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April 9, 2026 Margie Pierce, Authorized Agent Fellowship Recovery 1709 25th Ave N Minneapolis, MN 55411 License Number: 1109514 CORRECTION ORDER Dear Margie: On March 1 through 3, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Fellowship Recovery, located at 1516 W Lake St, Minneapolis, MN 55408. 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 for individuals with co-occurring disorders in accordance with Minnesota Statutes, section 254B.0507, subdivision 6. There was no documentation of the following: a. A mental health diagnostic assessment completed within 10 days of admission (client files numbered 1 through 4, 6, and 7); b. A multidisciplinary case review completed for February 2026 (client file numbered 4); and c. Co-occurring staff received 8 hours of training on co-occurring disorders for calendar year 2025 (personnel files numbered 1, 3, and 8). Statute Violated: Minnesota statutes, section 245A.191, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they were billed. Additionally, 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 service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. 2. Violation: The license holder did not meet requirements governing client rights protection in the following ways: a. The license holder’s client rights policy did not include client rights as identified in Minnesota Statutes, sections 144.651 and 253B; and b. There was no documentation that the response to the client’s grievance occurred within three days of a staff member’s receipt of the grievance on December 4, 2025. Statute Violated: Minnesota statutes, sections 245G.15, subdivisions 1 and 2, clause (3), and 245G.12, clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights protection meet all applicable requirements. Within 30 days of receipt of this order, submit a clients rights policy that demonstrates compliance. 3. Violation: The license holder did not meet requirements governing the description of treatment services. The treatment service description did not define 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 service description meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment services description that demonstrates compliance. 4. Violation: The license holder did not meet requirements governing the program abuse prevention plan. The license holder’s governing body or the governing body’s delegated representative did not review the plan for calendar year 2024. Statute Violated: Minnesota statutes, section 245A.65, subdivision 2, paragraph (a), clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. 5. Violation: The license holder did not meet requirements for monitoring implementation of program policies and procedures necessary for maintain compliance with licensing requirements. The license holder’s maltreatment of vulnerable adults report policy included outdated statute definitions. 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 vulnerable adult maltreatment reporting policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a maltreatment of vulnerable adults reporting policy that demonstrates compliance. 6. Violation: The license holder did not meet requirements governing plans for transfer of clients and records upon closure. The license holder’s plan for transfer of clients and records upon closure was not reviewed and signed by a controlling individual for calendar years 2024 and 2025. 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 the plan for transfer of clients and records upon closure meets all applicable requirements. Personnel Files 7. Violation: Two of two personnel files reviewed for requirements governing treatment director qualifications (personnel files numbered 1 and 2) did not meet requirements. The personnel record did not document the treatment director’s knowledge and understanding of Minnesota Statutes, sections 626.557 and 626.5572, and chapters 245A and 260E. Statute Violated: Minnesota statutes, section 245G.11, subdivisions 2, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment director qualifications meet all applicable requirements. 8. Violation: One personnel file reviewed for requirements governing recovery peer qualifications (personnel file numbered 5) did not meet requirements in the following ways: a. The personnel file did not document a minimum one year in recovery from substance use disorder for a recovery peer; and b. A licensed drug and alcohol counselor did not meet with a recovery peer at least once per month to provide adequate supervision for the months of October 2024 through January 2025, May 2025, and June 2025. Statute Violated: Minnesota statutes, section 245G.11, subdivision 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that recovery peer qualifications meet all applicable requirements. 9. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit qualification (personnel file numbered 3) did not meet requirements. The supervising licensed alcohol and drug counselor did not document that supervision was provided on a weekly basis in the following ways: a. Supervision was not documented for the weeks of: 1) March 11, 18, and 25, 2024; 2) April 1, 8, 15, 22, and 29, 2024; 3) May 6, 13, 20, and 27, 2024; 4) June 3, 10, 17, and 24, 2024: 5) July 1, 8, 15, and 29, 2024; 6) August 5, 12, 19, and 26, 2024; 7) September 2, 9, 16, 23, and 30, 2024; 8) October 14 and 21, 2024; 9) November 24, 2024; 10) December 23 and 30, 2024 11) March 24 and 31, 2024; and 12) November 24, 2025; and b. Supervision did not document the amount of supervision provided on: 1) July 25, 2024; 2) December 12 and 18, 2024; 3) January 3, 8, 17, and 22, 2025; 4) February 5, 12, and 26, 2025; 5) March 6, 12, and 20, 2025; 6) April 16, 23, and 29, 2025; 7) May 9, 14, and 28, 2025; 8) June 6, 11, 19 and 25, 2025; 9) July 3, 9, 18, and 23, 2025; 10) August 7, 13, 22, and 27, 2025; 11) September 3, 10, 17, and 25, 2025; and 12) October 1, 8, 16, and 29, 2025. Statute Violated: Minnesota statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individuals with a temporary permit qualifications meet all applicable requirements. 10. Violation: Seven of eight personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. There was no documentation staff were oriented to the following within 24 working hours (personnel files numbered 1, 2, 3, 4, 6, 7, and 8): 1) The staff members specific job responsibilities; 2) Policies and procedures: 3) Client confidentiality; 4) Client needs; and 5) HIV minimum standards; and b. There was no documentation staff were oriented to the following within 72 hours of employment (personnel files numbered 1, 2, 3, 4, 6, 7, and 8): 1) Maltreatment of vulnerable adults reporting requirements; 2) The license holder’s program abuse prevention plan; and 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and c. There was no documentation staff were oriented to the maltreatment of minors reporting requirements before the employee had direct contact (personnel files numbered 1, 2, 3, 4, 6, 7, and 8). d. There was no documentation staff completed 12 hours of training in co-occurring disorders within six months of employment (personnel files numbered 3). Statute Violated: Minnesota statutes, section 245G.13, subdivision 1, clause (7) and subdivision 2, paragraph (d), (e), and (f), and 245A.65, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 11. Violation: Five of five personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation staff received training for the following: a. Maltreatment reporting requirements as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E for calendar year 2025 (personnel files numbered 1, 2, and 3); and b. HIV minimum standards for calendar year 2025 (personnel files numbered 1, 2, 3, 5, and 8). Statute Violated: Minnesota statutes, sections 245A.19, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff development meet all applicable requirements. 12. Violation: Eight of eight personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following: a. A completed application for employment signed by personnel (personnel files numbered 4, 6, and 7); b. The first date that a background study subject has direct contact with a person served by the license holders program (personnel files numbered 4 and 5); c. Documentation of an inquiry required by Minnesota Statutes, sections 601.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel file numbered 3); and d. A written job performance evaluation for calendar year 2025 (personnel files 1, 2, 3, 5, and 8). Statute Violated: Minnesota statutes, sections 245A.041, subdivision 6 and 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 files meet all applicable requirements. Client Files 13. Violation: Seven of eight client files reviewed for requirements governing client orientation (client files numbered 1 through 7) did not meet requirements. There was no documentation of orientation to the following within 24 hours of admission: a. Internal and external maltreatment of vulnerable adults reporting policies; and b. Program abuse prevention plan. Statute Violated: Minnesota statutes, sections 245G.09, subdivision 3, paragraph (a), clause (1) and 245A.65, subdivision 1, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meet all applicable requirements. 14. Violation: Eight of eight client files reviewed for requirements governing initial services plans (ISP) did not meet requirements in the following ways: a. The file did not contain an ISP completed within 24 hours of the day of service initiation (client file numbered 7); b. The ISP was not client-specific (client files numbered 5 and 8); c. The ISP did not address immediate health and safety concerns (client files numbered 1, 2, 3, 4, 6, and 7); and d. The ISP did not identify treatment needs to be addressed between the day of service initiation and the development of the individual treatment plan (client files numbered 2, 3, 4, 6, and 7). Statute Violated: Minnesota statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements. Within 30 days of receipt of this order, submit an initial service plan that demonstrates compliance. 15. Violation: Seven of eight client files reviewed for requirements governing comprehensive assessments did not meet requirements. There was no documentation of the following: a. The client’s age (client files numbered 1 through 7); b. The clients history of mental health treatment (client files numbered 1 through 7); c. Substance use history including: 1) Amount (client files numbered 2, 3, and 4); and 2) Frequency (client file numbered 2); and d. Potential brain injuries (client files numbered 1 through 7). 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. Within 30 days of receipt of this order, submit a comprehensive assessment that demonstrates compliance. 16. Violation: Six of eight client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not completed by the end of the tenth day on which a treatment service was provided from the day of service initiation, not to exceed 30 days (client files numbered 2, 6 and 7); b. The ITP did not contain the drug and alcohol counselor signature (client file numbered 6); c. The ITP was not updated based on new information gathered about the client’s condition, the client’s level of participation, whether methods identified have the intended effect (client files numbered 3, 4, and 6); d. The ITP did not contain a treatment strategy (client files numbered 3 and 4); and e. The ITP did not identify the participants involved in the client’s treatment planning (client files numbered 2, 3, 4, and 5). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 1 and 1a, clauses (3) and (5). Repeat Violation: The license holder was cited for a similar violation in the Correction Order dated November 20, 2025. 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: Six of eight client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Client record entries did not include the staff members title on: 1) December 22, 23, 26, 29, and 30, 2025 (client file numbered 1); 2) December 30, 2025 (client file numbered 4); 3) February 3, 4, 5, and 6, 2026 (client file numbered 5); 4) January 14, 15, 16, and 19, 2026 (client file numbered 6); and 5) January 2, 5, 6, 7, 8, 9, 12, 13, and 14, 2026 (client file numbered 7); and b. The client record entry was not signed within seven days of a treatment service provided on December 29, 2025 (client file numbered 1); and c. The client record entry was not signed or dated by the staff member making the entry on February 12, 2026 (client file numbered 3). Statute Violated: Minnesota statutes, sections 245G.06, subdivision 2b, paragraph (c) and 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 18. Violation: Five of six client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements as follows: a. The TPR did not indicate the span of time covered by the review (client file numbered 4); b. The TPR did not document toxicology results for alcohol and drug use when available (client file numbered 5); c. The TPR did not document the participation of others involved in the individuals treatment planning, including when services were offered to the client’s family or significant other (client file numbered 7); and d. The TPR was not completed once every 30 days (client files numbered 1, 3, 4 and 7). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3, clauses (2) and (3) 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 of two client files reviewed for requirements governing service discharge summaries (client file numbered 6) did not meet requirements. The service discharge summary was not completed within five days of the client’s service termination. Statute Violated: Minnesota statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that 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 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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