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July 9, 2026 Terri Senkow, Authorized Agent Metro Treatment of Minnesota LP 2500 Maitland Center Pkwy Ste 250 Maitland, FL 32751 License Number: 1036502 (245G)
Dear Terri Senkow: This matter arises from an Order of Conditional License, dated January 23, 2026, issued after a licensing review conducted on November 5 through 7 and 11, 2025. On February 10, 2026, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration of the Order of Conditional License. Additional information was received on February 17, 2026. You requested reconsideration of the following citations: 1, 2, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, and 29. You did not request reconsideration of the remaining citations, and those citations are therefore final and not included in the scope of this review. A. CONDITIONAL LICENSE DISPUTED, YOUR RECONSIDERATION REQUEST REGARDING STATUTORY CITATIONS AND LICENSING VIOLATIONS, AND DHS’ RESPONSE Citation 1: Minnesota Statutes, section 245G.07, subdivision 1, paragraph (b) Violation: The license holder did not provide treatment services to a client with consideration to the special needs of the client (client file numbered 2). The client received treatment services through telehealth and was assigned to a telehealth only counselor on October 21, 2025. However, documentation in the client record and client interview indicated this was not appropriate as follows: a. Group note from September 10, 2025, stated that this service was provided through telehealth, and the client was asked to leave the group due to not having a secure space to participate in the service from; b. Note dated October 21, 2025, stated that client did not want telehealth services as they do not have the technology to participate; and c. In an interview with a DHS Licensor on October 23, 2025, the client indicated that they did not want telehealth services and did not have the technology to participate. Request for reconsideration: You acknowledged that on September 10, 2025, the client was asked to leave a session when s/he got into a vehicle with another person, but you indicate the client was instructed to follow up with a primary counselor and did have a secure place to participate in the service. You also acknowledged that on October 21, 2025, the client requested to have an “in person counselor when available.” You stated the request was acknowledged and the client was scheduled to go in person that week to schedule a session with a counselor. You indicated documentation showed the client communicated a preference to complete sessions through telehealth while also stating they wanted to see an in-person counselor at the next scheduled visit. You provided supporting documentation. DHS’ response: The citation was issued because the client was assigned to a telehealth only counselor, but documentation in the client records and client interview indicated a telehealth only counselor was not appropriate given the client’s history of inappropriate use of telehealth. You acknowledged in the reconsideration request that the client was asked to leave a session on September 10, 2025, due to confidentiality concerns because the individual went into a vehicle with another driver during the session. You also acknowledged the client asked to have an in-person counselor when available, and the case note dated October 21, 2025, also indicated the client “does not have an email address, does not do much online,” and documentation available during the licensing review did not show any in-person counseling scheduled until November 4, 2025. Also, during a licensing visit on October 17, 2025, program staff indicated all clients were receiving telehealth services, and the client told licensors they were not able to connect to telehealth and wanted to have a counselor in-person. The statute requires that a treatment service provided to a client must be provided according to the individual treatment plan and must consider special needs of a client, and documentation indicates the client did choose to participate in telehealth services. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 2: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c) Violation: The license holder did not offer all treatment services in Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a), clauses (1) to (4),physically in-person to each client. Through staff interviews, it was identified there was no counseling staff physically present at the licensed location to provide treatment services from October 12 through 22, 2025. Request for reconsideration: You indicated in the reconsideration request that staff were present for in-person services from October 12 through October 22, 2025, and you provided supporting documentation. You also asserted the statute was incorrectly cited. You provided supporting documentation. DHS’ response: The statute requires that if the license holder provides treatment services by telehealth, the services mut be provided according to listed requirements, including that the license holder must maintain a licensed physical location in Minnesota where the license holder must offer all treatment services in subdivision 1a physically in-person to each client. On October 17, 2025, the program advised DHS in an email that there were no counselors on site as of October 13, 2025, and that other staff were on site to provide operational support. A follow-up email on October 20, 2025, confirmed that the license holder was unable to have counseling staff on site that day but that a counselor would be available starting on October 22, 2025. Although you provided case notes from October 8 through 17, 2025, the case notes do not document that treatment services were offered to clients but rather that staff were on site to support operations as indicated in the email from the program. The timecard dated October 13, 2025, does not indicate which staff worked or whether work was performed onsite. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 4: Minnesota Statutes, section 245G.22, subdivision 3 Violation: One of nine client files reviewed for requirements governing medication orders (client file numbered 11) did not meet requirements. A client-specific medication order was not received from a practitioner prior to the program dispensing medication used for the treatment of opioid use disorder. The client’s first dose was received on June 17, 2025. However, there was no medication order in the chart. Request for reconsideration: You indicated in the reconsideration request that the client received a guest dose on June 17, 2025, when they were admitted and started treatment the next day on June 18, 2025. The order for guest-dosing was completed on paper and not uploaded to the electronic system but has since been added to the paper chart. You provided supporting documentation. DHS’ response: Documentation showed the client had discharged from their previous outpatient treatment program on June 16, 2025, and planned to receive guest doses with the program from June 16 through 22, 2025. However, additional case notes from the client records show the program admitted the client to the program on June 17, 2025, and there was no medication order in the chart when the client’s first dose was received on that date. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 7: Minnesota Statutes, section 245G.22, subdivision 17, paragraph (e) Violation: The license holder did not meet requirements governing staff ratios. The program did not maintain documentation of the clients assigned to each counselor to demonstrate compliance with maintaining a ratio of one full-time equivalent alcohol and drug counselor for every 60 clients enrolled in the program. Request for reconsideration: You indicated in the reconsideration request that the program does maintain documentation of required staff ratios, submits weekly ratios to DHS, and has consistently adhered to self-disclosure requirements related to staffing ratios. You provided a summary of the monthly average counselor to client rations for 2025 and indicated the total monthly average ratio of full-time counselors to clients was 38 clients per counselor. You also submitted a “patient list” to document the counselor to which each patient is assigned. DHS’ response: Documentation to demonstrate compliance with ratio requirements was requested during a meeting on November 12, 2025, to discuss the licensing review. The program indicated the documentation would be sent to DHS by the end of the day on November 13, 2025, but no documentation was received. The weekly reports mentioned in the reconsideration request are submitted to the Behavioral Health Administration, and the reports identify the program’s capacity and current census rather than verifying that staffing ratios are present. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 8: Minnesota Statutes, section 245G.22, subdivision 1, paragraph (a), clause 1 Violation: The license holder did not comply with the requirements of the Code of Federal Regulations, title 42, part 8. Through staff interview and client record documentation review, it was identified that the program was closed on more than one weekend day, both Saturdays and Sundays starting October 18, 2025. Client record documentation indicates this was due to staff shortages. Request for reconsideration: You indicated in the reconsideration request that federal requirements do not govern how many days a program can be closed, and you submitted documentation regarding an exception request and approval. DHS’ response: The documentation provided is used to request exceptions to the limitation on take-home doses based on the client’s time in the program, but the citation was issued because the clinic was closed on more than one weekend day. Under Minnesota Statutes, section 245G.22, subdivision 6, to limit the potential for diversion of medication used for the treatment of opioid use disorder to the illicit market, medication dispensed to a client for unsupervised use shall be subject to the requirements of the subdivision. Any client in an opioid treatment program may receive their individualized take-home doses as ordered for days that the clinic is closed for business, on one weekend day (e.g. Sunday) and state and federal holidays, no matter their length of time in treatment, as allowed under Code of Federal Regulations, title 42, part 8.12 (i)(1). The program was informed in an email from DHS Licensing dated June 26, 2025, that the program is not allowed to be closed both weekend days. There is sufficient evidence to support the violation, and it is affirmed. Citation 9: Minnesota Statutes, sections 245G.05 and 245G.22, subdivision 15, paragraph (c) Violation: Five of six client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements as follows: a. The CA was not completed within 21 days from the day of service initiation and there was no documentation of the person-centered reason for the delay and the planned completion date as follows: a. The CA was due on July 08, 2025; however, there was no CA found in the client chart (client file numbered 11); and b. The CA was due on June 25, 2025; however, it was completed late on July 15, 2025 (client file numbered 1); and b. The CA did not contain the following: a. The status of the client’s basic needs (client files numbered 1 through 3 and 5); b. The client’s employment status (client file numbered 2); c. The client’s history of mental health and substance use disorder treatment (client file numbered 1); d. Important development incidents in the client’s life (client files numbered 1 through 3, 5, and 10); e. Potential brain injuries (client files numbered 1 through 3, 5, and 10); f. The client’s exposure to alcohol and drug usage and treatment (client file numbered 5); g. The client’s physical health history (client file numbered 1); h. The client’s family health history (client file numbered 5); i. The determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (client files numbered 1 through 3, 5, and 10); and j. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 through 3, 5, and 10). Request for reconsideration: With regard to paragraph a, items a and b, you indicated the CA was completed late on July 30, 2025, due to unsuccessful efforts to reach client 1, and you indicated the CA regarding client 11 was unable to be completed due to client 11’s life circumstances, including incarceration and other treatment. With regard to paragraph b, items a through d, f, g, h, I and j, you indicated client files contained documentation of the required items. You submitted supporting documentation. DHS’ response: With regard to paragraph a, item a, the client was admitted on June 4, 2025, and the comprehensive assessment was due on June 25, 2025. The progress note dated June 25, 2025, documented that a new counselor called the client to indicate they would reach out in the future to schedule an appointment to complete “any incomplete documentation resulting from the previous counselor’s departure,” and a progress note from June 30, 2025, is the first documentation in the client record of an attempt to schedule an appointment with the client. Although the program provided a reason for the delay in the note dated June 25, 2025, the reason related to program staffing rather than a client-centered circumstance, and there was no documented planned completion date. Regarding paragraph a, item b, the client was admitted on June 17, 2025, and the comprehensive assessment was due on July 8, 2025. There was no documentation in the file to indicate the client’s incarceration was the reason for the delay and no documentation of the planned completion date. With regard to paragraph b, items c, f, and g, upon further review of the file and the information submitted, it is appropriate to rescind those items. Regarding paragraph b, item a, for client 1, the comprehensive assessment does discuss the client’s stable housing, but other than shelter, it is unclear regarding the status of the client’s basic needs. Although the client’s salary is specified, the comprehensive assessment provides conflicting information about whether the work was stable, and the status of other basic needs was unclear. For client 2, although the comprehensive assessment indicates the client has financial strain, it does not indicate any potential impact on the client’s status of basic needs. Although you indicated other documentation indicates the client’s need for financial assistance, no documentation was submitted, and the information is required to be in the comprehensive assessment. For client 3, although the comprehensive assessment indicates the client has financial strain, it does not provide information about any potential impact on the client’s basic needs. For client 5, although the comprehensive assessment indicates the client does not have income and is “staying at other people’s houses,” there is no information about how that circumstance impacts the client’s ability to access basic needs. Regarding paragraph b, item b, client 2’s employment status information was not contained in the comprehensive assessment, and the documentation provided with the reconsideration request does not provide information about the client’s employment status. Regarding paragraph b, item d, information regarding development incidents was not contained in the comprehensive assessment for each listed client, and information provided with the reconsideration request did not address important developments in the client’s life. For client 1, the information provided relates to legal involvement and family history of substance use, and for client 2, the information provided relates to hospitalizations and history of mental health symptoms. For client 3, the information provided relates to legal involvement and goals/motivation for change, and for client 5, the information provided relates to impacts of substance use, housing status, goals/motivation for change, legal history, and family history of substance use. For client 10, the information provided relates to employment and housing due to substance use, legal history, and motivation for change. Regarding paragraph b, item e, you did not request reconsideration. Regarding paragraph b, item h, although the comprehensive assessment indicates there is family substance use, it does not provide further information regarding the client’s family health history. Regarding paragraph b, item i, documentation showed the screening tool used for the listed clients was PHQ-9 rather than the GAIN-SS. Under Minnesota Statutes, section 245.4863, individuals who perform substance use disorder assessments are required to screen clients for co-occurring mental health disorders, and screening tools must be approved by the commissioner. The approved tool is the GAIN-SS, and you acknowledged in the reconsideration request that the screening tool used by the program “might not be ‘approved by the commissioner.’” Regarding paragraph b, item j, Minnesota Statutes, section 245G.05, subdivision 3, paragraph 4, requires the comprehensive assessment to include a recommendation for the American Society of Addiction Medicine (ASAM) level of care identified in Minnesota Statutes, section 254B.19, subdivision 1. For client 1, the recommendation was to “dose methadone as directed and attend 1-1 sessions with this counselor weekly,” and for client 2, the recommendation was to enroll in medication assisted treatment (MAT) services. For client 3, the recommendation was outpatient treatment (OTP) services, and for client 5, the recommendation was to enroll in MAT services. None of those recommendations were consistent with Minnesota Statutes, section 254B.19, subdivision 1 as required. As a result, there is sufficient evidence to support the violation, and it is affirmed except for paragraph b, items c, f, and g, which are rescinded. Citation 10: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (1), (3), (4), and (6) Violation: 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 within 21 days from the day of service initiation as follows: a. The ITP was due on July 07, 2025; however, there was no ITP found in the client record (client file numbered 7); and b. The ITP was due on June 25, 2025; however, it was completed late on July 30, 2025 (client file numbered 1); b. The ITP was not based on the client’s’ comprehensive assessment (client files numbered 1, 3, and 11); c. The ITP was not updated based on new information gathered about the client’s condition and level of participation (client file numbered 11); and d. The individual treatment plan did not contain the following: a. A treatment strategy (client files numbered 1, 8, and 11); b. The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 through 5 and 8 through 11); and c. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 4). Request for reconsideration: You acknowledged in the reconsideration request that the ITP for client 1 was not completed until July 30, 2025, and client 7 had an ITP in their file effective March 17, 2022. You indicated the ITPs for clients 1, 3, and 11 were based on the comprehensive assessment, and you indicated the ITP for client 11, which was completed on June 20, 2025, contained updates regarding incarceration on June 21, 2025, and July 1, 2025. You indicated files for clients 1, 8, and 11 did contain treatment strategies, and you indicated client files 1 through 5 and 8 through 11 did contain ASAM levels of care. You acknowledged resources to refer the client to when the client’s needs will be addressed concurrently by another provider may have been missing from client 4’s file. You submitted supporting documentation. DHS’ response: You did not dispute paragraph a. With regard to paragraph b, for client 1, the treatment plan was completed on July 15, 2025, which was before the comprehensive assessment and therefore indicates the treatment plan was not based on the comprehensive assessment. For client 3, the treatment plan dated June 16, 2025, included a housing concern not included in the comprehensive assessment when it indicated a goal to maintain housing and “follow recommendations,” and the comprehensive assessment noted that the “the patient reports that [s/he] lives alone in a stable environment” and assigned a severity rating of 0 to the Recovery Environment. For client 11, there was no comprehensive assessment for the client, which therefore indicated the treatment plan was not based on the comprehensive assessment. Regarding paragraph c, client 11’s individual treatment plan was completed on Juine 20, 2025, and a progress note dated June 21, 2025, indicated the client was removed from sober housing and placed back in jail. However, the treatment plan completed on June 28, 2025, indicated no treatment plan updates were needed, but the client was not able to attend treatment services at the clinic as indicated in the initial treatment plan due to incarceration. With regard to paragraph d, item a, the reference to client 8 is rescinded. For clients 1 and 11, the treatment plan completed by the program identifies methods that are actions the client will take and does not describe the strategies the program will implement to support the client in achieving the goals. With regard to paragraph d, item b, the ASAM level of care was not documented in any of the listed client files, and no documentation was provided. There is sufficient evidence to support the violation, and it is affirmed, with the exception of paragraph d, item a, only as it relates to client 8, which is rescinded. Citation 11: Minnesota Statutes, section 245G.06, subdivisions 3 and 3a, paragraph (f). Violation: Nine of nine client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. There was no documentation of the following: a. The span of time covered by the review for notes signed on the following dates: 1. August 12, 22, 27, September 05, and October 07, 2025 (client file numbered 1); 2. January 09, 17, February 06, and August 30, 2025 (client file numbered 2); 3. June 28, 30, July 07, 18, August 05, 19, and October 19, 2025 (client file numbered 3); 4. May 23, 2025 (client file numbered 4); 5. June 06, July 03 and 11, 2025 (client file numbered 5); 6. March 25 and August 30, 2025 (client file numbered 8); 7. February 12, 2025 (client file numbered 9); and 8. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); b. Client goals addressed since the last treatment plan review for notes signed on the following dates: 1. January 17, 2025 (client file numbered 2); 2. June 28, 2025 (client file numbered 3); 3. June 06, 2025 (client file numbered 5); and 4. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); c. Toxicology results for alcohol and substance use on the following dates: 1. September 05, 2025 (client file numbered 1); 2. June 30, 2025 (client file numbered 3); 3. May 23, 2025 (client file numbered 4); and 4. June 06, 2025 (client file numbered 5); d. Participation of others involved in the individual’s treatment planning on June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); and e. Staff recommendations for changes in the methods identified in the treatment plan on: 1. August 12, 22, 27, September 05, and October 07, 2025 (client file numbered 1); and 2. June 28, July 08, 26, August 02, 09, 22, 29, and September 05, 2025 (client file numbered 11); b. Treatment plan reviews were not completed weekly for the first ten weeks following the completion of the treatment plan. Treatment plan reviews were missing for the weeks starting: a. July 16 and August 02, 2025 (client file numbered 1); b. March 08 and 15, 2025 (client file numbered 2); c. July 21, 28, August 11 and 25, 2025 (client file numbered 3); d. June 09, 16, and 23, 2025 (client file numbered 5); e. June 27, July 10, 17, 24, 31, August 07 and 14, 2025 (client file numbered 10); and f. June 30, 2025 (client file numbered 11); and c. Treatment plan reviews were not completed monthly thereafter. Treatment plan reviews were missing for the following months: a. May through October 2025 (client file numbered 2); b. September 2025 (client file numbered 3); c. January, March, April, June, July, September, and October 2025 (client file numbered 4); d. April through July, September, and October 2025 (client file numbered 8); e. March through October 2025 (client file numbered 9); and f. October 2025 (client file numbered 10). Request for reconsideration: With regard to paragraph a, item a, you acknowledged the treatment plan reviews do not include the span of time covered by the review, but you indicated that although the reviews do not document the span of time covered, the reviews are largely being done timely in substantial compliance with the statute. With regard to paragraph a, items b, c, d, and e, you expressed disagreement with the violations and provided information about circumstances related to each client. You submitted supporting documentation. DHS’ response: Regarding paragraph a, item a, you did not challenge the violation. Regarding paragraph a, item b, as to clients 2 and 5, the treatment plan review includes a question about progress toward the client’s goals, and for each of the goals the response was “Pt was absent on this date; not discussed.” The client is not required to be present for the treatment plan review. For client 5, the referenced date of the note should be changed from June 6, 2025, to June 5, 2025. For client 3, the response to the question about progress toward the client’s goals was, “No new goals were established or worked on due to patient not meeting this counselor yet” for each of the goals. The client’s chart review indicated there were no concerns with methadone dosing attendance and that the client had a goal to maintain attendance, and the counselor would have been able to determine the client’s progress by reviewing the client chart. For client 11, the response to the question about progress toward the client’s goals was, “No new goals were established or worked on due to not meeting this counselor yet…” for each of the goals. The response also indicated the client was either in jail or in residential treatment, but progress toward goals such as attending weekly sessions with a counselor could have been assessed without the client being present. Also, client progress notes indicated treatment coordination with the jail case worker and residential treatment had occurred and included updates on the client’s status. Regarding paragraph a, item c, as to client 1, the commissioner has determined it is appropriate to rescind the violation. As to client 3, although the treatment plan review indicates the client had one drug screen completed since the last treatment plan review, there was no documentation of the results of that drug screen. As to client 4, although the treatment plan review indicates the client had two drug screens completed since the last treatment plan review, there was no documentation of the results of those drug screens. As to client 5, although a case note dated May 29, 2025, indicates a client completed a drug screen, the treatment plan review indicates no toxicology screen had been done. Regarding paragraph a, item d, although client progress notes indicate treatment coordination had occurred with the jail case worker and residential treatment with updates on the client’s status, the treatment plan reviews do not document the participation of others involved. Regarding paragraph a, item e, with regard to client 1, although the treatment plan reviews indicate that updates to the treatment plans are needed, there is no additional documentation of staff recommendation for changes. For client 11, the treatment plan reviews beginning July 26, 2025, indicate that updates to the treatment plans are needed, but there is no additional documentation of staff recommendation for changes. Regarding paragraph b, as to client 1, the treatment plan was completed on July 15, 2025, and the first documented treatment plan review was completed on August 12, 2025. As to clients 2, 3, 5, and 11, although the clients may have been unable to attend appointments to complete the treatment plan review, the missing treatment plan reviews are undisputed, and clients are not required to participate in the treatment plan review. There was no information submitted to challenge the violation related to client 10. Regarding paragraph c, the commissioner has determined it is appropriate to rescind the violation. As a result, there is sufficient evidence to support the violation, and it is affirmed, with the exception of paragraph a, item c, as it relates to client 1, and paragraph c, which are rescinded. Citation 12: Minnesota Statutes, sections 245G.06, subdivision 4, paragraphs (a) and (b), clauses (3) and (6) Violation: Four of four client files reviewed for requirements governing services discharge summaries did not meet requirements as follows: a. The services discharge summary was not completed within five days of the client’s service termination. There was no services discharge summary in the chart (client files numbered 6 and 7); and b. There was no documentation of the following: a. A risk rating for each of the ASAM six dimensions (client files numbered 5 and 12); and b. Continuing care recommendations (client file numbered 5). Request for reconsideration: You indicated in the reconsideration request that the files contained the required information, and you submitted supporting documentation. DHS’ response: With regard to paragraph a, there were no discharge summaries in the chart for client 6 or client 7 at the time of the licensing review. You submitted screenshots with the request for reconsideration, but it is unclear to which client they relate, and they are not signed documents. Regarding paragraph a, item a, for client 5, the discharge summary does not have a risk rating associated with dimensions 2 and 3. Also, although there was not an assessed need in the comprehensive assessment for those two dimensions, documentation shows an incomplete option that says “(Choose)” rather than correctly reflecting a risk rating of 0. For client 12, the discharge summary does not reflect any risk rating associated with Dimension 2 and instead shows the incomplete option that says “(Choose).” Regarding paragraph b, although the discharge summary contains recommendations, they do not consistently address the identified needs from the discharge summary. The recommendations include a mental health referral, but the discharge summary indicates no concerns in that area. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 13: Minnesota Statutes, section 245G.22, subdivision 15, paragraph (a) Violation: Six of eight client files reviewed for requirements governing nonmedication treatment services did not meet requirements as follows: a. There was no documentation that the client was offered at least weekly individual or group treatment services for the first ten weeks following the day of service initiation for the following weeks: a. June 08, July 02, 23, and August 06, 2025 (client file numbered 1); b. July 21, 28, August 04, 11, 18, and 25, 2025 (client file numbered 3); c. June 02, 09, 16, and 23, 2025 (client file numbered 5); d. June 23, July 7, 17, 21, and 28, 2025 (client file numbered 10); and e. June 30 and July 21, 2025 (client file numbered 11); and b. There was no documentation of treatment services being offered monthly thereafter: a. June and July 2025 (client file numbered 2); and b. September 2025 (client file numbered 10). Request for reconsideration: You indicated in the reconsideration request that clients were offered treatment services as required. You provided supporting documentation. DHS’ response: With regard to paragraph a, the screenshots submitted show services provided by the license holder but do not indicate client names, and dates are not consistent with progress notes in client charts. Regarding client 1, the client was admitted on June 4, 2025. There is no documentation in the chart of engagement with the counselor until June 25, 2026, and there is no documentation of group or individual counseling being offered to the client for the weeks noted in the violation. Regarding client 3, the client was admitted on June 16, 2025, and there is no documentation in the progress notes for the weeks identified in the violation. Information you provided identified engagement that was not counseling, including drug screens, scheduling appointment, and treatment plan reviews. Regarding client 5, the client was admitted on May 21, 2025, and there is no documentation in the progress notes for the weeks specified in the violation. A progress note indicates the client was admitted on May 21, 2025, but was not seen for a weekly session until June 5, 2025. For client 10, the client was admitted on June 11, 2025, and there is no documentation in progress notes for the weeks specified in the violation. For client 11, the client was incarcerated during the week of June 30, 2025, and was in residential treatment the week of July 21, 2025. However, there is no documentation in the client chart of a reason for not offering counseling services during those times. With regard to paragraph b as to client 2, although you indicated there is documentation of individual counseling provided on June 5, 2025, and a progress note titled “Patient Engagement” shows eight minutes of services, the note does not indicate counseling services were provided and instead indicated the client was encouraged to attend therapy sessions. Regarding client 10, there is no documentation in the client record indicating treatment services were offered during the time specified and no supporting documentation was provided. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 14: Minnesota Statutes, section 245G.22, subdivision 6, paragraphs (b) and (c) Violation: Two of seven client files reviewed for requirements governing the criteria for unsupervised medication use did not meet requirements as follows: a. There was no documentation of a practitioner review of the criteria in the Code of Federal Regulations, title 42, part 8.12 (i)(2) when the number of take-home doses were increased on March 20, April 23, and October 23, 2025 (client file numbered 4); and b. Documentation of the practitioner review of the criteria in the Code of Federal Regulations, title 42, part 8.12 (i)(2) was completed on August 21, 2025; however, the increase in take-home doses occurred on August 14, 2025. Request for reconsideration: You indicated in the reconsideration request that notes in the client’s record reflect that increased dosages were reviewed and approved by a qualified practitioner. You provided supporting documentation. DHS’ response: There was no documentation found in the client record to support the decision to increase take-home doses from the practitioner. Paragraph b is mistakenly missing the identified client and is amended to reflect that it refers to client numbered 2. The notes provided for client 4 are nursing notes that indicate the take-home does increase was approved, but the notes do not include the basis of the determination. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 15: Minnesota Statutes, section 245C.07, paragraph (f) Violation: One of five personnel files reviewed for requirements governing background studies (personnel file numbered 6) did not meet requirements. Staff person 6 (SP6) began a position allowing direct contact with persons served by the program on October 17, 2025. A background study was submitted under license number 830320; however, SP6 was also working under license number 1036502. The license holder did affiliate SP6 to all required rosters. Request for reconsideration: You acknowledged in the reconsideration request that SP6 did not have a background study conducted for license number 1036502, and you indicated the program believed the study was transferrable under Minnesota Statutes, section 245C.07(f)(1) and (2). DHS’ response: Minnesota Statutes, section 245C.07, paragraph (f), requires that an entity’s active roster must be the system used to document when a background study subject is affiliated with multiple entities, and the program did not affiliate SP6 to all required rosters. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 16: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.242, subdivision 2, paragraph (a), 245A.65, subdivision 3, and 245G.13, subdivisions 1, clause (7), and 2, paragraphs (d) and (e) Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of the following orientation: a. Within 24 working hours of starting: a. Staff members specific job responsibilities (personnel file numbered 5); b. Policies and procedures (personnel files numbered 3 and 5); c. Client confidentiality (personnel files numbered 3 and 5); and d. Client needs (personnel files numbered 3 and 5); b. Within 72 hours of employment to HIV minimum standards (personnel files numbered 3 and 5); c. Within 72 hours of first providing direct contact services (client files numbered 3 and 5): a. Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; b. The program abuse prevention plan; and c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. Before direct contact (personnel files numbered 3 and 5); a. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E; b. Training in the specific mode of administration of emergency overdose treatment used at the program; and c. Drug and alcohol policy. Request for reconsideration: You indicated in the reconsideration request that the program had the required documentation regarding staff person 3 for all listed violations, and you also indicated the program had required documentation regarding paragraph d, item c. You submitted supporting documentation. DHS’ response: You did not challenge paragraph a, item a, and you did not challenge items b through d as they relate to staff person 5. Regarding staff person 3, documentation of the orientation requirements was not included in the initial documentation received with the personnel file. During a phone call with the program on November 7, 2025, a DHS licensor requested the information be provided by November 10, 2025, and the information was not received. With regard to paragraph d, item c, for staff person 5, no date of direct contact was provided by the program, and it is therefore unclear whether the item was completed on time. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 17: Minnesota Statutes, Minnesota Statutes, sections 245A.19, paragraph (b), 245G.13, subdivision 2, paragraphs (c) and (d) Violation: Two of two personnel files reviewed for requirements governing annual trainings did not meet requirements. There was no documentation of the following: a. Mandatory reporting requirements and definitions as specified in Minnesota Statutes, sections 626.557 and 626.5572 for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); b. Program abuse prevention plan for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); c. Policies for obtaining a release of client information for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 2 and 4); d. Mandatory reporting requirements as specified in Minnesota Statutes, chapter 260E for calendar year 2025 (personnel file numbered 4); and e. HIV minimum standards for calendar years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel file numbered 2 and 4). Request for reconsideration: You indicated in the reconsideration request that the program had the required training documentation, and you submitted supporting documentation. DHS’ response: Regarding the violations cited in paragraphs a through d, the annual training requirements were not included in the documents received during the licensing review. A DHS licensor requested the information during a phone call with the program on November 7, 2025, and the information was not received by the requested date of November 10, 2025. With regard to paragraph e, although information was provided regarding the content of the HIV trainings, nothing specific was received regarding staff person 2. It is appropriate to rescind it b only as to staff person 4. As a result, there is sufficient evidence to support the violation, and it is affirmed, with the exception of paragraph e, item b, only as to staff person 4, which is rescinded. Citation 19: Minnesota Statutes, section 245G.22, subdivision 18, clause (5) Violation: The license holder did not meet requirements governing quality improvement plans. The quality improvement plan for calendar year 2024 did not include a goal concerning oversight and monitoring of the premises around and near the exterior of the program to reduce the possibility of medication used for the treatment of opioid use disorder being inappropriately used by a client, including but not limited to the sale or transfer of the medication to others. Request for reconsideration: You indicated in the reconsideration request that the program employes exterior camera surveillance twenty-four hours per day to monitor the safety of its exterior building and parking lot, and you provided supporting documentation. You acknowledged the surveillance is not specifically cross-referenced in the 2024 Annual Performance Improvement Plan. DHS’ response: The documentation provided with the reconsideration request related to a prior year, and the documentation was not provided during the licensing review. Also, DHS held a virtual meeting with program on November 12, 2025, and discussed the citation, but the program did not follow-up with additional documentation regarding the requirement. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 20: Minnesota Statues, sections 245G.04, subdivision 3, 245A.65, subdivision 3, 245G.09, subdivision 3, paragraph (a), clause (1), and 245G.15, subdivision 3, paragraph (b) Violation: Six of six client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of the following orientation being completed: a. Personal electronic devices (client files numbered 5); b. Opioid education material approved by the commissioner on the day of service initiation (client files numbered 1 through 3, 5, and 10); and c. Within 24 hours admissions (client file numbered 11): a. Internal and external vulnerable adult maltreatment reporting policies within 24 hours of admission; and b. Program abuse prevention plan. Request for reconsideration: You indicated in the reconsideration request that the program met requirements, and you submitted supporting documentation. DHS’ response: With regard to paragraph a, you provided a screenshot of the Patient Handbook Acknowledgement Assessment. However, the personal electronic device policy included in the program’s Patient Handbook only identifies cell phone usage and is not consistent with the personal electronic device policy in the program’s policy manual, which had more specific details on other personal electronic devices and when electronic devices may be used at the program. Regarding paragraph b, although the program provided opioid education, the education provided through the Patient Handbook is not the commissioner approved education as required. With regard to paragraph c, there was no documentation of the required orientation in the client’s file. Documentation provided is a release of information allowing a report to be made, but no documentation of the program’s internal and external vulnerable adult reporting policies or program abuse prevention plan was provided. There is sufficient information to support the violation, and it is affirmed. Citation 22: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c) Violation: Five of eight client files reviewed for requirements governing documentation of treatment services did not meet requirements, as follows: a. There was no documentation of client response to the treatment service on the following dates: a. January 09 and April 03, 2025 (client file numbered 2); b. July 07, 18, and October 09, 2025 (client file numbered 3); c. March 25 and August 30, 2025 (client file numbered 8); and d. February 12, 2025 (client file numbered 9); b. An entry in the client record was not accurate. The treatment plan review dated June 30, 2025, indicated a treatment goal in Dimension 3; however, this was not reflected in the individual treatment plan (client file numbered 3); and c. An entry in the client record dated July 16, 2025, was not signed (client file numbered 4). Request for reconsideration: You indicated in the reconsideration request that the client files contained the required documentation, and you provided supporting documentation. DHS’ response: Regarding paragraph a, there was no documentation of client response to the treatment service on the dates listed in the violation. The program’s practice was to combine treatment plan review documentation with the documentation of the individual counseling treatment service. For the note dated January 9, 2025, regarding client 2, the note dated July 7, 2025, for client 3, and the note dated January 9, 2025, for client 8, there is no documentation of the client’s response to the individual counseling session that occurred on that date. The items listed in the reconsideration request are progress toward the goals worked on during the treatment plan review period rather than the client’s response to individual counseling. It is appropriate to rescind the following as to paragraph a: item a, only as to the April 3, 2025, date; item b, only as to the July 18, 2025, and October 9, 2025, dates; item c only as to the August 20, 3035 date, and item d. Regarding paragraph b, although the treatment plan review dated June 30, 2025, documents progress toward a goal in Dimension 3, the individual treatment plan dated June 16, 2025, did not include a goal related to Dimension 3. Regarding paragraph c, you acknowledged in the reconsideration request that the entry was not signed. As a result, there is sufficient evidence to support the violation, and it is affirmed, except for the following items in paragraph a, which are rescinded: item a, only as to the April 3, 2025, date; item b, only as to the July 18, 2025, and October 9, 2025, dates; item c only as to the August 30, 3035 date, and item d. Citation 23: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c), clause (2) Violation: Two of two client files reviewed for requirements governing services provided by telehealth, according to Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c) did not to meet requirements. There was no documentation of: a. The license holder’s basis for determine that telehealth is an appropriate and effective means for delivering the treatment service on the following dates: 1. September 11 and October 13, 2025 (client file numbered 2); and 2. June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); b. The mode of transmission used to deliver the service through telehealth on June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); c. The location of the originating site on the following dates: 1. September 11 and October 13, 2025 (client file numbered 2); and 2. June 16, August 13, September 10, and October 08, 2025 (client file numbered 4); and d. The location of the distance site on September 11 and October 13, 2025 (client file numbered 2). Request for reconsideration: You indicated in the reconsideration request that client files contained the required documentation related to telehealth, and you provided supporting documentation. DHS’ response: Regarding paragraph a, item 1, documentation of each occurrence of a health service delivered through telehealth must document the health care provider’s basis for determining telehealth is appropriate. Although a consent was signed by the client before the cited treatment services were provided through telehealth, the treatment service notes dated October 13, 2025, do not include the basis for determining the service was appropriate to deliver via telehealth. For item 2, although a consent was signed by the client before the cited treatment services were provided through telehealth, the treatment service notes from June 16, August 13, September 10, and October 8, 2025, do not include the basis for determining the service was appropriate to deliver via telehealth. Regarding paragraph b, although the notes reviewed identify that telehealth was provided through Doxy, they do not specify whether services were provided through audio only or through combined video and audio. Regarding paragraph c for client 2, the notes specify only that the originating cite is a “secure location,” and although the September 11, 2025, note identifies that a client got into a vehicle halfway through the group, there is no documentation regarding the client’s location prior to that time. For client 4, for the note dated June 16, 2025, there is no documentation of the originating site. Regarding paragraph d, the notes do not document the distance site or the location of the counselor. It is appropriate to rescind paragraph a, item 1, only as to the September 11, 2025, date, and paragraph c, item 2, only as to the August 13, September 10, and October 8, 2025, dates. As a result, there is sufficient evidence to support the violation, and it is affirmed, except paragraph a, item 1, only as to the September 11, 2025, date, and paragraph c, item 2, only as to the August 13, September 10, and October 8, 2025, dates, which are rescinded. Citation 24: Minnesota Statutes, section 245G.20, clause (6) Violation: One client file reviewed for requirements governing persons with co-occurring disorders (client file numbered 2) did not to meet requirements. There was no continuing documentation of collaboration with continuing care mental health providers. Request for reconsideration: You indicated in the reconsideration request that the client file contained the required documentation. DHS’ response: A case note dated April 9, 2025, indicates concerns with worsening depressive symptoms, and the client was asked to follow up with their primary care physician for assistance with access to additional mental health care. The release of information had been signed to allow coordination with the client’s existing mental health provider, but there was no documentation that the program coordinated with the existing mental health provider to address worsening depressive symptoms. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 25: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b), clause (2). Violation: One personnel file reviewed for requirements governing every two year trainings (personnel file numbered 2) did not meet requirements. There was no documentation of training to emergency procedures for calendar year 2025. Request for reconsideration: You indicated in the reconsideration request that training requirements were met, and you submitted supporting documentation. DHS’ response: The commissioner has determined it is appropriate to rescind the citation. Citation 26: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clauses (1) and (3) Violation: Three of four 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 the staff member and containing the staff member’s qualifications for employment (personnel files numbered 2 and 5); b. The first date that a background study subject had direct contact with a person served by the program (personnel files numbered 4 and 5); c. An inquiry required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel files numbered 4 and 5); and d. Written annual review for calendar year 2025 (personnel file numbered 4). Request for reconsideration: You indicated in the reconsideration request that the personnel files contained the required documentation, and you submitted supporting documentation. DHS’ response: With regard to paragraph a, for personnel files 2 and 5, the applications for employment were not contained in the initial documents received during the licensing review. Regarding paragraph b, for personnel files 4 and 5, the date of direct contact was not contained in the initial documents received during the licensing review. A DHS licensor later emailed the program to request the information identified in paragraphs a and b, and it was not received by the requested date of November 10, 2025. You did not challenge paragraph c. Regarding paragraph d, the staff roster provided by the program during the licensing review did not contain the start date for staff person 4, and the program later provided a start date of September 30, 2024, during a phone call with a DHS licensor on November 10, 2025. Given that start date, an annual review for staff person 4 needed to be completed by the end of September 2025 and was not included in the file. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 27: Minnesota Statutes, section 245G.22, subdivision 14, clauses (4) and (5) Violation: One of eight client files reviewed for requirements governing central registry requirements (client file numbered 2) did not meet requirements. The information submitted did not include: a. Social security number or alien registration number; and b. Current or previous enrollment status in another opioid treatment program. Request for reconsideration: You indicated in the reconsideration request that the information in paragraph b of the violation was included in the client’s file, and you submitted supporting documentation. DHS’ response: You did not challenge paragraph a. Regarding paragraph b, although you indicated the client’s enrollment in another program was documented as “Active Status,” an intake note dated December 31, 2024, indicates the client had “stopped treatment” and was being readmitted to the program. The methadone dose was an initiated dose and not a transfer dose. As a result, there is sufficient evidence to support the violation, and it is affirmed. Citation 28: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b), clauses (2) through (4) Violation: Six of seven client files reviewed for requirements governing the prescription monitoring program (PMP) did not meet requirements. There was no documentation of the following: a. The medical director or the medical director’s delegate’s review of the data from the PMP on July 09 and August 11, 2025 (client file numbered 4); b. A copy of the PMP data reviewed on: a. June 04, 2025 (client file numbered 1); b. June 16 and September 10, 2025 (client file numbered 3); c. September 10, 2025 (client file numbered 4); d. May 21, 2025 (client file numbered 5); and e. June 18 and September 10, 2025 (client file numbered 11); and c. When the PMP contains a recent history of multiple prescribers or multiple prescriptions for controlled substances, the physicians review of the data, subsequent actions, and determination of whether or not the prescriptions place the client at risk of harm within 72 hours of the review (client file numbered 2). Request for reconsideration: You indicated in the reconsideration request that information specified in paragraphs b and c of the violation are contained in the client file. You submitted supporting documentation. DHS’ response: You did not challenge paragraph a. Regarding paragraph b, the actual data report of the PMP was not included in the client record as required. Although the program provided documentation of the review of the data, the documentation does not include a copy of the PMP data. It is appropriate to rescind paragraph c of the violation. As a result, there is sufficient evidence to support the violation, and it is affirmed, with the exception of paragraph c which is rescinded. Citation 29: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (a), 245A.19, paragraph (d), 245A.65, subdivision 2, and 245G.12, clauses (2) and (9). Violation: The license holder did not develop program policies and procedures necessary to maintain compliance with licensing requirements, as follows: a. The license holder did not have a program abuse prevention plan. Documentation in client and personnel records indicated that orientation to the program abuse prevention plan was being done; however, the program was unable to provide a copy of the program abuse prevention plan to DHS Licensors upon request; and b. The policies and procedures regarding HIV were not consistent with the current HIV minimum standards. Request for reconsideration: You indicated in the reconsideration request that the license holder was in compliance with the requirements regarding program policies and procedures, and you submitted supporting documentation. DHS’ response: Although the program provided a copy of the program’s policy manual during the licensing review, it did not contain a site-specific Program Abuse Prevention Plan. During a video call with the program’s authorized agent and regional director, a DHS licensor asked where the Program Abuse Prevention Plan was located. After the meeting, the licensor located the posting related to the Plan but noted it had not been reviewed since 2022. On November 7, 2025, a DHS licensor requested that the program provide the most current site-specific Program Abuse Prevention Plan, and during the exit meeting on November 12, 2025, the program indicated they were unable to locate the most current version of the plan. Also, although you provided documentation of educational materials regarding HIV, the program’s policies and procedures were not consistent with the commissioner approved HIV minimum standards. As a result, there is sufficient evidence to support the violation, and it is affirmed. B. DISPOSITION Based on the foregoing, the Commissioner finds citations 1, 2, 4, 7, 8, 9 (except as noted in the following paragraph), 10 (except as noted in the following paragraph), 11 (except as noted in the following paragraph), 12, 13, 14, 15, 16, 17(except as noted in the following paragraph), 19, 20, 22(except as noted in the following paragraph), 23(except as noted in the following paragraph), 24, 26, 27, 28 (except as noted in the following paragraph), and citation 29 are supported by the record, and they are affirmed. The following citations are rescinded: citation 9 only as to paragraph b, items c, f, and g; citation 10 only as to paragraph d, item a, as it relates to client 8; citation 11 as to paragraph a, item c, as it relates to client 1, and paragraph c; citation 17, paragraph b, item b, only as it relates to personnel file number 4; citation 22, paragraph a, item a, only as to the April 3, 2025, date, item b, only as to the July 18, 2025, and October 9, 2025, dates, item c only as to the August 30, 3035 date, and item d; citation 23, paragraph a, item 1, only as to the September 11, 2025, date, and paragraph c, item 2, only as to the August 13, September 10, and October 8, 2025, dates; citation 25; and citation 28, paragraph c. The citations for which you did not request reconsideration are now final. Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program. In the request for reconsideration, you requested that the Order of Conditional License be rescinded because you believe most of the cited violations were inaccurate and that when the incorrect violations were removed, a conditional license was not warranted. You also indicated the program is not aware of any client complaint or safety issue resulting from the cited violations. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and the effect of the violations on the health, safety, or rights of persons served by the program and determined that a conditional license is warranted. The Conditional Order cites twenty-nine citations reflecting that the program has failed to comply with multiple requirements. The license holder challenged twenty-four of the twenty-nine citations on reconsideration, which resulted in sixteen of the challenged citations being fully affirmed and seven of the challenged citations being affirmed in part. The affirmed citations along with the remaining citations that were unchallenged support the need for a conditional license because they demonstrate a history of serious licensing violations that indicate a failure to follow procedure and practice requirements which affect the health, safety, and rights of clients. The large number of citations strongly supports the need for a conditional license, the terms of which are focused on ensuring that the license holder is taking meaningful steps toward achieving compliance and thereby protecting clients’ health, safety, and rights. The citations involved a failure to follow requirements which affected the health and safety of the persons served, including not complying with staff orientation requirements, not ensuring staffing ratios were maintained, and not complying with background studies requirements. Background study requirements and requirements regarding staff orientation, annual training and ratios are in place to ensure the safety of the residents served by the program. Compliance with requirements regarding orientation and training are essential to ensure staff are familiar with policies and procedures related to resident safety and well-being and that staff are able to provide qualified care to residents. The health and safety violations alone warrant a conditional license. The program also received multiple citations for not providing required services including not providing treatment services according to the individual treatment plan and the special needs of the client and not offering all required treatment services. Other violations included not having a qualified treatment director, not ensuring monthly supervision was provided by a registered nurse and not complying with the unsupervised use of methadone hydrochloride. The presence of specialized staff, compliance with requirements regarding the dispensing of medication, and the provision of essential treatment services are all essential to ensuring clients’ well-being and safety. Also, the license holder failed to meet requirements which resulted in violations that were severe in number related to treatment documentation, including not completing comprehensive assessments as required, not completing individual treatment plans as required, not completing treatment plan reviews as required, and not completing discharge summaries as required. Accurate documentation and determinations in client files are necessary to demonstrate that services are being provided, that the services being provided are relevant, how the client is responding to services, and whether the services are effective. These violations alone warrant a conditional license. Due to the need to monitor the program for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on January 23, 2026. The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. C. TERMS OF THE CONDITIONAL LICENSE In addition to the 245G licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from the date of this decision, you must notify current clients and all parties who refer clients to your program of the conditional status of your license. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. The notification must be approved by your DHS Licensor prior to being sent to clients and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this decision. While the license is on conditional status, you must notify new clients and referral sources that the license is on conditional status before they begin receiving services. The notification to new clients must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Documentation of notification of the conditional status must be maintained in each client’s file. Within 30 days of receipt of this decision, you must submit to your DHS Licensor, a copy of the notice and a list of all referral sources that received the notice. 2. Within 15 days from the date of this decision, you must identify a Compliance Officer, located in the State of Minnesota, who will be responsible for correcting the violations identified in the Order of Conditional license, completing the terms identified in the order, and monitoring ongoing compliance with requirements for Substance Use Disorder treatment programs. The Compliance Officer cannot also hold the position of Treatment Director or Alcohol and Drug Counselor Supervisor. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. 2 years of professional experience in the following: 1) A regulatory or compliance position; 2) Involved in direct care as a substance use counselor; or 3) The development and implementation of mental health or substance use disorder treatment planning in a DHS licensed 245G Substance Use Disorder program. b. Experience must demonstrate knowledge of Minnesota Statutes, Chapter 245A (Human Services Licensing) and Chapter 245G (Substance Use Disorder). c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field. 3. Within 15 days from the date of this decision, you must submit a description of how a registered nurse will provide supervision as defined in Minnesota Statutes, section 148.171, subdivision 23, to staff members who have been delegated the task of administration of medication or assisting with self-medication. The description must identify how supervision will be provided, including a minimum of monthly on-site supervision or more often if warranted by a client’s health needs. The description must also address how supervision will be documented, including documenting review of medication administration records and documenting supervision provided to address missing documentation. The description must be approved by the DHS Licensor and be included in the policies and procedure manual upon approval. 4. Within 15 days from the date of this decision, you must identify a Treatment Director who will be responsible for all aspects of the delivery of treatment service. The program’s Treatment Director must meet the qualifications in Minnesota Statutes, section 245G.11, subdivision 2 and must be approved by DHS Licensing. 5. Within 30 days from the date of this decision, you must implement the DHS Licensing self-monitoring plan that ensures and ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules and statutes. The Compliance Officer must conduct within the first quarter a review of the license holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapters 245A and Chapter 245G. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the monthly reviews are outlined in the DHS self-monitoring plan. Discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of the month following the quarter, for 2 years from the date of this decision or otherwise determined by DHS licensing. 6. Within 45 days from the date of this decision, the approved Compliance Officer must provide training on the requirements for substance use disorder treatment programs under Minnesota Statutes, chapter 245G. Individuals required to attend are the Treatment Director, ADC Supervisor, Registered Nurse, Authorized Agent, Medical Director, and Human Resource designee. D. RIGHT TO APPEAL TO THE MINNESOTA COURT OF APPEALS This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, please contact Maura McGarry, Unit Supervisor, at (651) 431-6671. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General cc: Christianna L. Finnern, Winthrop & Weinstine
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