245C, 260E, and sections 626.557 and 626.5572 (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245G.10, subdivision 1 and 245G.11, subdivision 3, clause (3). 6. Violation: The license holder did not follow their own process for performing diversion control measures. The program contacted less than five percent of clients who had unsupervised use of medication to require clients to physically return to the program monthly for March, April, and June through October 2025. Staute Violated: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (c), clause (2). 7. Violation: The license holder did not meet the requirements governing staff ratios. The program did not maintain documentation of the clients assigned to each counselor to demonstrate compliance with maintaining a ratio of one full-time equivalent alcohol and drug counselor for every 60 clients enrolled in the program. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (e). 8. Violation: The license holder did not comply with the requirements of the Code of Federal Regulations, title 42, part 8. Through staff interview and client record documentation review, it was identified that the program was closed on more than one weekend day, both Saturdays and Sunday starting October 18, 2025. Client record documentation indicates that this was due to staff shortages. Statute Violated: Minnesota Statutes, section 245G.22, subdivisions 1, paragraph (a), clause (1). 9. Violation: Five of six client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements as follows: a. The CA was not completed within 21 days from the day of service initiation and there was no documentation of the person-centered reason for the delay and the planned completion date as follows: a. The CA was due on July 08, 2025; however, there was no CA found in the client chart (client file numbered 11); and b. The CA was due on June 25, 2025; however, it was completed late on July 15, 2025 (client file numbered 1); and b. The CA did not contain the following: a. The status of the client’s basic needs (client files numbered 1 through 3 and 5); b. The client’s employment status (client file numbered 2); c. The client’s history of mental health and substance use disorder treatment (client file numbered 1); d. Important development incidents in the client’s life (client files numbered 1 through 3, 5, and 10); e. Potential brain injuries (client files numbered 1 through 3, 5, and 10); f. The client’s exposure to alcohol and drug usage and treatment (client file numbered 5); g. The client’s physical health history (client file numbered 1); h. The client’s family health history (client file numbered 5); i. The determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (client files numbered 1 through 3, 5, and 10); and j. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 through 3, 5, and 10). Statute Violated: Minnesota Statutes, sections 245G.05 and 245G.22, subdivision 15, paragraph (c). 10. Violation: Ten of ten client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not completed within 21 days from the day of service initiation as follows: a. The ITP was due on July 07, 2025; however, there was no ITP found in the client record (client file numbered 7); and b. The ITP was due on June 25, 2025; however, it was completed late on July 30, 2025 (client file numbered 1); b. The ITP was not based on the client’s’ comprehensive assessment (client files numbered 1, 3, and 11); c. The ITP was not updated based on new information gathered about the client’s condition and level of participation (client file numbered 11); and d. The individual treatment plan did not contain the following: a. A treatment strategy (client files numbered 1, 8, and 11); 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 through 5 and 8 through 11); and c. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (1), (3), (4), and (6). 11. Violation: Nine of nine client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. There was no documentation of the following: a. The span of time covered by the review for notes signed on the following dates: 1. August 12, 22, 27, September 05, and October 07, 2025 (client file numbered 1); 2. January 09, 17, February 06, and August 30, 2025 (client file numbered 2); 3. June 28, 30, July 07, 18, August 05, 19, and October 19, 2025 (client file numbered 3); 4. May 23, 2025 (client file numbered 4); 5. June 06, July 03 and 11, 2025 (client file numbered 5); 6. March 25 and August 30, 2025 (client file numbered 8); 7. February 12, 2025 (client file numbered 9); and 8. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); b. Client goals addressed since the last treatment plan review for notes signed on the following dates: 1. January 17, 2025 (client file numbered 2); 2. June 28, 2025 (client file numbered 3); 3. June 06, 2025 (client file numbered 5); and 4. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); c. Toxicology results for alcohol and substance use on the following dates: 1. September 05, 2025 (client file numbered 1); 2. June 30, 2025 (client file numbered 3); 3. May 23, 2025 (client file numbered 4); and 4. June 06, 2025 (client file numbered 5); d. Participation of others involved in the individual’s treatment planning on June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); and e. Staff recommendations for changes in the methods identified in the treatment plan on: 1. August 12, 22, 27, September 05, and October 07, 2025 (client file numbered 1); and 2. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); b. Treatment plan reviews were not completed weekly for the first ten weeks following the completion of the treatment plan. Treatment plan reviews were missing for the weeks starting: a. July 16 and August 02, 2025 (client file numbered 1); b. March 08 and 15, 2025 (client file numbered 2); c. July 21, 28, August 11 and 25, 2025 (client file numbered 3); d. June 09, 16, and 23, 2025 (client file numbered 5); e. June 27, July 10, 17, 24, 31, August 07 and 14, 2025 (client file numbered 10); and f. June 30, 2025 (client file numbered 11); and c. Treatment plan reviews were not completed monthly thereafter. Treatment plan reviews were missing for the following months: a. May through October 2025 (client file numbered 2); b. September 2025 (client file numbered 3); c. January, March, April, June, July, September, and October 2025 (client file numbered 4); d. April through July, September, and October 2025 (client file numbered 8); e. March through October 2025 (client file numbered 9); and f. October 2025 (client file numbered 10). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a, paragraph (f). 12. Violation: Four of four client files reviewed for requirements governing services discharge summaries did not meet requirements as follows: a. The services discharge summary was not completed within five days of the client’s service termination. There was no services discharge summary in the chart (client files numbered 6 and 7); and b. There was no documentation of the following: a. A risk rating for each of the ASAM six dimensions (client files numbered 5 and 12); and b. Continuing care recommendations (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (3) and (6). 13. Violation: Six of eight client files reviewed for requirements governing nonmedication treatment services did not meet requirements as follows: a. There was no documentation that the client offered at least weekly individual or group treatment services for the first ten weeks following the day of service initiation for the following weeks: a. June 08, July 02, 23, and August 06, 2025 (client file numbered 1); b. July 21, 28, August 04, 11, 18, and 25, 2025 (client file numbered 3); c. June 02, 09, 16, and 23, 2025 (client file numbered 5); d. June 23, July 7, 17, 21, and 28, 2025 (client file numbered 10); and e. June 30 and July 21, 2025 (client file numbered 11); and b. There was no documentation of treatment services being offered monthly thereafter: a. June and July 2025 (client file numbered 2); and b. September 2025 (client file numbered 10). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 15, paragraph (a). 14. Violation: Two of seven client files reviewed for requirements governing the criteria for unsupervised medication use did not meet requirements as follows: a. There was no documentation of a practitioner review of the criteria in the Code of Federal Regulations, title 42, part 8.12 (i)(2) when the number of take-home doses were increased on March 20, April 23, and October 23, 2025 (client file numbered 4); and b. Documentation of the practitioner review of the criteria in the Code of Federal Regulations, title 42, part 8.12 (i)(2) was completed on August 21, 2025; however, the increase in take-home doses occurred on August 14, 2025. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 6, paragraphs (b) and (c). 15. Violation: One of five personnel files reviewed for requirements governing background studies (personnel file numbered 6) did not meet requirements. Staff person 6 (SP6) began a position allowing direct contact with persons served by the program on October 17, 2025. A background study was submitted under license 830320; however, SP6 was also working under license number 1036502. The license holder did not to affiliate SP6 to all required rosters. Statute Violated: Minnesota Statutes, sections 245C.07, paragraph (f). 16. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation: a. Within 24 working hours of starting: a. Staff members specific job responsibilities (personnel file numbered 5); b. Policies and procedures (personnel files numbered 3 and 5); c. Client confidentiality (personnel files numbered 3 and 5); and d. Client needs (personnel files numbered 3 and 5); b. Within 72 hours of employment to HIV minimum standards (personnel files numbered 3 and 5); c. Within 72 hours of first providing direct contact services (client files numbered 3 and 5): a. Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; b. The program abuse prevention plan; and c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. Before direct contact (personnel files numbered 3 and 5); a. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E; b. Training in the specific mode of administration of emergency overdose treatment used at the program; and c. Drug and alcohol policy. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.242, subdivision 2, paragraph (a), 245A.65, subdivision 3, and 245G.13, subdivisions 1, clause (7), and 2, paragraphs (d) and (e). 17. Violation: Two of two personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following: a. Mandatory reporting requirements and definitions as specified in Minnesota Statutes, sections 626.557 and 626.5572 for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); b. Program abuse prevention plan for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); c. Policies for obtaining a release of client information for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); d. Mandatory reporting requirements as specified in Minnesota Statutes, chapter 260E for calendar year 2025 (personnel file numbered 4); and e. HIV minimum standards for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel file numbered 2 and 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245G.13, subdivision 2, paragraphs (c) and (d). 18. Violation: The license holder did not meet requirements governing grievance procedures. There was no documentation that a client grievance received on February 27, 2025, was responded to within three days of a staff member’s receipt of the grievance. Documentation from March 08, 2025, indicated that the client requested follow-up; however, there is no additional documentation of a program response after that date. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (3). 19. Violation: The license holder did not meet requirements governing quality improvement plans. The quality improvement plan for calendar year 2024 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 mediation to others. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 18, clause (5). 20. Violation: Six of six client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation being completed: a. Personal electronic devices (client files numbered 5); b. Opioid education material approved by the commissioner on the day of service initiation (client files numbered 1 through 3, 5, and 10); and c. Within 24 hours admissions (client file numbered 11): a. Internal and external vulnerable adult maltreatment reporting policies within 24 hours of admission; and b. Program abuse prevention plan. Statute Violated: Minnesota Statues, sections 245G.04, subdivision 3, 245A.65, subdivision 3, 245G.09, subdivision 3, paragraph (a), clause (1), and 245G.15, subdivision 3, paragraph (b). 21. Violation: Three of six client files reviewed for requirements governing initial services plans (client files numbered 1, 3, and 5) did not meet requirements. The initial services plan was not person-centered and client specific. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. 22. Violation: Five of eight client files reviewed for requirements governing documentation of treatment services did not meet requirements, as follows: a. There was no documentation of client response to the treatment service on the following dates: a. January 09 and April 03, 2025 (client file numbered 2); b. July 07, 18, and October 09, 2025 (client file numbered 3); c. March 25 and August 30, 2025 (client file numbered 8); and d. February 12, 2025 (client file numbered 9); b. An entry in the client record was not accurate. The treatment plan review dated June 30, 2025, indicated a treatment goal in Dimension 3; however, this was not reflected in the individual treatment plan (client file numbered 3); and c. An entry in the client record dated July 16, 2025, was not signed (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). 23. Violation: Two of two client files reviewed for requirements governing services provided by telehealth, according to Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c) did not to meet requirements. There was no documentation of: a. The license holder’s basis for determine that telehealth is an appropriate and effective means for delivering the treatment service on the following dates: 1. September 11 and October 13, 2025 (client file numbered 2); and 2. June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); b. The mode of transmission used to deliver the service through telehealth on June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); c. The location of the originating site on the following dates: 1. September 11 and October 13, 2025 (client file numbered 2); and 2. June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); and d. The location of the distance site on September 11 and October 13, 2025 (client file numbered 2). Statute Violated: Minnesota Statutes, section245G.07, subdivision 4, paragraph (c), clause (2). 24. Violation: One client file reviewed for requirements governing persons with co-occurring disorders (client file numbered 2) did not to meet requirements. There was no continuing documentation of collaboration with continuing care mental health providers. Statute Violated: Minnesota Statutes, section 245G.20, clause (6). 25. Violation: One personnel file reviewed for requirements governing every two year trainings (personnel file numbered 2) did not meet requirements. There was no documentation of training to emergency procedures for calendar year 2025. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b), clause (2). 26. Violation: Three of four personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following: a. Completed application for employment signed by the staff member and containing the staff member’s qualifications for employment (personnel files numbered 2 and 5); b. The first date that a background study subject had direct contact with a person served by the program (personnel files numbered 4 and 5); c. An inquiry required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel files numbered 4 and 5); and d. Written annual review for calendar year 2025 (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clauses (1) and (3). 27. Violation: One of eight client files reviewed for requirements governing central registry requirements (client file numbered 2) did not meet requirements. The information submitted did not include: a. Social security number or alien registration number; and b. Current or previous enrollment status in another opioid treatment program. Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, clauses (4) and (5). 28. Violation: Six of seven client files reviewed for requirements governing the prescription monitoring program (PMP) did not meet requirements. There was no documentation of the following: a. The medical director or the medical director’s delegate’s review of the data from the PMP on July 09 and August 11, 2025 (client file numbered 4); b. A copy of the PMP data reviewed on: a. June 04, 2025 (client file numbered 1); b. June 16 and September 10, 2025 (client file numbered 3); c. September 10, 2025 (client file numbered 4); d. May 21, 2025 (client file numbered 5); and e. June 18 and September 10, 2025 (client file numbered 11); and c. When the PMP contains a recent history of multiple prescribers or multiple prescriptions for controlled substances, the physicians review of the data, subsequent actions, and determination of whether or not the prescriptions place the client at risk of harm within 72 hours of the review (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b), clauses (2) through (4). 29. Violation: The license holder did not develop program policies and procedures necessary to maintain compliance with licensing requirements, as follows: a. The license holder did not have a program abuse prevention plan. Documentation in client and personnel records indicated that orientation to the program abuse prevention plan was being done; however, the program was unable to provide a copy of the program abuse prevention plan to DHS Licensors upon request; and b. The policies and procedures regarding HIV were not consistent with the current HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (a), 245A.19, paragraph (d), 245A.65, subdivision 2, and 245G.12, clauses (2) and (9). Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with substance use disorder treatment requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Submit documentation to your licensor as outlined in the Conditional License terms below: 1. By secure email to: Lucy.Versalles@state.mn.us; or 2. By Mail to: Commissioner, Department of Human Services ATTN: Lucy Versalles Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Additionally, DHS will not approve a request to open a new licensed program from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the substance use disorder licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from the effective date of this conditional license order, you must notify clients and all parties who refer clients to the program of the conditional status of the license. The notification must specify the length of time of the conditional status of the license, the reason your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. The notification must be approved by DHS licensing prior to being sent to clients and all other parties. Therefore, the draft notice must be submitted to DHS Licensing for approval within 10 days of receipt of the order. While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving treatment services. The notification to new clients must specify the length of time of the conditional status of the license, the reason the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Documentation of notification of the conditional status must be maintained in each client’s file. Within 30 days of receipt of this order, you must submit to your DHS Licensor a copy of the notice and a list of all referral sources that received the notice. 2. Within 15 days from the effective date of this conditional license order, you must identity a Compliance Officer, located in the state of Minnesota, who will be responsible for correcting the violations identified in this order, completing the terms identified in this order, and monitoring ongoing compliance with requirements for Substance Use Disorder treatment programs. The Compliance Officer cannot also hold the position of Treatment Director or Alcohol and Drug Counselor Supervisor. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. 2 years of professional experience in the following: i. A regulatory or compliance position; ii. Involved in direct care as a substance use counselor; or iii. The development and implementation of mental health or substance use disorder treatment planning in a DHS licensed Minnesota Statutes, chapter 245G Substance Use Disorder program b. Experience must demonstrate knowledge of Minnesota Statutes, Chapter 245A (human services licensing) and Chapter 245G (substance use disorder) c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology or a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field. 3. Within 15 days from the effective date of this conditional license order, you must submit a description of how a registered nurse will provide supervision as defined in Minnesota Statutes, section 148.171, subdivision 23 to staff members who have been delegated the task of administration of medication or assisting with self-medication. The description must identify how supervision will be provided, including a minimum of monthly on-site supervision or more often if warranted by a client's health needs. The description must also address how supervision will be documented, including documenting review of medication administration records and documenting supervision provided to address missing documentation. The description must be approved the DHS Licensor and be included in the policies and procedure manual upon approval. 4. Within 15 days from the effective date of this conditional license order, you must identify a Treatment Director who will be responsible for all aspects of the delivery of treatment service. The program’s Treatment Director must meet the qualifications in Minnesota Statutes, section 245G.11, subdivision 2 and must be approved by DHS Licensing. 5. Within 30 days of the receipt of this order, you must implement the DHS Licensing self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapters 245A and Chapter 245G. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the conditional license or otherwise determined by DHS licensing. 6. Within 45 days of receipt of this order, the approved Compliance Officer must provide a training on the requirements for substance use disorder treatment programs under Minnesota Statutes, chapter 245G. Individuals required to attend are the Treatment Director, ADC Supervisor, Registered Nurse, Authorized Agent, Medical Director, and Human Resource designee. 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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: Commissioner, Department of Human Services 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 10 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two from that date. You continue to be required to comply with all substance use disorder treatment laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Substance use disorder treatment programs are required to follow Minnesota Statutes, chapter 245G. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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