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June 18, 2026
Francene Lizette Young Rolstad, Authorized Agent Amherst H. Wilder Foundation 451 Lexington Parkway N St. Paul, MN 55104-4636 License Number: 802690 (MHC) 1083231 (245G)
AMENDED CORRECTION ORDER NOTICE: This Amended Correction Order supersedes a Correction Order issued February 25, 2026, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on March 18, 2026. This Amended Order reflects the final decision on the request for reconsideration issued on June 10, 2026. Dear Francene Lizette Young Rolstad, On December 1 through December 5, 2025, Department of Human Services (DHS) licensor(s) conducted a licensing and certification review at your facility, Amherst H. Wilder Foundation, located at 451 Lexington Parkway N, St. Paul, MN 55104. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance use disorder treatment under Minnesota Statutes, Chapter 245G and mental health clinics under Minnesota Statutes, Chapter 245I. 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 and certification rules and statutes, as described below. Throughout this order, the licensed programs will be referenced as follows: · Amherst H Wilder Foundation Community Mental Health Services– mental health clinic (MHC) · Amherst H Wilder Foundation- substance use disorder treatment (245G) · When citations are specific to both licensed and certified programs (ALL) Policies, Procedures and Practices 1. Violation: The license holder did not have the self-initiation criteria either posted or handed to the client (245G). Statute Violated: Minnesota Statute, section 245G.14, subdivision 1. Corrective Action Required: Correct immediately and maintain compliance. 2. Violation: The license holder did not notify the Commissioner of all mental health clinic locations (MHC). DHS licensing was not notified of the Etna Location East Clinic on 445 Elna Street Suite 62, St. Paul. Statutes Violated: Minnesota Statute, section 245I.20, subdivision 3, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. Within 14 days of receipt of this order, please submit a change of licensing information form that identifies all current satellites. 3. Violation: The license holder quality assurance and improvement plan (MHC) did not meet requirements. The quality assurance plan did not include the following: a. Obtaining and evaluating feedback about services from family, natural supports, referral sources and staff persons in calendar year 2024 and 2025; b. Measuring and evaluating client outcomes in calendar year 2024; and c. A review of client suicide deaths and suicide attempts annually in calendar year 2024 and 2025. Statute Violated: Minnesota Statute, section 245I.20, subdivision 9, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. Violation: A controlling individual of the program (ALL) did not annually review and sign the transfer of clients and records upon closure plan for calendar year 2024. Statute Violated: Minnesota Statute, section 245A.04, subdivision 13a, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. 4. Violation: The license holder’s policy and procedures related to suspected or alleged maltreatment for adults (245G) did not meet requirements. The maltreatment reporting policy did not include the following: a. Within 30 calendar days, an internal review is completed and that the corrective action is taken as necessary to protect the health and safety of vulnerable adults when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. b. The review must include an evaluation of whether: i. Related policies and procedures were followed; ii. The policies and procedures were adequate; iii. There is a need for additional staff training; iv. The reported event is similar to past events with the vulnerable adults or the services involved; and v. There is a need for any corrective action to be taken by the license holder to protect the health and safety of vulnerable adults or children when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made; c. Based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct the current lapses and prevent future lapses in performance by individuals or the license holder, if any; d. The policy must identify the primary and secondary person or position who will ensure that, when required, internal reviews are completed; e. The secondary person shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and f. The LH must document and make internal reviews accessible to the commissioner upon the commissioner's request. The documentation provided to the commissioner by the license holder may consist of a completed checklist that verifies completion of each of the requirements of the review. Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order submit a maltreatment of a vulnerable adult policy that meets all requirements. 5. Violation: The license holder’s policy on maltreatment of minors (245G) did not meet requirements for an internal review according to section 142B.54, subdivision 1. Statute Violated: Minnesota Statute, section 245A.66, subdivision 1. Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a maltreatment of a minor policy that meets all requirements for an internal review. 6. Violation: The license holder’s client rights policy (ALL) did not meet requirements in the following ways: a. The written statement of the client’s rights and responsibilities (245G) did not identify all sections of 148F.165. The statement is missing the rights identified in 1485.165, subdivisions 3 to 9; b. The client rights policy (MHC) did not include the following components: i. Health care bill of rights in 144.651; ii. Freedom from discrimination based on age, race, color, creed, retaliation, national origin, gender, marital status, disability, sexual orientation, and status with regard to public assistance; iii. If the license holder restricts a client’s rights, mental health professional’s approval and reason for the restriction must be documented in the client file; and iv. Right to client’s funds and other property. Statute Violated: Minnesota Statute, section 245G.15, subdivision 1. Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a statement of client’s rights and responsibilities that meet all requirements. 7. Violation: The grievance policy (ALL) did not meet requirements. The grievance policy did not include the following required components: a. The policy had incorrect phone numbers for The Board of Behavior Health and Therapy and Department of Health Office of Health Facilities Complaint; and b. The policy did not list all applicable health-related licensing boards. Statute Violated: Minnesota Statute, sections 245G.12, subdivision 5, paragraph (a) and 245I.12, subdivision 5, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a revised grievance policy that meets all requirements. 8. Violation: The treatment services description (245G) did not meet requirements. The description did not include the following: a. Issues related to co-occurring disorders, including: i. Client education on symptoms of mental illness, the possibility of comorbidity, and the need for continued medication compliance while recovering from substance use disorder; ii. A group must address co-occurring disorders, as needed; iii. When treatment for mental health problems is indicated, the treatment must be integrated into the client's individual treatment plan; and b. Prenatal care according to the client’s needs. Statute Violated: Minnesota Statute, section 245G.07, subdivision 1. Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a revised treatment service description that meets all requirements. 9. Violation: The license holder’s practice did not include a description of each staff person’s position (ALL) that included the staff person’s responsibility and authority to execute the responsibilities. Statute Violated: Minnesota Statute, sections 245I.03, subdivision 8, clause (8) and 245G.13, subdivision 1. Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit job descriptions that meets all requirements. 10. Violation: The license holder’s policy reporting a death in the program (245G) did not meet requirements. The policy did not identify that the license holder shall notify the commissioner of the death within 24 hours of receiving knowledge of the death of an individual served by the program. Statute Violated: Minnesota Statute, section 245A.04, subdivision 16. Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit a reporting a death in the program policy that meets all requirements. Client Files · Client files 1 through 8 (MHC) · Client files 1, 2, 4 and 6 (MHC and 245G) 11. Violation: One of four client files reviewed (client file numbered 4) for orientation did not meet requirements (245G). No documentation for the following: a. Within 72 hours of admission, client received orientation to the HIV minimum standards; b. On the day of the service initiation, client received opioid education material; and c. Within 24 hours of the day of service initiation, a non-residential program must determine whether a client is a vulnerable adult as defined in section 626.5572, subdivision 21, paragraph (a), clause (4). Statute Violated: Minnesota Statutes, sections 245A.09, paragraph (b), 245A.65, subdivision 1a, paragraph (a), clause (1) and 245G.04, subdivisions 2 and 3 and 245G.09, subdivision 3, clause (1). Corrective Action Required: Correct immediately and maintain compliance. 12. Violation: One of three client files reviewed (client file numbered 4) for functional assessment did not meet requirements (MHC). No documentation of how mental health symptoms impacted the following areas: a. Substance use; b. Vocational and educational; c. Use of leisure time; d. Dental needs; e. Financial needs; and f. Transportation. Statute Violated: Minnesota Statutes, section 245I.10, subdivision 9. Corrective Action Required: Correct immediately and maintain compliance. Personnel Files · Personnel Files numbered 1 through 4 (245G) · Personnel Files numbered 5 through 7 (MHC) 13. Violation: Three of three personnel files reviewed for first date of direct contact did not meet requirements. License holder had no documentation of the first date of contact for staff person (personnel files numbered 1, 4 and 7). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245I.07, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. 14. Violation: One personnel file reviewed for treatment supervision plans did not meet requirements (personnel numbered 7) in the following ways: a. The treatment supervision plan was not developed within 30 days of the staff person’s first day of employment; and b. The scope of practice and a description of the treatment methods and modalities that the staff person may use to provide services to clients was generalized and not specific to the staff person. Statute Violated: Minnesota Statutes, section 245I.06, subdivision 2, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of receipt of this order, submit revised treatment supervision plan for personnel file numbered 7 that meets all requirements. 15. Violation: Four of four personnel file reviewed for requirements governing staff orientation training and development did not meet requirements. No documentation of the following: a. Orientation within 24 hours; i. Client confidentiality (personnel file numbered 3 and 4); ii. The specific activities and job functions for which the staff person is responsible (personnel file numbered 1 and 4); iii. Policies and procedures applicable to the staff person’s position (personnel file numbered 1 and 4); iv. Special needs of clients (personnel file numbered 1, 3 and 4); and a. Orientation prior to direct contact i. Minnesota Health records Act including client confidentiality, family engagement and client privacy (personnel file numbered 7); ii. Emergency procedures, including fire/weather, missing persons, behavioral emergencies, and medical emergencies(personnel file numbered 7); iii. The specific activities and job functions for which the staff person is responsible (personnel file numbered 7); iv. Professional boundaries (personnel file numbered 7); v. Special needs of clients (personnel file numbered 7); vi. And the maltreatment of minor reporting requirements and definitions in chapter 260E (personnel file numbered 1,3,4 and 7); and vii. The additional 30 hours of training for a behavioral health practitioner about mental illness, client recovery and resiliency, mental health de-escalation techniques, Co-occurring, psychotropic medications and medication side effects (personnel file numbered 7). b. Within 72 hours of employment the following trainings (personnel file numbered 1 and 3): i. HIV minimum standards ii. Mandated reporting requirement and definitions; iii. The license holder’s program abuse prevention plan; and iv. All internal policies and procedures related to the prevention and reporting of maltreatment and individuals receiving services; and c. Within 90 days of first providing direct contact training on trauma-informed care, and person-centered treatment planning (personnel file numbered 7). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.65, subdivision 3, and 245G.13, subdivisions 2, 3 and 7, and 245I.05, subdivision 3, paragraphs (a), (c) and (d). Corrective Action Required: Correct immediately and maintain compliance. 16. Violation: Five of five personnel files reviewed for requirements governing ongoing training did not meet requirements. Documentation did not demonstrate the staff person received annual training on the following required topics: a. Vulnerable adult maltreatment reporting and maltreatment of minor reporting requirements for (all) calendar year 2024 (personnel file numbered 2) and calendar year 2025 (personnel file numbered 2, 4 and 7); b. The license holder’s program abuse prevention plan (personnel files numbered 2 and 4); c. HIV minimum standards including (245G) (personnel files numbered 2): i. HIV basics; ii. HIV transmission and prevention; iii. substance use and HIV; iv. Opioid overdose prevention; v. Resources for support with HIV or SUD; and vi. Program policies and procedures for working with HIV-infected clients and referring clients to individual HIV counseling and services when needed; and d. Client rights and protections under section 245I.12 for calendar year 2024 (personnel file numbered 5,6 and 7); e. Minnesota Health Records Act, including family engagement under section Minnesota Statutes 144.294 (MHC): i. For calendar year 2024 (personnel files numbered 5 and 6); ii. For calendar year 2025 (personnel files numbered 7); and f. Emergency procedures, including fire and inclement weather, responding to a report of a missing person, behavioral emergencies, and medical emergencies (MHC): i. For calendar year 2024 (personnel files numbered 5 and 6); ii. For calendar year 2025 (personnel files numbered 7); and Statutes Violated: Minnesota Statutes, sections 245A.19, 245A.65, subdivision 3, 245G.13, subdivision 2, paragraphs (c) and (d), and 245I.05, subdivision 4, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. 17. Violation: Three of three personnel files reviewed for training documentation did not meet requirements (MHC). Documentation of training did not include the following required components: a. The name and credentials of the trainer (personnel files numbered 5, 6 and 7); and b. The license holder’s method of evaluating the trainee’s competency upon completion of training. Statute Violated: Minnesota Statutes, section 245I.05, subdivision 2, paragraph (a). Corrective Action Required: Correct immediately and maintain compliance. Within 30 days of the order, you must submit a training plan and/or tracking document that outlines the requirements in the above paragraphs (a) and (b). Final Agency Decision As stated above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated February 25, 2026. As such, the decision is not subject to appeal. 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 your licensor at 651-431-4585 or at maddy.moore@state.mn.us Sincerely, Maddy Moore, Senior Licensor Licensing Division Office of Inspector General
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