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April 06, 2026 CERTIFIED MAIL James Michaud, Authorized Agent Kingdom Pathways 11825 Bittersweet St NW Coon Rapids, MN 55433 License Number 1055735 (245G) ORDER OF LICENSE REVOCATION Dear James Michaud: The Department of Human Services (DHS) is revoking your license to provide substance use disorder treatment services at 1088 University Avenue W, Saint Paul, MN 55104. This revocation is based on failure to comply with licensing laws and rules and commissioner’s evaluation of program. Details of our findings are provided below. Our next steps and your options are also detailed. The revocation goes into effect on April 20, 2026 at 5:00 p.m. to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. LICENSING VIOLATIONS DETERMINED ON DECEMBER 11, 12, 15 – 19, 2025: DHS determined that your program did not follow licensing rules and statutes, as described below. 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided in the following ways: a. Services were billed; however, not provided as follows: i. One hour of individual counseling was billed; however, there was no supporting documentation in the client record on: 1. June 16 and 18, 2025 (C1); 2. September 30, 2025 (C2); 3. October 1 and 8, 2025 (C4); and 4. September 16, 2025 (C5); ii. Two hours of peer support services were billed; however, the amount of service was unable to be determined as the documentation was signed prior to the end of the session on: 1. June 18 and 19, 2025 (C1); 2. September 17 through 19, 30, and October 2, 2025 (C5); iii. Two hours of peer support services were billed on September 3, 2025; however, there was no supporting documentation in the client record (C2); iv. Thirty minutes of treatment coordination was billed on October 3, 2025; however, there was no supporting documentation in the client record (C4); v. One hour and 30 minutes of treatment coordination was billed on September 30, 2025; however, only one hour is documented (C5); and vi. Five hours of group counseling was billed on October 1, 2026; however, only 3 hours and 30 minutes are documented (C5); b. Multiple services were billed during the same time frame as follows: i. Documentation shows that both treatment coordination and peer recovery services were provided to the client on June 16, 2025, from 3:30 pm to 4:00 pm and June 20, 2025, from 3:30 pm to 4:30 pm (C1); ii. Documentation shows that both group counseling and treatment coordination were provided to the client on: 1. June 20, 2025, from 10:50 am to 11:20 am (C1); 2. September 2 and 3, 2025 from 10:45 am to 11:15 am and September 4, 2025, from 8:40 am to 9:10 am (C2); 3. October 1, 2025, from 9:30 am to 10:05 am and October 10, 2025, from 9:30 am to 10:00am (C4); and 4. September 17, 2025, from 10:10 am to 10:40 am, September 19, 2025, from 11:30 am to 12:00 pm, and October 1, 2025, from 9:25 am to 9:55 am (C5); iii. Documentation shows that both group and individual counseling were provided to the client on: 1. September 4, 2025, from 10:24 am to 10:55 am (C2); and 2. September 18, 2025, from 11:50 am to 12:00 pm (C5); and iv. Documentation shows that both individual counseling and treatment coordination were provided to the client on September 5, 2025, from 1:30 pm to 2:15 pm (C2); c. Treatment coordination was not provided according to Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a), clause (5) as follows: i. Documentation indicates that treatment coordination was provided in a group setting on: 1. June 17, 2025 (C1); and 2. September 30 and October 7, 2025 (C4); ii. Documentation consisted of only client updates on: 1. June 18 and 19, 2025 (C1); 2. September 4 and 5, 2025 (C2); 3. September 30, October 2, 6, and 7, 2025 (C4); and 4. September 18, 30 and October 1, 2025 (C5); and iii. Treatment coordination notes indicate the coordination was between internal staff on: 1. October 1 and 2, 2025 (C4); and 2. September 15 ,19, and October 3, 2025 (C5); d. Peer recovery support services were provided by an individual who did not meet the qualifications as a recovery peer according to Minnesota Statutes, section 245I.04, subdivision 18 on September 30, October 2, 3, and 6 through 8, 2025 (C4); and e. The license holder did not meet applicable requirements under Minnesota Statutes, section 254B.0507, subdivision 6 for enhanced rates for services provided to individuals with co-occurring mental health and substance use disorder problems as follows: i. Diagnostic assessments (DA) were not completed within 10 days of admission: 1. DA was due on June 20, 2025; however, it was completed on July 3, 2025 (C1); 2. DA was due on August 24, 2025; however, it was completed on December 14, 2025 (C2); 3. DA was due on September 13, 2025; however, it was completed on September 18, 2025 (C3); and 4. DA was due on September 12, 2025; however, it was completed on September 24, 2025(C4); ii. There was no documentation of a multidisciplinary case review that included a licensed mental health professional and licensed alcohol and drug counselor. Through staff interviews during the licensing review, it was determined that the staff were unaware of this licensing requirement (C1 through C4); and iii. There was no documentation that co-occurring counseling staff received 8 hours of co-occurring disorder training for calendar years 2024 and 2025 (SP2 and SP3); Statute Violated: Minnesota Statutes, sections 245A.167, paragraph (a) and 245A.191, paragraph (a). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated December 16, 2021 · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 2. Violation: The license holder did not meet requirements governing treatment services as follows: a. Treatment coordination was not provided according to Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a), clause (5) as follows: i. Documentation consisted of only client updates on July 7 through 11, 2025 (C1); and ii. Documentation indicated that treatment coordination was provided in a group setting on September 30, 2025 (C4); and b. Peer support services were not provided by a recovery peer qualified according to Minnesota Statutes, section 245I.04, subdivision 18 on September 16, 2025 (C5). The following violation is not included in violation number one as the program did not bill for the services for CI, C4, and C5 above. Statute Violated: Minnesota Statutes, section 245G.07, subdivisions 1, paragraph (a), 2, clause (8) and 3. 3. Violation: The license holder did not meet requirements for developing and monitoring implementation of program policies and procedures necessary for maintaining compliance with licensing requirements as follows: a. The license holder did not have assessment and treatment planning policies; and b. The license holder did not follow their own discharge policy. Through client interviews, it was determined that clients enrolled in the 245G program were required by the license holder to live in the license holder’s housing program and would be discharged from the 245G program for violating housing rules. Review of client documentation also demonstrated that a client was discharged from the 245G program for violating housing rules (C4). Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraphs (a) and (b) and 245G.12, clause (1). 4. Violation: The license holder did not protect against unauthorized disclosure according to Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67 as follows: Through staff interviews during the licensing review, it was determined that the program’s practice was to allow communication between 245G staff and external housing staff without client consent disclosure. Review of client documentation for treatment coordination indicates that 245G staff disclosed information to external housing staff without a release of information on September 30 and October 6, 2025 (C4). Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on June 13, 2025, you were previously found in violation of this same statute. 5. Violation: The license holder did not meet requirements governing responsible staff members. Schedules were reviewed for the date range of November 24, 2025, through December 5, 2025. During that time frame, the treatment director did not designate a staff member who, when present in the facility, was responsible for the delivery of treatment service on: a. November 24, 26, December 1, 3, and 4, 2025, from 7:00 pm to 10:00 pm; b. November 25 and December 2, 2025, from 5:00 pm to 10:00 pm; and c. November 28 and December 5, 2025, from 8:00 am to 9:00 am and 12:00 pm to 4:00 pm. Statute Violated: Minnesota Statutes, section Minnesota Statutes, section 245G.10, subdivision 3. 6. Violation: The license holder did not meet requirements governing staff requirements. Group counseling exceeded 16 clients on the following dates: a. 20 clients on November 28, 2025; b. 21 clients on November 6, 2025, c. 22 clients on November 14 and 19, 2025; d. 23 clients on November 3 through 5, 7, 13, 20, 21, 24, and 25, 2025; e. 24 clients on November 10 through 12, 17, and 26, 2025; and f. 25 clients on November 18, 2025. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 4. 7. Violation: The license holder did not meet requirements governing medical emergencies. The license holder did not ensure that at least one staff member on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate from July 30, 2025, through December 16, 2025. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. 8. Violation: The license holder did not meet requirements governing emergency overdose treatment in the following ways: a. The description of health care services did not include the program’s procedures for administering opiate antagonist medications; and b. The license holder did not maintain a supply of opiate antagonists on site. Statute Violated: Minnesota Statutes, sections 245A.242, subdivision 2, paragraphs (a) and (b), clause (3) and 245G.08, subdivision 3. 9. Violation: Three of four client files reviewed for requirements governing initial services plans did not meet requirements in the following ways: a. The initial services plan was not person-centered and client specific (C1, C3, and C4); and b. The initial services plan did not identify treatment needs to be addressed during the time between the day of service initiation and the development of the treatment plan (C4). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. 10. Violation: Four of four client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not updated based on the client’s condition and level of participation (C4); b. The ITP was not person-centered. The methods for the treatment plans were consistent and required four hours of group therapy and one hour of co-occurring individual counseling Monday through Friday, two hours of weekly recreational therapy, and 30 minutes of treatment coordination and two hours of peer support services five days per week, regardless of client’s assessed need (C1, C2, C3, and C4); c. The ITP was not based on the comprehensive assessment (C3 and C4); and d. The ITP did not include the following: i. How the family or others will be involved in the client's treatment or the reason why the license holder did not involve the client’s family in the client’s treatment planning (C2); ii. A treatment strategy (C1, C2, C3, and C4); iii. A schedule for accomplishing the client’s treatment goals and objectives (C1, C2, C3, and C4); and iv. The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (C1, C2, C3, and C4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a, clauses (1) through (5). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 11. Violation: Four of four client files reviewed for requirements governing documentation of treatment services did not meet requirements as follows: a. Entries did not include the amount of treatment services provided on: i. June 16, 17, and July 7 through 11, 2025 (C1); ii. September 5, 2025 (C2); iii. September 30, October 2, 6, 7, and 9, 2025 (C4); and iv. September 15 through 17, 19, and 30, 2025 (C5); b. Entries did not include the client’s response to the treatment services on the following dates: i. June 17, 19, and July 8, 2025 (C1); and ii. September 29, October 6, and 10, 2025 (C4); c. Entries in the client record did not include the job title or position of the staff that made the entry on the following dates: i. June 16, 20, and July 7 through 11, 2025 (C1); and ii. September 5, 2025 (C2); d. Entries in the client record did not include the type of treatment service provided on July 11, 2025 (C1); and e. Entries in the client record were not accurate. The client record indicated that the client received treatment coordination from two separate staff persons during an overlapping time period on October 6, 2025 (C4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 12. Violation: One of two client files reviewed for requirements governing discharge summaries (C1), did not meet requirements in the following ways: a. The discharge summary was not completed within five days of the client’s service termination; and b. The discharge summary did not document the client's issues, strengths, and needs while participating in treatment. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraphs (a) and (b), clause (2). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated June 13, 2025 · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 13. Violation: One of three personnel file reviewed for requirements governing recovery peer qualifications (SP4) did not meet requirements. There was no documentation that the staff person met the following requirements: a. A minimum of one year in recovery from substance use disorder; and b. A current credential from the Minnesota Certification Board, the Upper Midwest Indian Council on Addictive Disorders, or the National Association for Alcoholism and Drug Abuse Counselors. Statute Violated: Minnesota Statutes, sections 245G.11, subdivision 8, and 245I.04, subdivision 18, paragraph (a). 14. Violation: Two of two personnel files reviewed for requirements governing annual training (SP2 and SP3) did not meet requirements. There was no documentation of the following training for calendar years 2024 and 2025: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E, including specific training covering the license holder's policies for obtaining a release of client information; b. Program abuse prevention plan; c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services and reporting as specified for the reporting of maltreatment of minors; and d. HIV minimum standards. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Repeat Violation: In a Correction Order that DHS issued on August 31, 2020, you were previously found in violation of this same statute. 15. Violation: Two of two personnel files reviewed for requirements governing every two-year training (SP2 and SP3) did not meet requirements. There was no documentation on the following training for the calendar year 2025: a. Client confidentiality and client ethical boundaries; and b. Emergency procedures and client rights as specified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b). 16. Violation: Two of two personnel files reviewed for requirements governing additional training (SP2 and SP3) did not meet requirements. There was no documentation of 12 hours of specific training in co-occurring disorders completed within six months of employment. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (f). Repeat Violation: In a Correction Order that DHS issued on August 31, 2020, you were previously found in violation of this same statute. 17. Violation: Five of five personnel files reviewed for requirements governing personnel file contents did not meet requirements in the following ways: a. There was no documentation of a completed application for employment containing the staff member's qualifications for employment (SP3); b. The license holder did not document the date a staff person first had direct contact with persons served by the program (SP1, SP4, and SP5); c. There was no documentation of the staff member’s current licensure (SP2); d. There was no documentation of employer names and addresses for the past five years for which the staff member provided psychotherapy services, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member's former employers regarding substantiated sexual contact with a client (SP2); and e. The written annual review of the staff member’s job performance was not completed for calendar years 2024 and 2025 (SP2 and SP3). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clauses (1) and (3). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 18. Violation: The license holder did not meet requirements governing program abuse prevention plan as follows: a. The program abuse prevention plan was not posted in a prominent location in the program; The program abuse prevention plan did not include an assessment of the population that includes the evaluations of the following factors: i. Age ii. Gender; and iii. Mental functioning; and b. There was no documentation of annual review of the plan by the license holder’s governing body or the governing body's delegated representative review of the calendar year 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (5). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 19. Violation: The license holder did not meet requirements governing client rights protection. The client rights protection policy did not include rights according to Minnesota Statutes, sections 144.651, 148F.165, and 253B.03. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. 20. Violation: The license holder did not meet requirements governing grievance procedures as follows: a. The grievance procedure did not identify the current address of the Office of Ombudsman for Mental Health and Developmental Disabilities; and b. The grievance procedure was not posted in a place visible to clients. Statute Violated: Minnesota Statutes, sections 245G.15, subdivision 2 and 245G.12, clause (5). 21. Violation: The license holder did not meet requirements governing co-occurring disorder specialization requirements. The license holder did not have continuing access to a medical provider with appropriate expertise in prescribing psychotropic medication. Statute Violated: Minnesota Statutes, section 245G.20, clause (2). 22. Violation: The license holder did not meet requirements governing HIV policies and procedures. 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). 23. Violation: The license holder did not meet requirements governing plans for transfer of clients and records upon closure. There was no documentation of annual review of the plan by a controlling individual for calendar years 2024 and 2025. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on August 31, 2020, you were previously found in violation of this same statute. 24. Violation: Three of four client files reviewed for requirements governing client orientation (C2 through C4) did not meet requirements. There was no documentation of orientation to client rights and responsibilities as identified in Minnesota Statutes, section 144.651 on the day of service initiation. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. 25. Violation: Four of four client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include the following information: a. The status of the client’s basic needs (C2); b. The client's perceptions of the client's condition (C2); c. The reason for the client's referral (C2, C3, and C4); d. Substance use history, including: i. Types of substances (C4); and ii. Duration (C2); e. Important developmental incidents in the client’s life (C4); f. The client’s family health history (C2); and g. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (C1, C2, C3, and C4). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018 26. Violation: Four of four client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirement. There was no documentation of the following: a. Client goals addressed since the last treatment plan review (C4); b. Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (C3); and c. Continuing documentation of collaboration with continuing care mental health providers, and involvement of the providers in treatment planning meetings (C1 through C4). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 3, clause (1) and 245G.20, clause (6). Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated August 31, 2020 · Correction Order dated May 09, 2018
REASON FOR LICENSE REVOCATION 1. Failure to comply with licensing laws and rules DHS determined that your program failed to fully comply with the laws and rules that apply to licensed Substance Use Disorder Treatment programs. DHS has also considered the nature, chronicity, or severity of the violations and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that revocation of your license is appropriate. Nature and severity of licensing violations determined Many of the violations cited in the Order of Revocation are violations impacting the health, safety, or rights of individuals served by the program. The violations include: § Six violations related to the documentation and provision of treatment services were determined (violations 1, 2, 6, 11, 12, and 24). These violations were found in all client files reviewed. As a SUD treatment license holder, you are required to provide person-centered treatment services based on recommendations from the client’s comprehensive assessment. Staff interviews, along with review of client documentation, demonstrated that clients’ received services according to the program’s treatment requirements, not as clinically indicated by their comprehensive assessment and specific client need. Further, services provided were not consistent with what was reimbursed through public funding, with client files indicating that clients were receiving multiple services during the same time frame. § Eight violations related to maintaining compliant policies and procedures were determined (violations 3, 8, and 18 through 23). Not being able to maintain compliant policies and procedures presents a significant safety risk, because policies and procedure direct staff how to operate the program. Noncompliant policies and procedures also demonstrate the license holder’s lack of competent knowledge related to Minnesota Statutes, chapters 245A and 245G. § One violation related to the unauthorized disclosure of client records was determined (violation 4). This is concerning regarding the client rights to confidentiality according to the Code of Federal Regulations, title 42 and puts both clients and staff at risk. § Three violations related to staffing requirements and qualifications were determined (violations 5, 7, and 13). Staff providing treatment services in an SUD treatment program must be qualified to do so, and you did not verify that staff were qualified. You allowed unqualified staff to provide peer support services. Further, you did not ensure that there was a staff member on site when clients were present, that was CPR and first aid trained. This presents a significant safety risk to clients. § Four violations related to client assessment and treatment planning were determined (violations 9, 10, 25, and 26). Completion of the required assessments is a critical component of treatment, so that services provided are person-centered. Further, individual treatment plans were not individualized. § Four violations related to staff orientation and development were determined (violations 14 through 17). A risk to the health and safety of your clients is compromised when staff are not trained on items such as emergency procedures, maltreatment reporting, and the program abuse prevention plan. Chronicity Your program received its license on January 1, 2010. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: · August 4, 2025: Fine Order: $1600 for nine background study fines · June 13, 2025: Correction Order (Investigation): two violations · December 16, 2021: Correction Order (Investigation): Two of two violations were repeat violations · August 31, 2020: Correction Order (Licensing Review & Investigation): Nine out of twenty-one violations were repeat violations · May 16, 2018: Fine Order: $200 for one background study fine · May 9, 2018: Correction Order: twenty-four violations Specifically, you have received repeat violations for noncompliance with billing requirements, including citations completing documentation of treatment services. You have been cited previously for completing documentation of treatment services prior to the end of the treatment service. This is concerning because it makes it difficult to discern how much of the treatment service was provided to the client and brings the accuracy of the notes into question. Further, there are repeat violations related to an investigation that was conducted several months prior to this licensing review. These repeat violations include unauthorized disclosure of client information to housing staff. Despite being informed that this practice was a violation of statute requirements in June 2025, the program continued to disclose confidential information without signed releases of information. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1). 2. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of persons served by your program, information about the qualifications of staff persons that are working in your program, and the license holder’s ability to demonstrate competent knowledge of the applicable requirements of statutes and rules. As a license holder, you are enrolled to receive public funding reimbursement for services. You must comply with enrollment requirements as licensing standards. You have egregiously violated these standards as described in violation number one above. You additionally have not engaged in person centered treatment planning as demonstrated by requiring all individuals enrolled in your program to attend the same amount of specific hours and the same treatment modalities. The health and safety of clients was put in jeopardy, as you did not ensure that staff on site with clients were trained in CPR and first aid. Further, the numerous violations related to noncompliance of policies and failure to ensure staff were qualified to provide treatment services indicate a lack of competency related to statutory requirements governing substance use disorder treatment programs. Lastly, the chronicity of repeat violations further indicate a lack of competency as the program did not demonstrate they were able to correct licensing violations. DHS has determined that revocation of your license is appropriate based on the Commissioner’s evaluation of the program. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder treatment services is revoked. YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must comply with the conditions described below. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license. If you continue to operate pending the outcome of your appeal, you must comply with the following conditions: 1. While operating pending appeal, you cannot apply for or be issued an additional DHS License; 2. Within 14 days of filing an appeal, you must notify current clients and all parties who refer individuals to your program of the status of your license: revoked operating under appeal. While operating pending appeal, you must notify new clients and referral sources that the license is revoked and operating under appeal before they begin receiving services. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file.
3. Within 14 days of filing an appeal, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of owner, treatment director or authorized agent. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. Two years of professional experience in the following: 1) A regulatory or compliance position; 2) Involved in direct care as a providing mental health services, or 3) If applicable, the development and implementation of mental health or substance use disorder treatment planning in a DHS licensed mental health or substance use disorder licensed program. b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and MN Statutes, Chapter 245G, Substance Use Disorder Licensed Treatment Facilities; and c. A bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field. 4. Within 30 days of compliance officer approval, you must implement DHS Licensing’s self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapter 245A and 245I. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the appeal or otherwise determined by DHS licensing. 5. Within 30 days of filing an appeal within the timeframes described above, you must submit documentation to demonstrate all violations identified above have been corrected. This includes verification of staff training, revising noncompliant policies and procedures, etc. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. · The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). · Minnesota Statutes, section 245.095 defines which programs administered by DHS are included in the exclusion provision, and further defines “excluded,” “individual,” and “provider.” · License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. · If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. · Under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (b), the commissioner may include terms the license holder must follow pending a final order on appeal. Questions If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Jason Flint, Assistant Director Licensing Division Office of Inspector General
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