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July 8, 2026 Kris Marie Osborne, Authorized Agent Duluth Bethel Chemical Dependency Services 23 Mesaba Ave Duluth, MN 55806 License Number: 801955 Report Numbers: 202500056, 202511920 CORRECTION ORDER Dear Kris: On May 4 through 8, 2026, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Duluth Bethel Chemical Dependency Services located at 23 Mesaba Ave, Duluth, MN 55806. This review was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment under Minnesota Statute, chapter 245G. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies, Procedures, and Practices 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided. The license holder did not ensure that all services were provided in the amount and type that were billed for. Three hours of group counseling was billed for on March 2, 2026; however, there was only supporting documentation for one hour group counseling on that day (client file numbered 2). Statute Violated: Minnesota Statutes, section 245A.167. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure and document that services provided meet the requirements for payment from the behavioral health fund. 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 physical plant postings as follows: a. The grievance procedure was not posted in a place visible to all clients; b. The program abuse prevention plan was not posted in a prominent location in the program; c. The vulnerable adult maltreatment reporting policies and procedures were not posted in a prominent location in the program; d. The services initiation criteria was not posted in the area of the facility where services were initiated or given to interested persons upon request; and e. The visiting policy was not posted. Statute Violated: Minnesota statutes, sections 245A.65, subdivisions 1, paragraph (d) and 2, paragraph (c), clause (6), 245G.14, subdivision 1, 245G.15, subdivision 2, and 245G.21, subdivisions 2 and 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that physical plan postings meet all applicable requirements. 3. Violation: The license holder did not meet requirements governing client rights protections. The policy and procedure manual did not contain policies and procedures that protect client rights as identified in Minnesota Statues, section 144.651. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights policy and procedure meet all applicable requirements. Within 30 days of receipt of this order, submit a client rights policy that demonstrates compliance. 4. Violation: The license holder did not meet requirements governing grievance procedures as follows: a. The procedure did not identify the highest level of authority that a client may bring the grievance to; and b. Eight of nineteen grievances reviewed did not have documentation that the license holder responded to client’s grievance within three days of a staff member’s receipt of the grievance on the following dates: 1) November 28, 2025; 2) January 21, 2026; 3) March 10, 2026; 4) March 13, 2026; 5) March 18, 2026; 6) April 13, 2026; and 7) April 22, 2026. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that grievance procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that demonstrates compliance. 5. Violation: The license holder did not meet requirements governing treatment services. The license holder did not offer group counseling in the residential treatment program per the treatment services description. Staff interview confirmed group counseling has not been offered since July 2025. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 1, paragraph (a) and 245G.12, clause (10). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that demonstrates compliance. 6. Violation: The license holder did not meet requirements governing telehealth services according to Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (b). The license holder did not: a. Identify categories or types of services the health care provider will provide through telehealth; b. Have policies and procedures that adequately address patient safety before, during, and after the service is delivered through telehealth; c. Have established protocols addressing how and when to discontinue telehealth services; and d. Have an established quality assurance process related to delivering services through telehealth. 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 services meet all applicable requirements. Within 30 days of receipt of this order, submit a telehealth service policy that demonstrates compliance. 7. Violation: The license holder did not meet requirements governing the program abuse prevention plan as follows: a. The program abuse prevention plan did not contain an evaluation of factors that may encourage or permit abuse including: 1) Mental functioning; 2) Physical & emotional health or behavior of clients; 3) Need for specialized programs of care for clients; 4) Need for training of staff to mee identified individual needs; and 5) Knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; and b. There was no documentation of the license holder’s governing body or governing body’s delegated representatives review of the program abuse prevention plan for calendar year 2026. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program abuse prevention plan meets all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that demonstrates compliance. 8. Violation: The license holder did not meet requirements governing vulnerable adult internal reviews as follows: a. The license holder did not complete an internal review within 30 days for a report made on March 11. 2026; and b. The license holder did not provide written notice to a mandated reporter for a report made on March 27, 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraphs (a), clause (1) and (b), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult internal reviews meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing health and safety practices. The license holder did not have a staff person on premise with a current first aid certificate and a current CPR certificate on May 1 and 2, 2026. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health and safety practices meet all applicable requirements. 10. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. There was no documentation that a controlling individual reviewed and signed 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 11. Violation: Four of four personnel files reviewed for requirements governing staff qualifications for individuals with temporary permit (personnel files numbered 3, 5, 14, and 15) did not meet requirements. a. Supervision was not documented for the following weeks: 1) January 30, 2024 through March 4, 2024, March 25, 2024 through April 8, 2024, April 22, 2024 through May 6, 2024, January 4 through February 1, 2026, February 15 through February 22, 2026, and May 3, 2026 (personnel file numbered 3); 2) February 1, 2026, March 15, 2026, May 3, 2026 (personnel file numbered 5); 3) August 7, 2023- November 27, 2023, March 24, 2024- May 6, 2024, July 7, 2025, and August 18, 2025 (personnel file numbered 14); and 4) June 3, 2019-April 28, 2022, September 12, 2022, August 7, 2023- November 27, 2023, December 25, 2023-March 4, 2024, March 25, 2024- May 6, 2024, and July 22, 2024 (personnel file numbered 15); and b. The amount of supervision was not documented on: 1. March 4, 18, 20 and 25, 2026, and April 1, 8, 15, 22, and 29, 2026 (personnel file numbered 3); and 2. February 11, 20, and 23, 2026, March 2, 10 and 25, 2026, and April 1, 7, 22, and 29, 2026 (personnel file numbered 5); and c. There was no documentation the supervision was related to clinical practice on December 27, 2023, January 3, 10, 17, 24, and 31, 2024, February 7, 14, 21, and 28, 2024, and March 6, 2024 (personnel file numbered 14). Statute Violated: Minnesota statutes, section 245G.11, subdivision 11, paragraph(a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications for an individual with a temporary permit meet all applicable requirements. 14. Violation: Nine of nine personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. There was no documentation orientation was completed within 24 working hours for the following (personnel files numbered 1, 7, 8, 9, and 11): 1) Staff member’s specific job responsibilities; 2) Policies and procedures 3) Client confidentiality; and 4) Client needs; b. There was no documentation of orientation completed within 72 hours of employment for HIV minimum standards (personnel files numbered 1, 2, 3, 5, 7, 8, 9, and 11); c. There was no documentation of orientation completed within 72 hours of first providing direct contact for the following (personnel files numbered 1, 7, 8, 9, and 11): 1) Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572; 2) Program abuse prevention plan; and 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services); d. There was no documentation of orientation provided before direct contact for the following: 1) Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E (personnel files numbered 1, 7, 8, 9, and 11); 2) Emergency overdose treatment (personnel files numbered 2, 3, 7, 8, and 9); and 3) Drug and alcohol policy (personnel files numbered 1, 7, 8, 9, and 11); and e. There was no documentation of 12 hours of training in co-occurring disorders within 6 months of employment (personnel file numbered 1); and f. There was no documentation of medication administration training with demonstrated competency to a registered nurse to perform delegated activity (personnel files numbered 1, 6, and 11). Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.242, subdivision 2, paragraph (a), 245A.65, subdivision 3, 245G.08, subdivisions 3 and 5, paragraph (b), clause (3), and 245G.13, subdivisions 1, clause (7), and 2, paragraphs (d) , (e), and (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meet all applicable requirements. 15. Violation: Two of two personnel files reviewed for requirements governing annual training did not meet requirements. The personnel files did not contain documentation of the following annual trainings: a. For calendar year 2024 (personnel file numbered 4): 1) Vulnerable adult maltreatment reporting policy on obtaining a release of client information; 2) Program abuse prevention plan; 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and 4) HIV minimum standards; b. For calendar year 2025 (personnel files numbered 3 and 4): 1) Vulnerable adults maltreatment reporting policy on obtaining a release of client information; 2) Program abuse prevention plan; 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and 4) HIV minimum standards Statute Violated: Minnesota Statutes, sections 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 training meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff above received annual training that demonstrates compliance. 16. Violation: One personnel file reviewed for requirements governing every two-year training (personnel file numbered 4) did not meet requirements. The personnel file did not contain documentation of the following every two-year trainings for calendar year 2025: a. Client confidentiality; b. Emergency procedures; and c. Client rights as specified in Minnesota Statutes, sections 144.651, 145F.165, and 253B.03. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that every two-year trainings meet all applicable requirements. 18. Violation: Five of eight personnel files reviewed for requirements governing personnel file contents did not meet requirements. Personnel files did not contain the following: a. A completed application for employment signed by the staff member and containing the staff member’s qualifications for employment (personnel files numbered 1, 2, and 3); b. The first date of direct contact (personnel files numbered 1 and 11); c. Documentation of 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 2 and 3); and d. A job performance evaluation for calendar year 2026 (personnel file numbered 5). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6 and 245G.13, subdivisions 1, clause (3) and 3, clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel files meet all applicable requirements. Client Files 19. Violation: Four of four client files reviewed for requirements governing orientation did not meet requirements. There was no documentation of the following orientation: a. A written statement of client rights and responsibilities in Minnesota Statutes, sections 144.651 and 148F.165 on the day of service initiation (client files 1 and 2); b. Maltreatment of vulnerable adults internal and external reporting policies within 24 hours of admission (client files 1, 2, 3, and 5); and c. Program abuse prevention plan within 24 hours of admission (client files 1, 2, 3, and 5). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 1, paragraph (c), ,245G.09, subdivision 3, paragraph (a), clause (1)245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation meet all applicable requirements. 20. Violation: Two of four client files reviewed for requirements governing vulnerable adult assessment and determination (client files numbered 1 and 2) did not meet requirements. The license holder did not determine whether a client was a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult assessment and determination meets all applicable requirements. Within 30 days of receipt of this order, submit a vulnerable adult assessment and determination that demonstrates compliance. 21. Violation: Four of four client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client file numbered 1, 2, 3, and 5) did not meet requirements. The license holder did not document that the person receiving services participated in the development of the IAPP. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit an individual abuse prevention plan that demonstrates compliance. 22. Violation Three of four client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not contain the following: a. Route of administration (client file numbered 2); b. The client’s evaluation of the quality of each personal relationship (client file numbered 1, 2, and 3); c. Important developmental incidents in the client’s life (client file numbered 2); and d. The client’s family health history (client file numbered 2). 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. 23. Violation: Five of five client files reviewed for requirements governing documentation of treatment services did not meet requirements as follows: a. The client file did not contain documentation of the following: 1) The client response to each treatment service on: (i) April 23, 2026 (client file numbered 3); and (ii) October 16, 2025, and November 7, 10, 12, and 13, 2025 (client file numbered 4); and 2) The date, amount or response of the client to treatment coordination provided as documented on: (i) March 26, 2026 (client file numbered 1): (ii) April 4, 2026 (client file numbered 2); (iii) April 30, 2026 (client file numbered 3); (iv) December 19, 2025 (client file numbered 4); and (v) April 15, 2026 (client file numbered 5); and 3) The job title or position of the staff making the entry on March 9, 10, and 12, 2026 (client file numbered 2); and 4) Significant events that occur at the program within 24 hours of the event on August 27, 2025, September 10, 2025, and November 18, 2025 (client file numbered 4); and 5) Medical and other appointments the client attended on the day it occurred on: (i) January 8, 2026 and April 14, 2026 (client file numbered 3); (ii) October 6 and 10, 2025 and November 3, 2025 (client file numbered 4); and (iii) February 25, 2026, March 12 and 23, 2026, and April 17, 2026 (client file numbered 5); and 6) Concerns related to attendance of treatment services, including the reason for any client absence from the treatment service on the day it occurred (client files numbered 3, 4, and 5); and b. The documentation was not signed by the staff member who provided the treatment service on February 27, 2026 (client file numbered 5); and c. Documentation of treatment services was not signed within seven days of providing the treatment service on: 1) February 2, 3, 5, 6, 9, and 10, 2026 (client file numbered 1); 2) March 3, 5, 9, 10 and 12, 2026 (client file numbered 2); 3) January 19, 20, 22, 23, 24, 2026, April 17 and 23, 2026 (client file numbered 3); and 4) February 27, 2026, March 2, 3, and 5, 2026 (client file numbered 5); and d. Documentation of treatment services was not accurate on November 7, 10, and 12, 2025. Content of the group note appeared to be copy and paste, and did not accurately describe the group type (client file numbered 4); and e. The discharge summary identified the client was provided group counseling; however, there was no documentation of group counseling in the client chart (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraphs (a) and (b), clauses (1), (2), and (3), and paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation of treatment services meet all applicable requirements. 24. Violation: One client file reviewed for requirements governing services provided via telehealth (client file numbered 1) did not meet requirements. Documentation for services provided on February 2, 3, 9, 10, and 12, 2026 did not include the following: a. The license holder’s basis for determining that telehealth is an appropriate and effective means for delivering the treatment service; b. The mode of transmission used to deliver the service through telehealth; and c. The location of the originating and distance site. 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 documentation telehealth services meet all applicable requirements. 25. Violation: Two of five client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements as follows: a. There was no documentation of a TPR for March 3 through March 31, 2026 (client file numbered 2); and b. There was no documentation of staff recommendations for the changes in methods identified in the treatment plan (client file numbered 4). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. 26. Violation: One of five client files reviewed for requirements governing frequency of treatment plan reviews (client file numbered 5) did not meet requirements. The treatment plan review for a client receiving ASAM level 3.1 services was not completed every 30 days. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3a, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that frequency of treatment plan reviews meet all applicable requirements. 27. Violation: Two of three client files reviewed for requirements governing programs that administer medications did not meet requirements. The clients use of medication was not recorded for: a. Doxycycline Monohydrate on September 22, 2025 and October 21 through 26, 2025 (client file numbered 4); b. Tab-a-vite Tab on December 13 and 24, 2025 (client file numbered 4); c. Dexamethasone on March 23 through 31, 2026, and April 1 through 9, 2026; (client file numbered 5); d. Penicillin on March 19, 23 through 31, 2026, and April 1 through 9, 2026 (client file numbered 5); e. Lidocaine on March 19 and 20, 2026 (client file numbered 5); and f. Melatonin on March 19, 20, 22, and 28, 2026 (client file numbered 5). Statute Violated: Minnesota Statutes, section 245G.08 subdivision 5, paragraph (c), clause (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration meets all applicable requirements. 28. Violation: One of five client files reviewed for requirements governing record keeping (client file numbered 1) did not meet requirements. The client record was not protected against tampering. The vulnerable adult determination was signed; however, the document was able to be edited by DHS Licensors. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that record keeping meets all applicable requirements. 29. Violation: One of two client files reviewed for requirements governing client property management (client file numbered 5) did not meet requirements. The license holder did not immediately document the date or client signature for disbursement of property. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client property management meets all applicable requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at carrie.salsness@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Carrie Salsness Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General, Legal Counsel’s Office - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at (651) 431-3815 or at carrie.salsness@state.mn.us. Sincerely, Carrie Salsness, Licensor Licensing Division Office of Inspector General
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