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June 30, 2026 Sadie Broekemeier, Authorized Agent Recovering Hope Treatment Center 2031 Rowland Rd Mora, MN 55051-7119 License Number: 1080843 Report Numbers: 202508207, 202601940 CORRECTION ORDER Dear Sadie Broekemeier: On March 30 through April 2 and April 6, 2026, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility located at 2031 Rowland Road, Mora, MN, 55051-7119. As a result of this visit, DHS determined that you are in violation of the substance use disorder treatment statutes under Minnesota Statutes, chapter 245G. As a result, DHS is issuing this order which requires you to take the corrective action as described under each violation. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. The license holder did not meet the applicable requirements under Minnesota Statutes, section 254B.0507, subdivision 6for services provided to individuals with co-occurring mental health and substance use disorder problems. There was no documentation of: a. Diagnostic assessment completed within 10 days of admission (client files numbered 2 and 4); b. Multidisciplinary case review for: i. August, 2025 (client file numbered 6); and ii. January 2026 (client file numbered 3); and c. Co-occurring counseling staff receiving 8 hours of co-occurring disorder training annually for calendar year 2024 (personnel file numbered 6). Statute Violated: Minnesota Statute, section 245A.191. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services meet the applicable requirements to be eligible for enhanced funding. 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 services; disenrollment in the public payment program; or other administrative, civil, or criminal penalties provided by law. 2. Violation: The license holder did not meet requirements governing the personal electronic devices policy. The written policy only addressed the use of cell phones; however, it was program practice to allow other personal electronic devices, such as laptops and tablets, which the policy did not address. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that personal electronic device policies meet all applicable requirements. Within 60 days of receipt of this order, submit a personal electronic device policy that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing the description of treatment services. The description of treatment services did not: a. Describe how treatment coordination is offered; and b. Identify which groups and topics a guest speaker could provide. 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 description of treatment services meets all applicable requirements. Within 60 days of receipt of this order, submit a description of treatment services that meets all applicable requirements. 4. Violation: The license holder did not monitor the implementation of their own policies and procedures. The comprehensive assessment and treatment planning policies contained outdated statute references. Statute Violated: Minnesota Statute, sections 245A. 04, subdivision 14, paragraph (b), clause (3) and 245G.12, clause (1). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that policies and procedures are followed and meet all requirements. Within 60 days of receipt of this order, submit comprehensive assessment and treatment planning policies that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing program abuse prevention plans. The license holder’s governing body or the governing body’s delegated representative did not review the program abuse prevention plan for calendar year 2026. 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 maltreatment of vulnerable adult policies and procedures meet all applicable requirements. 6. Violation: The license holder did not meet requirements governing plans for transfer of clients and records upon closure. There was no documentation of a controlling individual of the program annually reviewing and signing the plan for calendar year 2026. 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: One personnel file reviewed for requirements governing staff qualifications for individuals with a temporary permit (personnel file numbered 6) did not meet requirements. There was no documentation of supervision provided to an individual with a temporary permit on a at least a weekly basis for the weeks beginning: a. August 12, 2024; and b. August 25, 2025. Statute Violated: Minnesota Statutes, section 245G.11, subdivision 11, paragraph (a). Corrective Action Required: Immediately, and on an ongoing basis, the license holder will ensure that staff qualifications for individuals with a temporary permit meet all applicable requirements. 8. Violation: Five of nine personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of the following annual training: a. Mandatory reporting as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E for the calendar years: i. 2024 (personnel files numbered 1 and 6); ii. 2025 (personnel files numbered 1, 2, 6, and 8); and iii. 2026 (personnel file numbered 4); b. Program Abuse Prevention Plan for calendar years: i. 2024 (personnel files numbered 1 and 6); ii. 2025 (personnel files numbered 1, 2, 6, and 8); and iii. 2026 (personnel file numbered 4); c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: i. 2024 (personnel files numbered 1 and 6); ii. 2025 (personnel files numbered 1, 2, 6, and 8); and iii. 2026 (personnel file numbered 4); and d. HIV minimum standards for calendar years: i. 2024 (personnel files numbered 1 and 6); ii. 2025 (personnel files numbered 1, 6, and 8); and iii. 2026 (personnel file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 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 annual trainings meet all applicable requirements. 9. Violation: Nine of ten personnel files reviewed for requirements governing personnel file contents did not meet requirements. The personnel file did not contain: a. A completed application for employment signed by the staff member (personnel file numbered 1); and b. A written annual review for calendar year: i. 2024 (personnel files numbered 2, 6, and 9); ii. 2025 (personnel file numbered 6, 8, and 9); and iii. 2026 (personnel file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clause (1). Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure that personnel file contents meet all applicable requirements. Client Files 10. Violation: Two of ten client files reviewed for requirements governing initial service plans (ISP) did not meet requirements. The ISP: a. Was not completed within 24 hours of the day of service initiation (client file numbered 9); and b. Did not address immediate safety concerns (client file numbered 1). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation meets all applicable requirements. 11. Violation: Five of five client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. There was no documentation of the following: a. An individualized assessment of the person’s susceptibility to abuse by other individuals (client files numbered 1, 2, 5, 6, and 10); b. An assessment of the person’s risk of abusing other vulnerable adults (client files numbered 1, 2, 5, 6, and 10); and c. Measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose when the facility knows that the vulnerable adult has committed a violent crime or an act of physical aggression towards others (client file numbered 10). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b), 245G.04, subdivision 2, paragraph (b), and 245G.21, subdivision 6. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. Within 60 days of receipt of this order, submit one IAPP that meets all applicable requirements. 12. Violation: Four of ten client files reviewed for requirements governing comprehensive assessments did not meet requirements. The comprehensive assessment did not include documentation of: a. The status of the client’s basic needs (client files numbered 5 and 6); b. The client’s description of the client’s symptoms (client file numbered 10); c. The client’s history of mental health treatment (client file numbered 10); d. Substance use history (client file numbered 10) including: i. Amounts of substances; and ii. Frequency and duration; e. The client’s relationship with family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client file numbered 10); f. Important developmental incidents in the client’s life (client files numbered 3, 5, 6, and 10); g. The client’s health history (client file numbered 10); and h. The client’s family health history (client files numbered 5, 6, and 10). 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. 13. Violation: Ten of ten client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. The ITP: a. Was not completed by the end of the tenth day on which a treatment session has been provided from the day of service initiation (client files numbered 7 and 8); b. Did not include how the family or others will be involved in the client's treatment (client file numbered 10); c. Did not document a treatment strategy (client files numbered 1 through 10); and d. Did not document the ASAM level of care (client files numbered 2, 6, and 10). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (3) and (4). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order, submit one individual treatment plan that meets all requirements. 14. Violation: Five of ten client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Documentation of treatment services did not include: i. Client response for: 1. July 15, 16, 18, and August 11, 2025 (client file numbered 6); 2. August 25, 2025 (client file numbered 10); 3. January 1, 3, 6 through 8, and 12 through 14, 2026 (client file numbered 5); 4. January 27 through 29, 31, and March 2 and 4 through 6, 2026 (client file numbered 2); and 5. February 2 through 6, March 9, and 11, 2026 (client file numbered 1); ii. Type of service for August 13, 2025 (client file numbered 6); iii. Signature of the staff person making the entry for: 1. July 14 and August 13, 2025 (client file numbered 6); and 2. August 20, 2025 (client file numbered 10); and iv. Job title of the staff person making the entry for February 5, 2026 (client file numbered 1); b. There was no documentation of medical and other appointments attended on the day that it occurred for events on: i. August 4, 2025 (client file numbered 6); ii. January 22 and February 2, 2026 (client file numbered 5); and iii. February 3, 2026 (client file numbered 1); and c. There was no documentation of concerns related to attendance for treatment services, including the reason for any client absence from the treatment service on the day that it occurred for August 18, 20, and 27, 2025 (client file numbered 10). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraphs (b), clauses (1) and (3) and (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that client record documentation meets all applicable requirements. 15. Violation: One of three client files (client file numbered 8) reviewed for requirements governing the provision of telehealth did not meet requirements. Documentation of treatment services provided by telehealth did not include the mode of transmission used to deliver the service through telehealth on December 22, 2025, and February 2, 2026. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c), clause (2). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that telehealth treatment service documentation meets all applicable requirements. 16. Violation: Seven of ten client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. The treatment plan review did not document: i. The span of time covered by the review on: 1. July 16, 2025 and September 10, 2025 (client file numbered 6); 2. December 31, 2025, and March 25, 2026 (client file numbered 3); 3. January 9 and February 19, 2026 (client file numbered 5); 4. January 22 and 28, February 19, and March 25, 2026 (client file numbered 2); 5. February 10 and 19, 2026 (client file numbered 1); and 6. March 12 and 20, 2026 (client file numbered 7); ii. Whether the identified methods continue to be effective on: 1. July 16 and September 10, 2025 (client file numbered 6); 2. December 18, January 8, February 2 and 11, 2026 (client file numbered 8); 3. December 31, 2025 and March 25, 2026 (client file numbered 3); 4. January 22, 28, February 19, and March 25, 2026 (client file numbered 2); and 5. February 10 and 19, 2026 (client file numbered 1); iii. Participation of others involved in the individual’s treatment planning on: 1. December 31, 2025, and March 25, 2026 (client file numbered 3); and 2. January 9 and February 19, 2026 (client file numbered 5); b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1. The treatment plan review was due on November 29, 2025, however, was not completed until December 4, 2025 (client file numbered 9). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 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. 17. Violation: Four of five client files reviewed for requirements governing service discharge summaries did not meet requirements in the following ways: a. The discharge summary was not completed within five days of service termination (client files numbered 6, 8, and 10); and b. Documentation did not include alternatives considered or attempted prior to discharging the client (client files numbered 10 and 11). Statute Violated: Minnesota Statutes, sections 245G.06, subdivision 4 and 245G.14, subdivision 3, clause (3). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements. 18. Violation: Two of three client files reviewed for requirements governing parental supervision of children did not meet requirements. There was no documentation of: a. The parent’s capacity to meet the health and safety needs of the child while on facility premises completed on or before the child’s initial physical presence at the facility (client file numbered 1); and b. A parental supervision plan (client files numbered 1 and 5). Statute Violated: Minnesota Statutes, section 245A.1443, subdivision 3, paragraphs (a) and (c). Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that parental supervision plans 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 Jennifer.White@state.mn.us Commissioner, Department of Human Services ATTN: Jennifer White 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) 431-6282 or at Jennifer.White@state.mn.us. Sincerely,
Jennifer White, MBA, LADC Licensor II Licensing Division Office of Inspector General
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