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March 13, 2026 Eric Vagle, Authorized Agent Minnesota Adult & Teen Challenge 740 E 24th St Minneapolis, MN 55404 License Number: 1102071 Report Numbers: 202504064, 202506913 CORRECTION ORDER Dear Eric: On January 12 through 14, 2026, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Minnesota Adult & Teen Challenge located at 2 E 2nd St, Duluth, MN 55802. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under Minnesota Statute, chapter 245G. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies, Procedures, and Practices 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided as follows: a. The license holder did not meet requirements for the rate enhancement for individuals with co-occurring disorders in accordance with Minnesota Statutes, section 254B.0507, subdivision 6. There was no documentation of the following: i. 8 hours of co-occurring training for calendar years 2024 and 2025 (personnel file numbered 4); ii. A mental health diagnostic assessment completed within 10 days of admission (client file numbered 1); and iii. A multidisciplinary case review completed for January 2025 and March 2025 (client file numbered 1); and b. One hour of group counseling was billed on February 6, 2025; however, there was no supporting documentation in the client record (client file numbered 1). Statute Violated: Minnesota statutes, sections 245A.167, paragraph (a), and 245A.191, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services provided meet the requirements for payment from the behavioral health fund. The noncompliance identified above may result in nonpayment of claims submitted by the license holder for public program reimbursement; recovery of payments made for the services; disenrollment in the public payment program; or other administrative, civil, or criminal penalties provided by law. 2. Violation: The license holder did not meet requirements governing implementation of policies and procedures. The license holder did not monitor implementation of their Medical Enhanced Services policy, requiring active interventions to stabilize physical health. During staff interviews, it was confirmed that this would include monitoring blood sugar for diabetic clients. The discharge summary indicated the program did not follow policy, as the client was discharged due to lack of appropriate and necessary care to treat Type 2 Diabetes. (client file numbered 1). Statute Violated: Minnesota statutes, section 245A.04, subdivision 14, paragraph (b), clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policy and procedure implementation meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing the program abuse prevention plan. The program abuse prevention plan was not posted in a place visible to clients. Statute Violated: Minnesota statutes, section 245A.65, subdivision 2, paragraph (a), clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing client rights protection in the following ways: a. The client rights policy did not identify the rights in Minnesota Statutes, sections 144.651 and 148F.165; b. The grievance policy did not contain the telephone number for the Department of Health Facilities Complaints; c. Grievances dated July 3, 2024, and July 17, 2024, were not responded to within three days of the staff member’s receipt of the grievance; and d. The grievance procedure was not posted in a place visible to clients. Statute Violated: Minnesota statutes, section 245G.15, subdivisions 1 and 2, clauses (2) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights protections meet all applicable requirements. Within 30 days of receipt of this order, submit a client rights policy and a grievance policy that demonstrates compliance. 5. Violation: The license holder did not meet requirements governing photographs of client. The license holder did not have a written policy regarding the use of any personal electronic devices that can record, transmit, or make images of another client. Statute Violated: Minnesota statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that policies regarding photographs of clients meet all applicable requirements. Within 30 days of receipt of this order, submit an electronic device policy that demonstrates compliance. 6. Violation: The license holder did not meet requirements governing HIV minimum standards. The policies and procures were not consistent with the HIV minimum standard. Statute Violated: Minnesota statutes, section 245A.19, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that HIV minimum standards meet all applicable requirements. Within 30 days of receipt of this order, submit a HIV minimum standards policy that demonstrates compliance. 7. Violation: The license holder did not meet requirements governing maltreatment of vulnerable adults in the following ways: a. An internal review was not completed within 30 calendar days for a report made on March 26, 2024; and b. The maltreatment reporting policies and procedures were not posted in a place visible to clients. Statute Violated: Minnesota statutes, section 245A.65, subdivision 1, paragraphs (b), clause (1), and (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult internal reviews meet all applicable requirements. 8. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. There was no documentation that a controlling individual reviewed and signed the plan in calendar year 2024. Statute Violated: Minnesota statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transfer of clients and records meet all applicable requirements. Personnel Files 9. Violation: Three of three personnel files reviewed for requirements governing staff orientation (personnel files numbered 3, 5, and 7) did not meet requirements. There was no documentation of orientation to the following within 24 working hours of starting: a. Policies and procedures; b. Client needs; and c. Program abuse prevention plan. Statute Violated: Minnesota statutes, sections 245G.13, subdivision 1, clause (7), and 245A.65, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meet all applicable requirements. 10. Violation: Four of six personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation annual training was completed for the following: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of client information for: 1) Calendar year 2024 (personnel files numbered 2 and 10); and 2) Calendar year 2025 (personnel files numbered 4 and 9); and b. HIV minimum standards for: 3) Calendar year 2024 (personnel files numbered 2 and 10); and 4) Calendar year 2025 (personnel files numbered 4 and 9). Statute Violated: Minnesota statutes, sections 245A.19, paragraph (b) and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that annual staff trainings meet all applicable requirements. 11. Violation: One of six personnel files reviewed for requirements governing every two-year training (personnel file numbered 9) did not meet requirements. There was no documentation that every two-year training was completed for calendar year 2024 for the following: a. Client confidentiality rules and regulations; b. Client ethical boundaries; c. Emergency procedures; and d. Client rights as specified in Minnesota Statutes, sections 144.651 and 148.165. Statute Violated: Minnesota statutes, section 245G .13, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that two-year training meet all applicable requirements. 12. Violation: One of three personnel files reviewed for requirements governing additional training (personnel file numbered 4) did not meet requirements. There was no documentation of 12 hours of training in co-occurring disorders within six months of hire. Statute Violated: Minnesota statutes, section 245G.13, subdivision 2, paragraph (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that additional staff trainings meet all applicable requirements. 13. Violation: Six of nine personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. The file did not contain an application for employment signed by the staff member (personnel files numbered 2, 4, 6, 8, 9, and 10); b. The first date that a background study subject had direct contact with a person served was not documented (personnel file numbered 7); c. For staff members who provide psychotherapy services, the file did not contain employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of 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 6); and d. A written annual job performance evaluation was not completed for calendar year 2024 (personnel files numbered 4 and 9). Statute Violated: Minnesota statutes, section 245G.13, subdivisions 1, clause (3), and 3, clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files 14. Violation: Two of four client files reviewed for requirements governing vulnerable adult (VA) assessment and determination did not meet requirements in the following ways: a. The VA assessment was not completed within 24 hours of the day of service initiation (client file numbered 3); and b. The VA determination did not determine if the client is a VA as defined in Minnesota Statutes, section 626.5572, subdivision 21 (client file numbered 4). Statute Violated: Minnesota statutes, section 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that VA assessments and determinations meet all applicable requirements. 15. Violation: Three of four client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. CA’s did not document: a. Substance use history including: 5) Amounts (client files numbered 1, 2, and 4); 6) Types (client files numbered 1 and 2); 7) Frequency (client files numbered 1, 2, and 4); 8) Duration (client files numbered 1 and 2); 9) Route of administration (client files numbered 1 and 2); 10) Periods of abstinence (client files numbered 1, and 2); and 11) Circumstances of relapse (client file numbered 1); b. The impact to functioning when under the influence of substances, including legal interventions (client file numbered 1); and c. The client’s physical health history (client file numbered 1). Statute Violated: Minnesota statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 16. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. ITP was not completed by the end of the tenth day on which a treatment service had been provided from the day of service initiation (client files numbered 1 and 4); b. The ITP did not contain a treatment strategy (client files numbered 1 through 4); and c. The ITP did not identify resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 2). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 1 and 1a, paragraphs (3) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan that demonstrates compliance. 17. Violation: Four of four client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. The comprehensive assessment did not include the job title or position of the staff person that made the entry (client files numbered 2 and 4); b. The comprehensive assessment contained an inaccurate job title of the staff person that made the entry (client file numbered 3); c. Group documentation on December 1, 2025, and December 11, 2025 was not signed by the staff person that made the entry (client file numbered 4); and d. A correction to the entry Revoked Authorization to Use/Disclose Protected Health Information for Marketing, Public Relationship and External Communications was not made in a way in which the original entry was still able to be read (client file numbered 1). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 18. Violation: Three of four client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. The TPR did not include toxicology results for alcohol and substance use from February 11, 2025 (client file numbered 1); and b. TPR’s were not completed once every 30 days (client files numbered 1 through 3). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3, clause (2) and 3a, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 19. Violation: One file was reviewed for requirements governing medication administration procedures (client file numbered 1) and did not meet requirements. The use of client’s medication, including staff signatures with date and time, was not recorded on May 8, 9, 29, 31, June 6, 7, and 8, 2025. Statute Violated: Minnesota statutes, section 245G.08, subdivision 5, paragraph (c), clause (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration procedures meet all applicable requirements. 20. Violation: Two of two client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 1); b. The discharge summary did not contain a description for each of the ASAM six dimensions (client file numbered 5); and c. The discharge summary did not contain a service termination diagnosis (client file numbered 5). Statute Violated: Minnesota statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses 3 and 7. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries 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 carrie.salsness@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Carrie Salsness 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) 431-3815 or at carrie.salsness@state.mn.us. Sincerely, Carrie Salsness, Licensor Licensing Division Office of Inspector General
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