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April 7, 2026 Rachel Mueller, Authorized Agent Pine Manors Inc. 22195 State 34 Nevis, MN 56467 License Number: 1033819 (Detox) CORRECTION ORDER Dear Rachel, On February 10 through 12, 2026, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Pine Manors located at22195 Nevis, MN 56467. This review was conducted to determine compliance with state and federal laws and rules governing the provision of detox services under Rule 32. 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. Policy, Procedure and Practice 1. Violation: The license holder did not meet requirements governing medical director requirements. The license holder did not document the annual review and approval by the medical director for the following policies for the calendar years: a. 2024: 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; and b. 2025: 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; and v. Condition specific protocols regarding the medications that require a withdrawal regimen that will be administered to patients. Rule Violated: Minnesota Rule, part, 9530.6560, subpart 5, items A through F and H. 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 for calendar year 2025 with the medical directors’ annual review and signature. 2. Violation: The license holders’ policy governing HIV did not meet requirements. The license holder’s policy was not consistent with the HIV Minimum Standards. Rule and Statute Violated: Minnesota Statutes, section 245A.19, paragraph (d), and Minnesota Rule, part 9530.6580, item J. Corrective Action Required: Immediately and on an ongoing basis the license holder must ensure that the HIV policy meets all applicable requirements. Within 30 days of receipt of this order the license holder will submit updated HIV policies. 3. Violation: The license holder did not meet requirements governing program abuse prevention plan in the following ways: a. The plan did not contain an assessment and evaluation of the following factors: i. Age; ii. Physical and emotional health or behavior of clients; iii. Need for specialized programs of care for clients; iv. Need for staff training to meet identified needs of the clients; and v. Knowledge a License Holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; and b. There was no documentation that the license holder’s governing body or the governing body’s delegated representative reviewed the plan in calendar years 2024 and 2025. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a), clauses 1 and 5. 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. 4. Violation: The license holder did not monitor the implementation of policies and procedures in the following ways: a. The Maltreatment of Vulnerable Adult policy and procedure included definitions of maltreatment that were not consistent with current licensing standards; and b. The policy manual contained three conflicting versions of a Maltreatment of Minors policy. Rule and Statute Violated: Minnesota Statutes, sections, 245A.04, subdivision 14, paragraph (a), 245A.65, subdivision 1, paragraph (a), clause (1) and Minnesota Rules, part, 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. 5. Violation: The license holders vulnerable adult reporting policy did not meet requirements. The license holder’s policy did not identify a secondary person or position that: a. Internal reports may be made; b. Is responsible or forwarding internal reports to the common entry point; and c. Must be involved with receiving and forwarding the report to the common entry point when there is reason to believe that the primary person was involved in the alleged maltreatment. Statute Violated: Minnesota statutes, section 245A.65 subdivision 1, paragraph (a), clause (2) Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that the vulnerable adult reporting policy meets all applicable requirements. Within 30 days of receipt of this order, the license holder will submit an updated vulnerable adult reporting policy that meets all applicable requirements. 6. Violation: The license holders did not meet requirements governing the plan for transfer of clients. The plan was not signed annually for the calendar years 2024 and 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. Personnel Files 7. Violation: Two of five personnel files reviewed for requirements governing background studies (personnel file numbered 2 and 4) did not meet requirements as follows: a. Personnel file numbered 2 began a position allowing direct contact with persons served by the program on July 27, 2022. A background study was submitted under license number 801918, however, personnel file numbered 2 was also working under license number 1033819. The license holder failed to affiliate personnel file numbered 2 to all required rosters; and b. Personnel file numbered 4 began a position allowing direct contact with persons served by the program on May 23, 2023. A background study was submitted under license number 801918, however, personnel file numbered 4 was also working under license number 1033819. The license holder failed to affiliate personnel file numbered 4 to all required rosters. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must comply with the background study requirements in Minnesota Statutes, chapter 245C. 8. Violation: One of five personnel files reviewed for personnel file documentation did not meet requirements (personnel file numbered 3). The personnel file did not contain documentation verifying the staff members’ qualifications for employment and current professional license or registration. Rule Violated: Minnesota Rule, part 9530.6575, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all personnel files contain all required documentation. Client Files 9. Violation: One of three client files reviewed for requirements governing Individual Abuse Prevention Plans (IAPP) (client file numbered 3) did not meet requirements. The IAPP did not assess the person’s susceptibility to abuse by other individuals including other vulnerable adults. Rule Violated: Minnesota Rule, part 9530.6585, subpart 3, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all IAPP meets 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: Jen 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 at651-431-6698 or at jennifer.eppel@state.mn.us Sincerely, Jen Eppel, Licensor Licensing Division Office of Inspector General
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