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March 30, 2026 Abah Mohamed, Authorized Agent South East Homes Inc 2732 Bloomington Ave Minneapolis, MN 55407 License Number: 1062832 CORRECTION ORDER Dear Abah: On January 27, 28, and 29, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, South East Homes Inc located at 2732 Bloomington Ave, Minneapolis, MN 55407. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under MN 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 governing program abuse prevention plans. The license holder did not have a copy of the program abuse prevention plan posted in a prominent location in the program. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (a), clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program abuse prevention plans meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 2. Violation: The license holder did not meet requirements governing grievance procedures. The license holder’s grievance procedure did not include: a) The current address of the following: a) Minnesota Board of Behavioral Health and Therapy; and b) Department of Health Facilities Complaints. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit an updated grievance procedure that meets all applicable requirements. 3. Violation: The license holder’s description of treatment services did not meet requirements. The description of treatment services did not: a) Identify the amount of individual counseling; b) Identify which services meet the definition of group counseling; and c) Identify the program’s treatment week. Statute Violated: Minnesota Statutes, section 245G.12, clause (10). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit an updated treatment services description that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing the administration of medication and assistance with self-medication. The policies and procedures did not include the following: a) A provision that a delegation of administration of medication is limited to a method a staff member has be trained to administer and limited to: 1) A medication that is administered orally, topically, or as a suppository, an eye drop, an ear drop, an inhalant, or an intranasal; and 2) An intramuscular injection of naloxone or epinephrine; a) A provision that each client’s file must include documentation indicating whether staff must conduct the administration of medication or the client must self-administer medication, or both; b) A provision that a client may carry emergency medication such as nitroglycerin as instructed by the client’s physician, advanced practice registered nurse, or physician assistant; c) A provision for the client to self-administer medication when a client is scheduled to be away from the facility; d) A provision that if a client self-administers medication when the client is present in the facility, the client must self-administer medication under the observation of a trained staff member; e) Requirements for recording the client’s use of medication, including staff signatures with date and time; f) Guidelines for when to inform a nurse of problems with self-administration of medication, including a client’s failure to administer, refusal of a medication, adverse reaction, or error; and g) Procedures for acceptance, documentation, and implementation of a prescription, whether written, verbal, telephonic, or electronic; and b) The license holder did not have documentation of monthly on-site supervision for the calendar year 2025. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the registered nurse supervision policies meet all applicable requirements. Within 30 days of receipt of this order, submit updated administration of medication policies that meet all applicable requirements. 5. Violation: The license holder’s policies and procedures regarding HIV did not meet requirements. The policies and procedures were not consistent with the HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (d) and 245G.12, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the HIV minimum standards policy meets all applicable requirements. Within 30 days of receipt of this order, submit an updated policies and procedures regarding HIV minimum standards that meets all applicable requirements. 6. Violation: The license holder’s program abuse prevention plan did not meet requirements. The program abuse prevention plan did not include an evaluation the following factors: a) Gender; b) Need for training of staff to meet identified individual needs; and c) Existence of areas in the building which are difficult. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan policy meets all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 7. Violation: The license holder’s personnel policies and procedures did not meet requirements. The personnel policies and procedures did not contain a chart or description of the organizational structure indicating lines of authority and responsibilities. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies and procedures meets all applicable requirements. Within 30 days of receipt of this order, submit a chart or description of the organizational structure indicating lines of authority and responsibilities that meets all applicable requirements. Personnel Files 8. Violation: Two of four personnel files reviewed for requirements governing personnel file contents (personnel files numbered 1 and 4) did not meet requirements as follows: a) Staff member’s current license on file (personnel file numbered 1); b) There was no documentation of date of first direct contact (personnel file numbered 1); and c) There was no documentation of job performance evaluation for calendar years 2024 and 2025 (personnel files numbered 4). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivision 1, clause (3). Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure personnel file contents meet all applicable requirements. Client Files 9. Violation: Three of three client files reviewed for requirements governing client orientation (client filed numbered 1 through 3) did not meet requirements. There was no documentation of orientation to the opioid education material approved by the commissioner on the day of service initiation. Statute Violated: Minnesota statutes, sections 245G.04, subdivision 3, 245G.09, subdivision 3, paragraph (a), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 10. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (CA) (client files numbered 1 through 3) did not meet requirements. The CA did not include documentation of the following: a) Status of the client’s basic needs; b) Any immediate risks to the client’s health and safety, including withdrawal symptoms, medical conditions, and behavioral and emotions symptoms; c) Periods of abstinence; d) Circumstances of relapse; and e) Important developmental incidents in the client’s life. Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that meets all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not signed by the alcohol and drug counselor (client file numbered 3); and b. There was no documentation of the following (client files numbered 1 through 3): 1) A treatment strategy; and 2) The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1. Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 1a, clauses (3) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual treatment plan that meets all applicable requirements. 12. Violation: Two of three client files reviewed for requirements governing documentation of treatment services and client records did not meet requirements. Documentation in the client record was inaccurate in the following ways: a. Entry did not include accurate job title or position of the staff that made the entry for the date January 19, 2026; b. Entry did not include accurate amount of treatment service provided for the entry date January 22, 2026 (client file numbered 1); and c. Individual treatment plan did not include accurate date of admission (client file numbered 2). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 13. Violation: One client file was reviewed for requirements governing service discharge summaries (client file numbered 4) and did not meet requirements. The discharge summary did not include documentation of progress toward achieving each goal identified in the treatment plan. Statute Violated: Minnesota statute, section 245G.06, subdivision 4, paragraph (b), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service 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 david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely,
David Her, Licensor Licensing Division Office of Inspector General
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