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May 15, 2026 Christopher McCalla, Authorized Agent Partners in Recovery, LLC 310 4th Avenue S, STE 5100 Minneapolis, MN 55415
License Numbers: 1104202, 1063780, 1123974 Dear Christopher McCalla: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration regarding citations 5, 6, 7 (paragraph c), 10, 11, and 12 in the Correction Order issued to you on February 27, 2026. After an independent review of the record, the Commissioner has determined it is appropriate to rescind citation 11. The remaining challenged citations are affirmed. Also, the violations for which you did not request reconsideration are final and not within the scope of this review. Reconsideration Determination Violation 5: Six of seven personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of the following: a. Vulnerable adult maltreatment reporting as specified in 245A.65, 626.557, and 626.5572 for calendar years: 1) 2024 (personnel files numbered 1 and 9); and 2) 2025 (personnel files numbered 6, 8, and 9); b. Program abuse prevention plan for calendar years: 1) 2024 (personnel files numbered 1, 2, and 9); and 2) 2025 (personnel files numbered 6, 8, and 9); c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: 1) 2024 (personnel files numbered 1, 2, and 9); and 2) 2025 (personnel files numbered 6, 8, and 9); d. Maltreatment of minors reporting for calendar years: 1) 2024 (personnel files numbered 1, 2, and 9); and 2) 2025 (personnel files numbered 6, 8, and 9); e. HIV minimum standards for calendar year 2024 (personnel files numbered 1 and 2); f. Every two year trainings for calendar year 2025 (personnel files numbered 2 and 9); 1) Client confidentiality rules and regulations and client ethical boundaries; and 2) Client rights; and g. 12 hours of training in co-occurring disorders within six months of employment (personnel files numbered 9 and 10). Applicable Law Under Minnesota Statutes, section 245A.19, paragraph (c), the license holder shall maintain a list of referral sources for the purpose of making necessary referrals of clients to HIV-related services. The list of referrals shall be updated at least annually. Under Minnesota Statutes, section 245A.65, subdivision 3, the license holder shall ensure that each new mandated reporter as defined in section 626.5572, subdivision 16, who is under the control of the license holder, receives and orientation within 72 hours of first providing direct contact services as defined in section 245C.02, subdivision 11, to a vulnerable adult and annually thereafter. The orientation and annual review shall inform the mandated reporters of the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder’s program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Under Minnesota Statutes, section 245G.13, subdivision 2, paragraphs (b) through (f), a license holder must ensure that each staff member has the training as described in the subdivision. Your Response You submitted a letter in which you indicated the citation was incorrect. You submitted supporting documentation to show that the personnel files in the citation contained the required documentation. Reconsideration Determination However, the documentation you submitted was reviewed during the licensing visit. Although the documentation showed the training was completed, it was not completed within the required timeframe. The statute requires that the training be completed annually, which is defined under Minnesota Statutes, section 245A.02, subdivision 2b, as prior to or within the same months of the subsequent calendar year. There is sufficient information to support the violation, and it is therefore affirmed. Violation 6: Seven of ten personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following: a. Completed application for employment signed by personnel (personnel file numbered 2); b. That the staff member meets the requirements for staff qualifications (personnel files numbered 1, 2, 6, and 10); and c. A written job performance evaluation for: 1) Calendar year 2024 (personnel files numbered 1, 2, and 9); and 2) Calendar year 2025 (personnel files numbered 4, 6, 8 and 9). Applicable Law Under Minnesota Statutes, section 245G.13, subdivision 1, clause (3), a license holder must have written personnel policies that are available to each staff member. The personnel policies must provide for a job performance evaluation based on standards of job performance conducted on a regular and continuing basis, including a written annual review. Under subdivision 3, clause (1), the license holder must maintain a separate personnel file for each staff member. At a minimum, the personnel file must conform to the requirements of this chapter. A personnel file must contain, for a staff member who provides psychotherapy services, employer names and addresses for the past five years for which the staff member provided psychotherapy service, and documentation of an inquiry required by sections 604.20 to 604.205 made to the staff member’s former employer regarding substantiated sexual contact with a client. Your Response You submitted a letter in which you indicated paragraph c of the violation was incorrect because the program did have written job performance evaluations. You also indicated that although the reviews were not signed, you were not aware that a signature was required. You did not submit information to challenge paragraphs a and b. Reconsideration Determination The statute requires a written annual review, and the performance evaluations were not completed annually, as defined under Minnesota Statutes, section 245A.02, subdivision 2b, as prior to or within the same months of the subsequent calendar year. The job performance evaluations that were dated were not completed prior to or within the same month of the subsequent calendar year, and other performance evaluations were not dated, which made it unclear whether the evaluation was completed annually as required. There is sufficient information to support the violation, and it is therefore affirmed. Violation 7: Two of ten client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation: a. That staff reviewed the written statement of client rights and responsibilities with the client on the day of service initiation (client file numbered 2); and b. That the client was given information on Tuberculosis within 72 hours of admission (client file numbered 1). Applicable Law Under Minnesota Statutes, section 245G.09, subdivision 3, paragraph (a), clause (1), client records must contain documentation that the client was given: information on client rights and responsibilities and grievance procedures on the day of service initiation; information on tuberculosis and HIV within 72 hours of service initiation; an orientation to the program abuse prevention plan required under section 245A.65, subdivision 2, paragraph (a), clause (4), within 24 hours of admission or, for clients who would benefit from a later orientation, 72 hours; and opioid educational material according to section 245G.04, subdivision 3, on the day of service initiation. Under Minnesota Statutes, section 245G.15, subdivision 1, a client has the rights identified in sections 144.651, 148F.165, and 253B.03, as applicable. The license holder must give each client on the day of service initiation a written statement of the client’s rights and responsibilities. A staff member must review the statement with a client at that time. Under Minnesota Statutes, section 245G.09, subdivision 1, the content and format of client records must be uniform and entries in each record must be signed and dated by the staff member making the entry. Your Response You submitted a letter in which you indicated the violation was incorrect because the program met the requirements. You submitted supporting documentation. Reconsideration Determination However, the documentation submitted with the reconsideration request was not submitted or provided within 24 hours of request. Also, the document provided for client 2 did not include a staff signature, and although documentation showed that information regarding Tuberculosis was covered, the documentation was signed as completed on August 4, 2025, which was more than 72 hours after admission. There is sufficient information to support the violation, and it is affirmed. Violation 10: Ten of ten 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 session had been provided from the day of service initiation (client files numbered 5 and 6); b. A change to the plan was not signed by the client (client files numbered 1 and 2); c. The ITP was not based on the client’s comprehensive assessment (client file numbered 2); and d. The ITP did not document: 1) The client’s treatment goals in relation to any or all of the applicable ASAM six dimensions to ensure measurable treatment objectives (client files numbered 1 and 2); 2) A treatment strategy (client files numbered 1 through 10); and 3) A schedule for accomplishing the client’s treatment goals and objectives (client files numbered 1 and 2). Applicable Law Under Minnesota Statutes, section 245G.06, subdivision 1, Each client must have a person-centered individual treatment plan developed by an alcohol and drug counselor within ten days from the day of service initiation for a residential program, by the end of the tenth day on which a treatment session has been provided from the day of service initiation for a client in a nonresidential program, not to exceed 30 days. Opioid treatment programs must complete the individual treatment plan within 14 days from the day of service initiation. The number of days to complete the individual treatment plan excludes the day of service initiation. The individual treatment plan must be signed by the client and the alcohol and drug counselor and document the client's involvement in the development of the plan. The individual treatment plan is developed upon the qualified staff member's dated signature. Treatment planning must include ongoing assessment of client needs. An individual treatment plan must be updated based on new information gathered about the client's condition, the client's level of participation, and on whether methods identified have the intended effect. A change to the plan must be signed by the client and the alcohol and drug counselor. If the client chooses to have family or others involved in treatment services, the client's individual treatment plan must include how the family or others will be involved in the client's treatment. If a client is receiving treatment services or an assessment via telehealth and the alcohol and drug counselor documents the reason the client's signature cannot be obtained, the alcohol and drug counselor may document the client's verbal approval or electronic written approval of the treatment plan or change to the treatment plan in lieu of the client's signature. Under subdivision 1a, paragraph (a), clauses (1) and (3), after completing a client’s comprehensive assessment, the license holder must complete an individual treatment plan. The license holder must: base the client’s individual treatment plan on the client’s comprehensive assessment; and identify the client’s treatment goals in relation to any or all of the applicable ASAM six dimensions identified in section 245B.04, subdivision 4, to ensure measurable treatment objectives, a treatment strategy, and a schedule for accomplishing the client’s treatment goals and objectives. Additionally, under clause (6), the license holder must identify resources to refer the client to when the client’s needs will be addressed concurrently by another provider. Your Response You submitted a letter in which you indicated the violation is incorrect because the requirements governing ITPs were met, and you provided supporting documentation. You requested reconsideration of paragraphs (c) and (d), clauses (1) and (3), of the violation, and you did not provide information to challenge the remaining paragraphs in the citation. Reconsideration Determination The comprehensive assessment and initial service plan both indicated the client wished to receive dental care, and there was no goal to address that need in the ITP, which indicates the ITP was not based on the client’s comprehensive assessment. Also, although the ITP described peer recovery services as a treatment need of 14 hours per week, it did not include a goal related to those services. Additionally, although you submitted documentation of a target date for accomplishing the client’s treatment goals and objectives, the August 1, 2026, date listed was nearly one year after the August 4, 2025, date of treatment plan completion of the outpatient program. There is sufficient information to support the violation, and it is affirmed. Violation 11: Two of ten client files reviewed for requirements governing treatment service and clients record documentation did not meet requirements in the following ways: a. Treatment service documentation did not include the client’s response to the treatment service on July 13, 2025 (client files numbered 4); and b. Client record entries did not include the staff member’s title on August 4 and 29, 2025 (client file numbered 1). Applicable Law Under Minnesota Statutes, section 245G.06, subdivision 2a, the license holder must ensure that the staff member who provides the treatment service documents in the client record the date, type, and amount of each treatment service provided to a client and the client’s response to each treatment service within seven days of providing the treatment service. In addition to the other requirements of this subdivision, if a guest speaker presents information during a treatment service, the alcohol and drug counselor who provided the service and is responsible for the information presented by the guest speaker must document the name of the guest speaker, date of service, time the presentation began, time the presentation ended, and a summary of the topic presentation. Under subdivision 2b, paragraph (c), each entry in a client’s record must be accurate, legible, signed, dated, and include the job title or position of the staff person that made the entry. A late entry must be clearly labeled “late entry.” A correction to an entry must be made in a way in which the original entry can still be read. Your Response You submitted a letter in which you indicated the violation is incorrect. Reconsideration Determination After further review of the information contained in the file and the information you submitted, the Commissioner has determined it is appropriate to rescind the violation. Violation 12: Ten of ten client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency did not meet requirements as follows: a. TPR was not completed once every 30 days for a client receiving ASAM level 1.0 outpatient or 2.1 intensive outpatient services (client files numbered 1, 2, and 8); b. TPR was not completed once every 14 days for ASAM level 2.5 partial hospitalization services (client file numbered 3); and c. The TPR did not document the following: 1) The span of time covered by the review (client files numbered 1 and 3); 2) The participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others (client file numbered 1); and 3) Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 1). Applicable Law Under Minnesota Statutes, sections 245G.06, subdivision 3, clauses (1), (3) and (4), a treatment plan review must be completed by the alcohol and drug counselor responsible for the client’s treatment plan. The review must indicate the span of time covered by the review and must: document client goals addressed since the last treatment plan review and whether the identified methods continue to be effective; document the participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others; and if changes to the treatment plan are determined to be necessary, document staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change. Under subdivision 3a, paragraphs (a) and (e), a license holder must ensure that the alcohol and drug counselor responsible for a client’s treatment plan completes and documents a treatment plan review that meets the requirements of subdivision 3 in each client’s file, according to the frequencies required in this subdivision. All ASAM levels referred to in this chapter are those described in section 254B.19, subdivision 1. For a client receiving nonresidential ASAM level 1.0 outpatient or 2.1 intensive outpatient services or any other nonresidential level not included in paragraph (d), a treatment plan must be completed once every 30 days. Your Response You submitted a letter in which you indicated the violation is incorrect because the TPRs included the span of time covered by the review, and you provided supporting documentation. You requested reconsideration of paragraph c, item 1 and you did not provide information to challenge the remaining portions of the violation. Reconsideration Determination For client 1, the client signed the document on August 25, 2025, and the counselor signed on August 29, 2025. The document incorrectly indicated the span of time covered by the review to include August 30, 2025, and August 31, 2025. For client 3, the client and the counselor signed the treatment plan review on November 4, 2025, but the span of time on the document was listed as October 13, 2025, to November 9, 2025. There is sufficient evidence to support the violation, and it is affirmed. Disposition The Commissioner has reviewed the relevant laws and all the information you submitted in response to the Correction Order. Violation 11 is rescinded. The remaining violations for which you requested reconsideration are affirmed, and the violations for which you did not request reconsideration are affirmed. DHS will issue an Amended Correction Order. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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