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02/11/2026 Annmarie Florest, Authorized Agent Wellstone Center for Recovery 624 13TH ST S Virginia, MN 55792-3149 License Number: 1060414 (IRTS/RCS) Report Number: 202402862 Program Location: 731 3RD ST S, Virginia, MN 55792-3007 CORRECTION ORDER Dear Annmarie Florest: On 11/17/2025, the Department of Human Services (DHS) conducted a licensing review at Wellstone Center for Recovery. DHS requires you to take the corrective action described below. Details of our findings, next steps, and your options are explained below. Standards reviewed The licensing review determined compliance with the provisions governing intensive residential treatment services and residential crisis stabilization services under Minnesota Statutes, chapter 245I. Licensing violations DHS determined that your program failed to follow the standard(s) described below. Physical Plant 1. Violation: The license holder's postings did not meet the following requirements: a. The client rights and responsibilities were not posted in a place visible or accessible to clients. Citation: Minnesota Statutes, section 245I.12, subdivision 3 Corrective Action Required This violation was corrected during the on-site licensing review. No additional action is required. 2. Violation: The license holder stored client medications and did not meet requirements in the following ways: a. Medications marked "for external use only" were not maintained in a compartment that is separate from other client medications. Citation: Minnesota Statutes, section 245I.11, subdivision 3, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. Policies and Procedures 3. Violation: The license holder did not maintain a policy or procedure for receiving referrals and making admissions determinations Citation: Minnesota Statutes, section 245I.23, subdivision 22, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy that demonstrates compliance. 4. Violation: The license holder did not maintain policies and procedures for discharging clients under subdivision 18 Citation: Minnesota Statutes, section 245I.23, subdivision 22, paragraph (c) Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy that demonstrates compliance. 5. Violation: The license holder did not maintain the following required policies or procedures: a. Policies and procedures for reporting a staff person's suspected maltreatment, abuse, or neglect of a client according to chapter 260E; b. Policies and procedures for reporting and maintaining records of critical incidents according to section 245I.13; and c. Policies and procedures that comply with all applicable state and federal law. Citation: Minnesota Statutes, section 245I.03, subdivisions 6, 7 and 10 Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy that demonstrates compliance. 6. Violation: The license holder's policy on client rights did not include the following required components: a. The rights listed in the health care bill of rights, in section 144.651; b. The client's right to be free from discrimination based on: 1. gender identity c. The client's right to be informed prior to a photograph or audio or video recording being made; d. Information about the restriction of client rights, including that a mental health professional must approve and document the reason for the restriction in the client file; and e. The rights of the client to have funds and property returned. Citation: Minnesota Statutes, section 245I.12, subdivision 1, clauses (1)-(3), subdivision 2 and subdivision 4, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. Submit a revised policy within 30 days of receipt of this order. 7. Violation: The license holder's grievance procedure did not meet requirements in the following ways: a. The procedure did not include current contact information for the following entities: 1. The Department of Health, Office of Health Facility Complaints. b. The procedure did not allow clients, former clients, and their authorized representatives to submit a grievance to the license holder; c. The procedure did not state that within three business days of receiving a client's grievance, the license holder will acknowledge in writing that they received the client's grievance; d. The procedure did not state that within 15 business days of receiving a client's grievance, the license holder will provide their final written response; e. The grievance procedure did not allow the client to bring a grievance to the person with the highest level of authority in the program; and f. The grievance procedure did not allow clients to voice grievances and recommend changes in policies and services to staff and others of their choice, free from restraint, interference, coercion, discrimination, or reprisal, including threat of discharge. Citation: Minnesota Statutes, section 245I.12, subdivision 5, paragraphs (a) and (c) Corrective Action Required Correct immediately and maintain compliance. Submit a revised policy within 30 days of receipt of this order. 8. Violation: The license holder's behavioral emergency procedures did not meet requirements in the following ways: a. Person-centered planning was not incorporated; b. Trauma-informed care was not incorporated; and c. The behavioral emergency procedure did not include the following required components: 1. Contact information for emergency resources that staff must consult when a client's behavior cannot be controlled by the behavioral emergency procedures. Citation: Minnesota Statutes, section 245I.03, subdivision 4, paragraphs (a) and (b) Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised procedure that meets requirements. 9. Violation: The license holder's health services policies and procedures did not meet requirements in the following ways: a. They were not reviewed and approved by a registered nurse or licensed prescriber; b. The license holder did not have procedures outlining the following: 1. Circumstances in which a staff must notify the registered nurse or licensed prescriber; and 2. Circumstances in which staff must obtain medical care for a client; c. The license holder's procedure for storing and accounting for medication did not include the following: 1. Schedule II drugs are stored in a locked compartment separately from other medications; 2. A documentation procedure to account for all schedule II to V drugs listed in MN Statutes, section 152.02, subdivisions 3 to 6; 3. A method to ensure that each incident when a staff person accepts or destroys client medication is recorded; 4. Prescription medications stored by the client must have a written medication order from a licensed prescriber; and 5. Prescription medications stored by the client include a prescriptions label that includes the client's name; d. The license holder's medication administration procedures did not include the following required components: 1. Assessing the client's ability to self-administer medication including an evaluation of the client's ability to: i. Comply with prescribed medication regimens; and ii. Store medications safely and in a manner that protects other individuals in the facility; 2. Monitoring the effectiveness of medications; 3. Monitoring side-effects of medication; 4. Monitor for symptoms and signs of tardive dyskinesia; 5. Addressing and documenting client concerns about medications; 6. Maintaining a record of incidents of deferring a client's medication; 7. Documenting any incident when a client's medication is omitted; 8. Documenting when a client refuses to take medications as prescribed; and 9. Documenting and tracking medication errors including: i. Documenting whether the license holder must notify anyone about the medication error; ii. Determining if the license holder must take any follow-up actions; and iii. Identifying the staff persons responsible for taking follow-up actions; and e. The license holder's procedure for medication orders did not include the following: 1. All orders to accept, administer, or discontinue client medications are written by a licensed prescriber; 2. Non-written medication orders are accepted to administer client medications and it was not an emergency circumstance; 3. Obtaining a written order with the licensed prescriber's signature when the license holder accepts a non-written order to administer client medications; 4. How the program will maintain the client's right to privacy and dignity; and 5. Informing the client of potential medication side effects and obtaining their informed consent when the license holder employed a licensed prescriber. Citation: Minnesota Statutes, section 245I.03, subdivision 5; and section 245I.11, subdivision 2, clauses (4) and (5); subdivision 3, paragraphs (a) and (b); subdivision 4, paragraphs (a) and (b); and subdivision 5, clauses (1), (2), (4) and (5). Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit policies and procedures that demonstrates compliance. 10. Violation: The license holder's personnel policies did not include the following required components: a. A written statement to ensure that staff member retention, promotion, job assignment, or pay are not affected by a good faith communication between a staff member and the Department of Human Services, the Department of Health, the Office of the Ombudsman for mental health and developmental disabilities, law enforcement, a health-related licensing board, or a local agency for the investigation of a complaint regarding a client's rights, health, or safety; b. Policies prohibiting staff from neglecting, abusing, or maltreating a client as described in chapter 260E and sections 626.557 and 626.5572; c. The drug and alcohol policy described in section 245A.04, subdivision 1, paragraph (c); d. A process for the disciplinary action, suspension, or dismissal of a staff person; and e. Position descriptions of each staff person, including: 1. The staff person's responsibilities; 2. The staff person's authority to execute the responsibilities; and 3. Qualifications for the position. Citation: Minnesota Statutes, section 245I.03, subdivision 8, clauses (2), (4)-(6) and (8) Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a policy that demonstrates compliance. 11. Violation: The license holder's training plan did not include a description of how the license holder will: a. Conduct ongoing training of each staff person, including whether training is based on the staff person's hire date or a specified annual cycle determined by the program; b. Verify and document previous training; and c. Determine when a staff person needs additional training, including when the license holder will provide additional training. Citation: Minnesota Statutes, section 245I.05, subdivision 1, clauses (2)-(4) Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a revised plan that demonstrates compliance. 12. Violation: The program abuse prevention plan did not meet requirements in the following ways: a. The population assessment did not include an evaluation of the following factors: 1. Physical health of clients; 2. Emotional health of clients; 3. Behavior of clients; 4. The need for specialized programs of care for clients; 5. Need for staff training to meet identified individual needs of the clients; and 6. Knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients. b. The physical plant assessment did not include an evaluation of the following factors: 1. The condition and design of the building as it relates to the safety of the clients; and 2. Existence of areas in the building which are difficult to supervise. c. The assessment of the environment did not include an evaluation of the following factors: 1. The type of internal programming; and 2. The program's staffing patterns. d. The plan did not identify factors which may encourage or permit abuse; and e. The plan did not include a statement of measures to be taken to minimize the risk of abuse. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a revised program abuse prevention plan that meets requirements. Program Practices 13. Violation: The license holder's review of their quality assurance and improvement plan did not meet requirements in the following ways: a. The license holder did not review, evaluate and update the quality assurance and improvement plan at least annually 1. For calendar year(s) 2023 and 2024 b. The license holder's review of the plan did not establish goals for improving their services to clients during the next year 1. For calendar year(s) 2023 and 2024 Citation: Minnesota Statutes, section 245I.23, subdivision 23, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 14. Violation: The license holder's weekly team meetings did not meet requirements in the following ways: a. Documentation did not demonstrate that each treatment team member participated in a team meeting or ancillary meeting for the following week(s): o 05/04/2025, 09/28/2025 and 11/09/2025 b. An ancillary meeting was not held by a qualified staff person who participated in the most recent weekly team meeting, for the following weeks: o 09/28/2025 c. A treatment team member worked only one shift during a week and could not participate in a weekly team meeting or ancillary meeting, and there was no documentation to demonstrate the treatment team member read the minutes of the weekly team meeting for the following weeks: o 05/04/2025, 09/28/2025, and 11/09/2025. Citation: Minnesota Statutes, section 245I.23, subdivision 14, paragraphs (b)-(d) Corrective Action Required Correct immediately and maintain compliance. 15. Violation: The license holder's policies and procedures did not meet requirements in the following ways: a. The policy or procedure was not reviewed every two years 1. Client Rights, Maltreatment Reporting, Reporting a Death of a Client, Behavioral Emergencies, Admission & Discharge Criteria, Treatment Services Description, Health Services, Quality Assurance and Improvement Plan, and Personnel Policies Citation: Minnesota Statutes, section 245I.03, subdivision 1 Corrective Action Required Correct immediately and maintain compliance. 16. Violation: The license holder did not meet critical incident reporting requirements: a. The critical incident was not reported to the Commissioner within 10 days of learning of the incident for incidents dated: o 09/30/2025, 10/01/2025 and 10/10/2025 Citation: Minnesota Statutes, section 245I.13 Corrective Action Required Correct immediately and maintain compliance. 17. Violation: The license holder did not have a training plan to ensure that staff persons receive required ongoing training Citation: Minnesota Statutes, section 245I.05, subdivision 1 Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a plan that demonstrates compliance. 18. Violation: The license holder failed to monitor implementation of their policies and procedures. The policies and procedures were not maintained in accordance with the applicable regulations governing the program. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 19. Violation: The license holder's use of electronic record keeping or electronic signatures did not meet requirements: a. The license holder's use of electronic record keeping limited the commissioner's access to required personnel record content. Citation: Minnesota Statutes, section 245A.041, subdivision 4 Corrective Action Required Correct immediately and maintain compliance. 20. Violation: The license holder's governing body or delegated representative did not review the program abuse prevention plan at least annually using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. · There was no documentation to demonstrate a review occurred during calendar year(s) 2024 Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 21. Violation: The license holder failed to meet the following internal review requirements: a. The license holder did not complete an internal review when they received an internal report or knew of an external report of alleged or suspected maltreatment. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 22. Violation: The license holder's plan for transfer of clients and records upon closure did not meet requirements in the following ways: a. The plans for the transfer of open cases and case records did not specify arrangements the program will make to transfer clients to another provider or county agency for continuation of services and to transfer the case record with the client; and b. There was no documentation to identify a controlling individual reviewed and signed the plan for transfer of clients and records upon closure annually, for calendar years 2023, 2024 and 2025. Citation: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a) and (b) Corrective Action Required Correct immediately and maintain compliance. 23. Violation: The license holder did not follow a risk reduction measure that was identified in their Program Abuse Prevention Plan (PAPP). Review of client file and program documentation determined that hourly, visual checks were not completed as required for an incident, dated 3/18/2024, involving a resident who had left the facility 12 hours earlier from the time it had been discovered. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), (2) and 626.557, subdivision 14, paragraph (a). Corrective Action Required Correct immediately and maintain compliance. Within 30 days receipt of this order, submit a template for documenting visual checks of residents to demonstrate compliance. Client Records 24. Violation: 3 of 4 client files reviewed for admission criteria did not meet requirements in the following ways: a. For Intensive Residential Treatment Services (IRTS), there was no written opinion from a mental health professional that the client needs mental health services that available community-based services cannot provide, or is likely to experience a mental health crisis or require a more restrictive setting if the individual does not receive IRTS (C2); and b. For Residential Crisis Stabilization (RCS), documentation did not demonstrate that the client was (C1 and C3): 1. Screened positive for a potential mental health crisis during a crisis screening; and 2. Experiencing a mental health crisis according to their crisis assessment. Citation: Minnesota Statutes, section 245I.23, subdivision 15, paragraph (a) and subdivision 16 Corrective Action Required Correct immediately and maintain compliance. 25. Violation: 4 of 4 client files reviewed for the immediate needs assessment did not meet requirements in the following ways: a. The assessment did not include an evaluation of the client's immediate needs in the following areas: 1. Safety, including the need for crisis assistance (C3); 2. Responsibilities for children (C1 and C5); 3. Responsibilities for family and other natural supports (C1, C2, C3 and C5); 4. Responsibilities for employers (C1, C3 and C5); 5. Housing issues (C1); and 6. Legal issues (C3 and C5). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 26. Violation: 2 of 2 client files reviewed for the initial treatment plan did not meet requirements in the following ways: a. The plan was not completed within 24 hours of admission (C5); b. The plan, completed by a mental health practitioner, was not approved by the treatment supervisor within ten business days of completion (C2 and C5); c. The plan was not based on the client's referral information (C2 and C5); d. The plan was not based on the client's immediate needs assessment (C2 and C5); e. The plan did not consider crisis assistance strategies that have been effective for the client in the past (C2 and C5); and f. The initial treatment plan did not identify the following required components: 1. The client's initial treatment goals (C2); 2. Measurable treatment objectives (C2); 3. Specific interventions that will be used to help the client engage in treatment (C2); and 4. Participants involved in the client's treatment planning (C2 and C5). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (b); and section 245I.08, subdivision 3 Corrective Action Required Correct immediately and maintain compliance. 27. Violation: 2 of 2 client files reviewed did not meet level of care assessment requirements in the following ways: a. The assessment was not completed within five days of admission (C2 and C5); and b. The level of care assessment, completed by a mental health practitioner, was not approved by the treatment supervisor within ten business days of completion (C2 and C5). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (d); and section 245I.08, subdivision 3 Corrective Action Required Correct immediately and maintain compliance. 28. Violation: 1 of 2 client files reviewed for requirements governing the substance use assessment did not meet requirements in the following ways: a. The substance use assessment did not include the following: 1. An evaluation of the client's: i. History of relapses (C2); ii. Hospitalizations related to substance use (C2); iii. Suicide attempts (C2); iv. Non-compliance with taking prescribed medications (C2); and v. Non-compliance with psychosocial treatment (C2). 2. An assessment of the effects of the client's substance use on the client's relationships including with family members and others (C2). Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (h) Corrective Action Required Correct immediately and maintain compliance. 29. Violation: 1 of 2 client files reviewed for requirements governing weekly reviews did not meet requirements in the following ways: a. The review of the client's treatment plan was not conducted by a mental health professional (C2) o For week(s) ending 09/15/2025, 09/22/2025 and 09/29/2025 b. The review of the client's individual abuse prevention plan was not conducted by a mental health professional (C2) o For week(s) ending 09/15/2025, 09/22/2025 and 09/29/2025 Citation: Minnesota Statutes, section 245I.23, subdivision 7, paragraph (i) Corrective Action Required Correct immediately and maintain compliance. 30. Violation: 2 of 2 client files reviewed for requirements governing crisis treatment plans did not meet requirements in the following ways: a. The plan, completed by a mental health practitioner, was not approved by a treatment supervisor within 5 business days of completion (C1); b. The plan was not based on the client's referral information and an assessment of the client's immediate needs (C1 and C3); c. The plan did not consider crisis assistance strategies that have been effective for the recipient in the past (C1 and C3); d. Documentation did not demonstrate the license holder used a person-centered, culturally appropriate planning process (C3); e. The client's family and other natural supports were not allowed to observe and participate in the client's treatment planning (C1 and C3); and f. The crisis treatment plan did not include the following required components: 1. Measurable treatment objectives (C1); 2. Specific interventions that the license holder will use to help the client engage in treatment (C1 and C3); and 3. Documentation of referral to and scheduling of services, including specific providers where applicable (C1 and C3). Citation: Minnesota Statutes, section 245I.08, subdivision 3; and section 245I.23, subdivision 8, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 31. Violation: 3 of 4 client files reviewed did not meet requirements for required treatment services in the following ways: a. For a client receiving Intensive Residential Treatment Services (IRTS), the license holder failed to provide: 1. Crisis prevention planning to assist clients including: i. Identifying and addressing patterns in the client's history and experience of mental health (C2 and C5); and ii. De-escalation strategies that have been effective in the past (C2 and C5). 2. Health services (C2); 3. Services engaging family and other natural supports (C2 and C5); 4. Services educating family and other natural supports (C2 and C5); 5. Referrals to other providers in the community (C2 and C5); and 6. Support for client to transition from residential crisis stabilization to another setting (C2 and C5). b. For a client receiving Residential Crisis Stabilization Services (RCS), the license holder failed to provide: 7. Referrals to other providers in the community (C3); and 8. Support for client to transition from RCS to another setting (C3). Citation: Minnesota Statutes, section 245I.23, subdivision 4, paragraph (b) and subdivision 5, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 32. Violation: 5 of 5 client files reviewed did not meet discharge requirements in the following ways: a. The license holder did not categorize the discharge as successful, program-initiated, or non-program-initiated (C1, C3, C5 and C6); b. The discharge summary was not completed prior to a successful discharge (C1); c. The discharge summary was not completed prior to a program-initiated discharge (C2); d. The client was not provided a copy of the discharge summary (C1, C2 and C5); e. For a successful discharge, the summary did not contain: 1. A brief review of the client's problems during their stay (C1); 2. The goals and objectives that the license holder recommends that the client addresses during the first three months after discharge (C1); 3. The recommended actions, supports and services that will assist the client with a successful transition to another setting (C1); and 4. The client's crisis plan (C1). f. For a non-program-initiated discharge, the summary did not contain: 1. A description of the attempts made by staff to enable the client to continue treatment (C3, C5 and C6); and 2. The recommended actions, supports and services that will assist the client with a successful transition to another setting (C3, C5 and C6). g. For a program-initiated discharge, the summary did not contain: 1. The recommended actions, supports and services that will assist the client with a successful transition to another setting (C2). Citation: Minnesota Statutes, section 245I.23, subdivision 18, paragraphs (a), (c), (e) and (h) Corrective Action Required Correct immediately and maintain compliance. 33. Violation: 1 of 1 client files reviewed for discharge review documentation required for program-initiated discharges did not meet requirements in the following ways: a. There was no documentation to demonstrate the license holder consulted with the client, the client's family and other natural supports, and the client's case manager, if applicable, to review the issues involved in the program's decision to discharge the client from the program (C2); b. There was no documentation of the client's discharge review (C2); c. The discharge review process exceeded five working days (C2); and d. Documentation did not include a determination of whether the license holder, treatment team, and any interested persons can develop additional strategies to resolve the issues leading to the client's discharge and to permit the client to have an opportunity to continue receiving services from the license holder (C2). Citation: Minnesota Statutes, section 245I.23, subdivision 18, paragraph (g) Corrective Action Required Correct immediately and maintain compliance. 34. Violation: 4 of 4 client files reviewed did not meet requirements for daily documentation in the following ways: a. The daily summary did not include: 1. Observations about the client's symptoms (C1, C2, C3 and C5). Citation: Minnesota Statutes, section 245I.23, subdivision 12, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 35. Violation: 4 of 4 client files reviewed did not meet requirements for giving clients notice of their rights in the following ways: a. Documentation did not demonstrate the license holder gave a copy of the client's rights to the client on the day of admission (C1, C2, C3 and C5); and b. Documentation did not demonstrate the license holder explained the grievance procedure to the client (C1, C2, C3 and C5). Citation: Minnesota Statutes, section 245I.12, subdivision 3 and subdivision 5, paragraph (b) Corrective Action Required Correct immediately and maintain compliance. 36. Violation: 2 of 2 client files reviewed did not meet standard diagnostic assessment (DA) requirements in the following ways: a. The file did not contain a DA or an update to an assessment (C5); b. The DA did not include the required information about the client's current life situation: 1. Substance use history, if applicable, including: i. Amounts and types of substances (C2); ii. Route of administration (C2); iii. Periods of abstinence (C2); iv. Circumstances of relapse (C2); and v. The impact to functioning when under the influence of substances, including legal interventions (C2). c. The DA did not document information related to the following required topics: 2. The client's relationship with family and other significant personal relationships, including the client's evaluation of the quality of each relationship (C2). Citation: Minnesota Statutes, section 245I.10, subdivision 2, paragraph (g) and subdivision 6, paragraphs (b) and (c) Corrective Action Required Correct immediately and maintain compliance. 37. Violation: 2 of 2 client files reviewed did not meet the following individual treatment plan (ITP) requirements: a. The client file did not contain an ITP (C2 and C5); and b. The treatment plan was not completed after completing a client's diagnostic assessment or reviewing a client's diagnostic assessment received from a different provider (C2). Citation: Minnesota Statutes, section 245I.10, subdivision 8, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 38. Violation: 4 of 4 client files reviewed did not meet requirements for assessing the client's ability to self-administer medication in the following ways: a. The file did not contain an assessment of the client's ability to self-administer medication (C1, C2, C3 and C5). Citation: Minnesota Statutes, section 245I.11, subdivision 5, clause (1) Corrective Action Required Correct immediately and maintain compliance. 39. Violation: 4 of 4 client files reviewed for medication administration did not meet requirements in the following ways: a. There was no documentation to demonstrate the license holder monitored the following: 1. The effectiveness of the client's medications (C1, C3 and C5). b. The license holder did not document the following: 2. The client’s medication orders (C1, C2, C3 and C5); and 3. Incidents of when the administration of the client's medication is omitted (C1). Citation: Minnesota Statutes, section 245I.11, subdivision 5, clauses (2) and (4) Corrective Action Required Correct immediately and maintain compliance. 40. Violation: 4 of 4 client files reviewed did not meet progress note requirements. The progress note did not include the following required components: a. The type of service (C1) 1. For progress note(s) dated 08/30/2025 (C1) b. Documentation of the scope of the service, including the following required components: 1. The targeted goal and objective (C2, C3 and C5) ■ For progress note(s) dated 09/08/2025, 09/10/2025, 09/12/2025, 09/14/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025, 09/20/2025 and 09/24/2025 (C2) ■ For progress note(s) dated 08/27/2025, 08/28/2025, 08/29/2025, 08/30/2025, 08/31/2025 and 09/02/2025 (C3) ■ For progress note(s) dated 10/26/2025, 10/27/2025 and 10/28/2025 (C5) 2. The staff person's plan to take future actions, including changes in treatment that the staff person will implement if the intervention was ineffective (C1 and C3) ■ For progress note(s) dated 08/30/2025 and 08/31/2025 (C1) ■ For progress note(s) dated 08/28/2025 and 08/30/2025 (C3) c. Documentation of significant observations by staff, if applicable, including the following required components: 1. The client's current risk factors (C2 and C3) ■ For progress note(s) dated 09/30/2025 and 10/01/2025 (C2) ■ For progress note(s) dated 08/28/2025 and 08/30/2025 (C3) 2. Emergency interventions by staff (C2) ■ For progress note(s) dated 09/30/2025 and 10/01/2025 (C2) 3. Consultations with or referrals to other professionals, family, or significant others (C2, C3 and C5); and 4. Changes in the client's mental or physical symptoms (C1 and C3) ■ For progress note(s) dated 08/30/2025 and 08/31/2025 (C1) ■ For progress note(s) dated 08/28/2025 and 08/30/2025 (C3) Citation: Minnesota Statutes, section 245I.08, subdivision 4 Corrective Action Required Correct immediately and maintain compliance. 41. Violation: 3 of 4 reviewed for requirements governing progress notes did not meet requirements. Each occurrence of a mental health service was not documented in a progress note (C2, C3 and C5) · A progress note was not completed for services provided on 09/18/2025 and 09/19/2025 (C2) · A progress note was not completed for services provided on 09/01/2025 (C3) · A progress note was not completed for services provided on 10/27/2025 and 10/28/2025 (C5) Citation: Minnesota Statutes, section 245I.08, subdivision 4 Corrective Action Required Correct immediately and maintain compliance. 42. Violation: 4 of 4 client files reviewed did not meet requirements when the license holder assisted the client with the safekeeping of funds or other property: a. The receipt and disbursement of the funds or other property was not immediately documented at the time of receipt or disbursement (C1, C2, C3 and C5). Citation: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c) Corrective Action Required Correct immediately and maintain compliance. 43. Violation: 1 of 4 client files reviewed did not meet requirements for orienting clients to vulnerable adult maltreatment reporting policies and procedures in the following ways: a. The client was not oriented to the program abuse prevention plan (PAPP) (C2); and b. The client was not oriented to the internal and external maltreatment reporting procedures (C2). Citation: Minnesota Statutes, section 245A.65, subdivision 3 Corrective Action Required Correct immediately and maintain compliance. 44. Violation: 4 of 4 client files reviewed did not meet individual abuse prevention plan (IAPP) requirements: a. The client file of a vulnerable adult did not contain an IAPP (C5); b. The IAPP was not completed as part of the client's crisis treatment plan (C1) c. The IAPP did not include an individualized assessment of the person's: 1. Susceptibility to abuse by other individuals, including other vulnerable adults (C1 and C2); and 2. Risk of abusing other vulnerable adults (C1, C2 and C3). Citation: Minnesota Statutes, section 245A.65, subdivision 2; and section 245I.23, subdivision 8, paragraph (c) Corrective Action Required Correct immediately and maintain compliance. Staff Records 45. Violation: 5 of 5 personnel files reviewed for requirements governing the contents of a personnel file did not meet requirements. The file did not contain the following: a. Verification of the staff person's qualifications (SP1, SP2, SP3, SP4 and SP5); b. The hiring date of the staff person (SP2); c. The date the staff person's duties and responsibilities became effective (SP1, SP2, SP3, SP4 and SP5); and d. The date the staff person began having direct contact with clients (SP2). Citation: Minnesota Statutes, section 245I.07, paragraph (a), clauses (1), (3) and (5) Corrective Action Required Correct immediately and maintain compliance. 46. Violation: 5 of 5 personnel files reviewed for training documentation did not meet requirements. Documentation of training did not include the following required components: a. The name and credentials of the trainer (SP1, SP2, SP3, SP4 and SP5). Citation: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 47. Violation: 1 of 1 personnel files reviewed for requirements governing the direct observation of a mental health rehabilitation worker or mental health behavioral aide did not meet requirements in the following ways: a. A progress note was not completed for the observed treatment (SP3); b. The progress note, did not include the approval of the staff providing the direct observation (SP3); c. The staff person performing the direct observation did not approve of the progress note twice per month for the first 6 months of employment (SP3); and d. The staff person performing the direct observation did not approve the progress report as needed after the first 6 months of employment (SP3). Citation: Minnesota Statutes, section 245I.06, subdivision 3, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 48. Violation: 4 of 4 personnel files reviewed for treatment supervision plans did not meet requirements in the following ways: a. A written treatment supervision plan was not developed (SP2 and SP5); b. The treatment supervision plan was not developed within 30 days of the staff person's first day of employment (SP3); and c. The staff person's treatment supervision plan did not include the following required components: 1. The names and licensures of the treatment supervisors who are supervising the staff person (SP3 and SP4); 2. The staff person's authorized scope of practice (SP3 and SP4); 3. A description of the client population that the staff person serves (SP3 and SP4); and 4. A description of the treatment methods and modalities that the staff person may use to provide services to clients (SP3 and SP4). Citation: Minnesota Statutes, section 245I.06, subdivision 2, paragraphs (a) and (b) Corrective Action Required Correct immediately and maintain compliance. 49. Violation: 1 of 5 personnel files reviewed for requirements governing staff qualifications did not meet requirements in the following ways: a. The staff person was not qualified as a mental health rehabilitation worker (SP3) Citation: Minnesota Statutes, section 245I.04, subdivision 14 Corrective Action Required Correct immediately and maintain compliance. 50. Violation: 1 of 5 personnel files reviewed for requirements governing provider scope of practice did not meet requirements in the following ways: a. The mental health certified peer specialist provided services to a client outside of their scope of practice (SP4) Citation: Minnesota Statutes, section 245I.04, subdivision 11 Corrective Action Required Correct immediately and maintain compliance. 51. Violation: 4 of 4 personnel files reviewed for requirements governing initial training did not meet requirements in the following ways: a. Documentation did not demonstrate the staff person was oriented to the following required topics, prior to providing direct contact services: 1. Client rights and protections under section 245I.12 (SP3, SP4 and SP5); 2. Emergency procedures, including fire and inclement weather (SP2, SP3, SP4 and SP5); 3. Emergency procedures, including reporting missing persons (SP2, SP3, SP4 and SP5); 4. Emergency procedures, including behavioral emergencies (SP5); 5. Emergency procedures, including medical emergencies (SP2, SP3, SP4 and SP5); 6. Specific activities and job functions for which the staff person is responsible (SP2, SP3, SP4 and SP5); 7. The license holder's program policies and procedures applicable to the staff person's position (SP2, SP3, SP4 and SP5); 8. Professional boundaries that the staff person must maintain (SP3); and 9. Specific needs of each client to whom the staff person will be providing direct contact services (SP2, SP3, SP4 and SP5). b. Documentation did not demonstrate the staff person received the following required orientation within 72 hours of providing direct contact services: 1. Vulnerable adult maltreatment reporting requirements (SP2, SP3, SP4 and SP5); 2. The program abuse prevention plan (SP2 and SP5); and 3. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (SP2, SP3, SP4 and SP5). c. Documentation did not demonstrate the staff person received training about the maltreatment of minor reporting requirements and definitions in chapter 260E within 72 hours of first providing direct contact services to a client (SP2, SP3, SP4 and SP5); d. For staff identified as needing additional trainings before providing direct contact services, documentation did not demonstrate the staff person received 30 hours of training about: 1. Client recovery and resiliency (SP3); and 2. Co-occurring mental illness and substance use disorders (SP3). e. Documentation did not demonstrate the staff person received the 30 hours of training required for their position prior to providing direct contact services (SP3); f. There was no documentation to demonstrate the employee, subcontractor or volunteer was trained on the program's drug and alcohol policy before the employee, subcontractor, or volunteer had direct contact, as defined in section 245C.02, subdivision 11, with a person served by the program (SP2 and SP5) g. Documentation did not demonstrate the staff person received training to the following required topics within 90 days of first providing direct contact services to an adult client: 1. Trauma-informed care and secondary trauma (SP2); 2. Person-centered individual treatment plans, including seeking partnerships with family and other natural supports (SP2); 3. Co-occurring substance use disorders (SP2); and 4. Culturally responsive treatment practices (SP2). Citation: Minnesota Statutes, section 245I.05, subdivision 3, paragraphs (b), (a), (c) and (d); section 245A.65, subdivision 3; and section 245A.04, subdivision 1, paragraph (c) Corrective Action Required Correct immediately and maintain compliance. 52. Violation: 1 of 1 personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: a. Documentation did not demonstrate the staff person received annual training on the following required topics: 1. Vulnerable adult maltreatment reporting requirements (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 2. The license holder's program abuse prevention plan (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 3. The maltreatment of minor reporting requirements and definitions in chapter 260E (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 4. Client rights and protections under section 245I.12 (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 5. Emergency procedures, including fire and inclement weather (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 6. Emergency procedures, including responding to a report of a missing person (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 7. Emergency procedures, including behavioral emergencies (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) 8. Emergency procedures, including medical emergencies (SP1) ■ For calendar year(s) 2024 and 2025 (SP1) Citation: Minnesota Statutes, section 245I.05, subdivision 4, paragraph (a) Corrective Action Required Correct immediately and maintain compliance. 53. Violation: 1 of 5 personnel files reviewed did not contain documentation of the first date the staff person had direct contact with a person served by the license holder's program (SP2) Citation: Minnesota Statutes, section 245A.041, subdivision 6 Corrective Action Required Correct immediately and maintain compliance. How to respond If you fail to correct the violation(s) within the time limits identified above, DHS may impose a fine or take an action on your license. If requested above, Send your written response and any supporting documentation to your licensor at: Commissioner, Department of Human Services ATTN: Tina Christensen 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 • Identify what is inaccurate or incomplete about the information in this 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 Attention: Licensing Legal Unit P.O. Box 64953 Saint 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. 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 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 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 651-431-6610 or at Tina.Christensen@state.mn.us. Sincerely, Tina Christensen, Licensor Office of Inspector General Licensing Division
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