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February 23, 2026 Kathryn Daniels, Authorized Agent Missions Inc. Programs 3409 E Medicine Lake Blvd Plymouth, MN 55441 License Number: 1102554 (245F) License Number: 801566 (Rule 32) CORRECTION ORDER Dear Kathryn: On December 2, 3 and 4, 2025, a Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Judy Retterath Withdrawal Management Center located at 3409 E Medicine Lake Blvd Plymouth, MN 55441. This review was conducted to determine compliance with state and federal laws and rules governing the provision of withdrawal management and detox under Rule 9530 (Rule 32) and Statute 245F. 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. Throughout the correction order, references to the statute or rule requirement will be identified as follows: · Withdrawal Management Program as (245F); and · Detoxification Program as (Rule 32) · Withdrawal Management and Detoxification program (all) Policies, Procedures and Postings 1. Violation: The license holder (all) did not monitor the implementation of policies and procedures in the following ways: a. Maltreatment of Vulnerable Adult policy and procedure was not: i. Posted in a prominent location; and ii. Referenced repealed Minnesota Rule part, 9555.7100 to 9555.7300 and 9555.7600; and b. Maltreatment of Minors reporting policy under Minnesota Statutes, chapter 260E, did not include a person mandated to report physical or sexual child abuse or neglect occurring within a licensed facility shall report the information to the Department of Human Services; and c. Personnel policies did not: i. Prohibit patient maltreatment as specified under Minnesota Statutes, chapter 260E and sections, 245A.65, 626.557 and 626.5572; and ii. Include a chart or description of organizational structure indicating the lines of authority and responsibility; and d. The license holder’s policy for reporting a death in the program, policy 707, did not contain the correct contact information for reporting a death to the commissioner. Rule and Statute Violated: Minnesota Statutes, sections, 245A.04, subdivision 14, paragraph (b), subdivision 16, 245A.65, subdivision 1, paragraph (d), 245F.16, subdivision 1, clause (5) and (6), and Minnesota Rules, parts, 9530.6570, subpart 1, items E and F, and 9530.6580, item H. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the policy and procedure manual meets all applicable requirements. Within 30 days of receipt of this order, the license holder will submit policies listed above that meet all applicable requirements. 2. Violation: The license holder did not meet requirements governing duties of the medical director (all). The license holder did not document the annual review and approval by the medical director for the 2025 calendar year on the following policies: i. Admission, Discharge and transfer criteria and procedures; ii. Health Services Plan; iii. Physical indicators for physician or hospital referral and procedures for referral; iv. Procedures to follow in case of accident, injury or death of a patient; v. Condition specific protocols regarding the medications that require a withdrawal regimen that will be administered to patients; vi. Infection control program; and vii. Medication control plan. Rule and Statute Violated: Minnesota Statute, section, 245F.14, subdivision 5, and Minnesota Rule, part, 9530.6560, subpart 5. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all policies and procedures requiring annual review and signature of the medical director meet all applicable requirements. Within 30 days of receipt of this order, the license holder will submit all policies listed above with the medical directors’ annual review and signature. 3. Violation: The license holders’ policy governing the plan for transfer of clients did not meet all applicable requirements (all). The plan was not signed annually for the calendar year 2025 by a controlling individual 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 policy governing the plan for transfer of clients meets all applicable requirements. Within 30 days of receipt of this order, the license holder will submit a plan for transfer of clients’ policy that meets all requirements. 4. Violation: The license holder did not meet requirements governing grievance procedures in the following ways: a. The procedure was not posted in a place accessible to all patients and former patients upon request (all); b. The staff with the highest level of authority in the program were no longer applicable (all); c. The procedure did not include the following: i. An initial response to the patient who filled out the grievance within 24 hours of the program’s receipt of the grievance (all); and ii. Address and telephone numbers of the board of Behavioral Health and Therapy (all); the Board of Medical Practice (245F); and the Board of Nursing (245F). Rule and Statute Violated: Minnesota Statutes, section 245A.04, subdivision 1, 245F.10 subdivision 2 and Minnesota Rule 9530.6540 subpart 1, item B, C, and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that their Grievance Procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a revised grievance procedure policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing program abuse prevention plans (all) in the following ways: a. The plan did not contain an assessment and evaluation of the following factors: i. The type of internal programming; and ii. The program’s staffing patterns; and b. No documentation of the license holder’s governing body or the governing body’s delegated representative reviewed the plan in calendar year 2025; and c. The program abuse prevention plan and maltreatment reporting policies and procedures, including the internal and external reporting policies and procedures and the phone number of the common entry point, was not posted in a prominent location in the program. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (d) and 2, paragraph (a), clause 3 and 6, Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 6. Violation: The license holders policy governing patient education did not meet requirements. The license holder did not provide education to each client on the following: a. Signs and symptoms of fetal alcohol spectrum disorder (245F); b. Tuberculosis and reporting known cases of tuberculosis disease to heal care authorities according to section 144.4804(all); c. Hepatitis C treatment and prevention (245F); d. HIV as required in section 245A.19 paragraphs (b) and (c) (all); e. Nicotine cessation options, if applicable (245F); f. Opioid tolerance and overdose risks if applicable (245F); and g. Long-term withdrawal issues related to use of barbiturates and benzodiazepines, if applicable (245F). Rule and Statute Violated: Minnesota Statutes, section 245F.08, subdivision 4, clause (1) through (7) and Minnesota Rule, part 9530.6530, subpart 4, item B and C. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that patient education meets all applicable requirements. Within 30 days of receipt of this order, the license holder will submit updated patient education policies. 7. Violation: The license holders stabilization services policy did not meet requirements (245F). The license holder did not offer the following services to patients: a. Peer recovery support services; and b. Referrals to mutual aid, self-help and support groups. Statute Violated: Minnesota Statutes, section 245F.08 subdivision 1, clause (5) and (7). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure all requirements governing stabilization services are met. Within 30 days of receipt of this order the license holder will submit updated stabilization services policies. 8. Violation: The license holders’ policy governing patient property management did not meet requirements (all). The policy did not require the following: a. Immediately document receipt and disbursement of the person’s funds and property at the time of receipt or disbursement, including the person’s signature, or the signature of the conservator or payee; b. Return to the patient upon request, funds and property in the license holders’ possession, subject to restrictions in the person’s treatment plan, as soon as possible, but no later than three working days after the date of request; and c. Therefore, the staff did not immediately document receipt and disbursement of the patient’s funds or other property at the time of receipt and disbursement, including the patient’s signature, or the signature of the conservator or payee. Rule and Statute Violated: Minnesota Statutes, section 245A.04 subdivision 13, paragraph (c), clause 1 and 2, and 245F.11 and Minnesota Rule, part 9530.6545, Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure the policy governing patient property management meets all applicable requirements. Within 30 days of receipt of this order the license holder will submit policies that meet all applicable requirements. Personnel Files 9. Violation: Three of five personnel files reviewed for personnel file documents did not meet requirement (245F and Rule 32). The personnel files did not contain the following: a. A completed application that was signed by the staff member (personnel file numbered 1 and 4); b. Documentation verifying the staff member’s current professional license or registration (personnel file numbered 3); c. A current first aid certificate from American Red Cross or an equivalent organization, a current cardiopulmonary resuscitation certificate from the American Red Cross, the American Heart Association, a community organization, or an equivalent organization (personnel file numbered 4); and d. Annual job performance evaluation for the following years: i. Calendar year 2024 (personnel files numbered 2 and 5); and ii. Calendar year 2025 (personnel file numbered 2). Rule and Statute Violated: Minnesota Statute, section 245F.15 subdivision 6, paragraph (3), 245F.17, clause (1), (2), and (5) and Minnesota Rule, part 9530.6565 subpart 5A, item (3), and 9530.6575, items A, B, and E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personnel files contain all required documentation. 10. Violation: Three of three staff files reviewed for staff orientation did not meet requirements (all). There was no documentation of the following orientation training: a. Within 72 hours of beginning employment on the following topics: i. Patient confidentiality, patient ethical boundaries and patient rights, including the rights of patients admitted under chapter 253B, mandatory reporting under section 245A.65, 626.557, 626.5572 and chapter 260E, including facilities policy on obtaining a release of information, and Motivational counseling techniques and stages of change (personnel file numbered 4); ii. HIV minimum standards (personnel files numbered 1 and 4); b. Specific job functions (personnel file numbered 1); and c. Client needs (personnel files numbered 1, 3 and 4). Rule and Statute Violated: Minnesota Statutes, section 245F.16, subdivision 1, clause (7), and subdivision 2, paragraph (b), clause (1), (3), (5) through (7), and Minnesota Rule, part 9530.6570, subpart 1, item G, and subpart 2, item A, C, and E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 11. Violation: Three of three personnel files reviewed for annual training did not meet requirements (all). There was no documentation of the following annual trainings for the following years: a. Calendar year 2024: i. Infection Control Policies (personnel files numbered 2 and 5); ii. Mandatory reporting under sections 245A.65 and 626.667 and chapter 260E, including policies concerning obtaining patient releases of information (personnel files numbered 2 and 5); and iii. HIV minimum standards (personnel files numbered 2 and 5); and iv. Motivational counseling techniques and identifying stages of change (personnel files numbered 2 and 5) b. Calendar year 2025: i. Infection Control Policies (personnel files numbered 2 and 3); ii. Mandatory reporting under sections 245A.65 and 626.667 and chapter 260E, including policies concerning obtaining patient releases of information (personnel files numbered 2 and 3); iii. HIV minimum standards (personnel files numbered 2 and 3;) and iv. Motivational counseling techniques and identifying stages of change (personnel files numbered 2 and 3). Rule and Statute Violated: Minnesota Statutes, section 245F.16, subdivision 2, paragraph (c), and Minnesota Rules, part 9530.6570, subpart 2, items D, E and F. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that annual trainings meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for the above personnel files that demonstrate compliance. 12. Violation: Two of two personnel files reviewed for every two-year training did not meet requirements (all). There was no documentation of biannual training for the following years: a. Calendar year 2024 (personnel file numbered 2): i. 30 hours of continuing education training; ii. Patient confidentiality; and iii. Patient ethical boundaries and patient rights, including rights of patients admitted under chapter 253B; and b. Calendar year 2025 30 hours of continuing training (personnel file numbered 5). Rule and Statute Violated: Minnesota Statutes, section 245F.16, subdivision 2, paragraph (d), clause (1) and (3) and Minnesota Rules, part 9530.6570, subpart 2, items A, and C. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that biannual trainings meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for the above personnel files that demonstrate compliance. Client Files · 245F Patient Files numbered 1 and 2 · Rule 32 Patient files numbered 3 and 4 13. Violation: One of three patient files reviewed for requirements governing individual abuse prevention plan (IAPP) did not meet requirements (patient file numbered 2). The IAPP did not assess the person’s susceptibility to self-abuse. Statute Violated: Minnesota Statutes, section 245F.19, subdivision 3, clause 4. Corrective Action Required: Immediately, and on an ongoing basis, the license holder will ensure that all individual abuse prevention plans meet all applicable requirements. 14. Violation: One of four patient files reviewed for requirements governing comprehensive assessment did not meet requirements (patient file numbered 2). The license holder did not document prior to a medically stable discharge, or 72 hours following admission if a comprehensive assessment was offered to the patient who has a positive screening for a substance use disorder or why the assessment was not completed. Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements 15. Violation: One of two patient files reviewed for requirements governing individualized stabilization plans did not meet requirements (patient file numbered 2). The stabilization plan did not document the patient’s participation in developing the stabilization plan. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization plans meet all applicable requirements. 16. Violation: Two of two patient files reviewed for requirements governing progress notes (patient files numbered 1 and 2) did not meet requirements. The progress note documentation did not include the amount of each stabilization service. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit two patient progress note documentation that meets all applicable requirements. 17. Violation: Two of two patient files reviewed for requirements governing discharge plans did not meet requirements in the following ways: a. The license holder did not document that a copy of the discharge plan was provided to patients before leaving the facility (patient file numbered 1); and b. The discharge plan did not document the patient’s participation in the development of the discharge plan (patient files numbered 1 and 2). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of the discharge plans from two clients that meet all requirements. 18. Violation: One of one patient files reviewed for requirements governing care coordination did not meet requirements (patient file numbered 2). The license holder did not document: a. Care coordination with significant others to assist in the stabilization planning process; b. Referrals to economic assistance in accordance with the patients’ needs; and c. Addressing cultural and socioeconomic factors affecting the patients access to services. Statute Violated: Minnesota Statutes, section 245F.08, subdivision 2, clause (1), (5) and (8). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure care coordination meets all applicable requirements. 19. Violation: Two of two patient files reviewed for requirements governing patient records did not meet requirements as follows: a. The entry was not signed and dated by the staff member making the entry: i. MINDS assessment and vital sign record on November 6 and 7, 2025 (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.19 subdivision 1. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure patient records 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 651-431-6698 or at jennifer.eppel@state.mn.us Sincerely, Jennifer Eppel, Licensor Licensing Division Office of Inspector General
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