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July 9, 2026 Lewis Zeidner, Authorized Agent Gateway Recovery Center II LLC 550 Main St Suite 230 New Brighton, MN 55112 License Number: 1116195 Withdrawal Management License Number: 1116184 Detox Services License Report Number: 202405147, 202507222, 202511892 CORRECTION ORDER Dear Lewis, On April 20, 21, 22, and 23, 2026, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 6840 78th Ave N, Brooklyn Park, MN 55445. As a result of this visit, DHS determined that you are in violation of the withdrawal management statutes under Minnesota Statutes, chapter 245F. 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, Practices, and Procedures 1. Violation: The license holder did not meet requirements for addressing the needs of individuals who are denied admission to the program. Documentation did not include the time of the admission request on March 27, 28, April 2, 8, June 14, July 28, August 27, 2025, January 31, March 2, 27, 31, and April 11, 2026. Statute Violated: Minnesota Statutes, section 245F.05, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission denials meet all applicable requirements. 2. Violation: The license holder did not meet requirements governing the use of law enforcement. There was no documentation the following: a. The date and time law enforcement arrived and left the program on August 7, 2025, October 27, 2025, March 11, 2026, and April 17, 2026; b. The reason for the use of law enforcement on August 7, 2025; c. If law enforcement used force or a protective procedure and which protective procedure was used on August 7, 2025; and d. Whether any injuries occurred on August 7, 2025. Statute Violated: Minnesota Statutes, section 245F.09, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the involvement of law enforcement meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing grievance procedures. The license holder did not ensure that an initial response to the patient who filed the grievance was completed within 24 hours of the programs receipt on September 25, 2025. Statute Violated: Minnesota Statutes, section 245F.10, subdivision 2, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing vulnerable adult maltreatment internal review practices. Internal review completed July 21, 2025 did not include an evaluation of whether the reported event is similar to past events with the vulnerable adults or the services involved. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the vulnerable adult maltreatment internal reporting practices meets all applicable requirements. 5. Violation: The license holder did not ensure that the medical director annually reviewed and approved the following procedures for calendar year 2026: a. Admission, discharge, and transfer criteria and procedures; b. Health services plan; c. Physical indicators for physician, registered nurse, or hospital, and procedures for referral; d. Procedures to follow in case of accident, injury, or death of a patient; e. Formulation of condition specific protocols regarding the medications that require a withdrawal regimen that will be administered to patients; f. Infection control program; and g. Medication control plan. Statute Violated: Minnesota Statutes, section 245F.14, subdivision 5, clauses (1) through (6) and (8). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the medical director annual approval of procedures meets all applicable requirements. Within 30 days of receipt of this order, submit medical director approval of (d), (e), and (f) that demonstrates compliance. Personnel Files 6. Violation: One personnel file reviewed for requirements governing staff qualifications (personnel file numbered 2) did not meet requirements. There was no documentation the employee demonstrated competency prior to direct client contact in the following areas: a. Knowledge of and ability to perform basic health screening procedures with intoxicated patients that consist of blood pressure, pulse, temperature, and respiration readings; b. Interviewing to obtain relevant medical history and current health complaints; c. Visual observation of a patient’s health status, including monitoring a patient’s behavior as it relates to health status; and d. Knowledge of and ability to perform basic activities of daily living and personal hygiene. Statute Violated: Minnesota Statutes, section 245F.15, subdivision 6, clauses (2) and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the staff qualifications meets all applicable requirements. 7. Violation: Two of three personnel files reviewed for requirements governing staff orientation did not meet requirements in the following ways: a. There was no documentation within 72 hours of beginning employment of the following: 1) Specific license holder and staff responsibilities for patient confidentiality (personnel files numbered 2 and 4); 2) Patient ethical boundaries and patient rights, including the rights of patient admitted under Minnesota Statutes, chapter 253B (personnel files numbered 2 and 4); 3) Infection control procedures (personnel files numbered 2 and 4); 4) Mandatory reporting under Minnesota Statutes, chapter 260E, and sections 245A and 626.557, including specific training covering the facilities policies concerning obtaining patient releases of information (personnel files numbered 2 and 4); 5) HIV minimum standards (personnel files numbered 2 and 4); 6) Motivational counseling techniques and identifying stages of change (personnel files numbered 2 and 4); 7) The specific job functions for which the staff member was hired (personnel file numbered 2); 8) Program policies and procedures (personnel file numbered 2); 9) Patient needs (personnel files numbered 2 and 4); 10) The license holder provided training to employees, subcontractors, and volunteers about the program’s drug and alcohol policy (personnel file numbered 2); and 11) The specific mode of administration of emergency overdose treatment used at the program (personnel files numbered 2 and 4); and b. Vulnerable Adult Requirements within 72 hours of first providing direct contact services to a vulnerable adult including reporting requirements and definitions in sections 626.557 and 626.5572; the license holder's program abuse prevention plan; and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2 and 4), Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.242, subdivision 2, 245A.65, subdivision 3, and 245F.16, subdivisions 1, clause (7), 2, paragraph (b), clauses (1), (3), (4), (5), (6), and (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that staff orientation meets all applicable requirements. 8. Violation: Three of three personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of the following: a. Infection control procedures for: 1) Calendar year 2024 (personnel file numbered 3); 2) Calendar year 2025 (personnel files numbered 2 and 3); and 3) Calendar year 2026 (personnel file numbered 4); b. Reporting requirements and definitions for maltreatment of vulnerable adults in sections 245A.65, 626.557 and 626.5572for: 1) Calendar year 2024 (personnel file numbered 3); and 2) Calendar year 2025 (personnel files numbered 2 and 3); c. Specific training covering the facility's policies for obtaining patient releases of information required by Minnesota Statutes, section 626.557, subdivision 3a, paragraph (a) for: 1) Calendar year 2024 (personnel file numbered 3); 2) Calendar year 2025 (personnel files numbered 2 and 3); and 3) Calendar year 2026 (personnel file numbered 4); d. Mandatory reporting under Minnesota Statutes, chapter 260E for calendar year 2025 (personnel files numbered 2 and 3); e. HIV minimum standards for: 1) Calendar year 2024 (personnel files numbered 2 and 3); and 2) Calendar year 2026 (personnel file numbered 2, 3, and 4); and f. Motivational counseling techniques and identifying stages of change for: 1) Calendar year 2024 and 2026 (personnel file numbered 2); and 2) Calendar year 2025 (personnel file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245F.16, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that that annual training meets all applicable requirements. 9. Violation: Four of four personnel files reviewed for requirements governing personnel file documents did not meet requirements. There was no documentation of the following: a. There was no documentation of the first date that a background study subject has direct contact, as defined in section 245C.02, subdivision 11, with a person served by the license holder’s program (personnel files numbered 2 and 4); b. A completed application signed by the staff member that contains the staff member’s qualifications for employment (personnel files numbered 1 and 3); c. Documentation verifying the staff member’s current professional license or registration (personnel files numbered 1, 3, and 4); and d. An annual job performance evaluation for the 2024 calendar year (personnel files numbered 2 and 3). Statute Violated: Minnesota Statutes, sections 245A.041, subdivision 6, and 245F.17, clauses (1), (2), and (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file documents meet all applicable requirements. Patient Files 10. Violation: Three of three patient files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. There was no documentation of: a. The specific actions the program would take to minimize the risk of abuse within the scope of the licensed services (patient file numbered 3); and b. A review and evaluation of the IAPP as part of the service plan review (patient files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b). 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 the receipt of this order, submit documentation of (b) that demonstrates compliance. 11. Violation: Three of three patient files reviewed for requirements governing medical services did not meet requirements. There was no documentation of the following: a. A screening conducted between 4 and 12 hours after service initiation to collect information related to other health complaints and behavioral risk factors that the patient may not have communicated at service initiation (patient files numbered 1 through 3); and b. Hourly observation (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.12, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medical services meet all applicable requirements. Within 30 days of receipt of this order, submit a screening document that demonstrates compliance. 12. Violation: Three of three patient files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements in the following ways: a. The CA was not completed within 72 hours following admission (patient file numbered 1); and b. There was no documentation of: 1) The patient’s household members (patient file numbered 1); 2) Substance use history, including the route of administration (patient file numbered 3); and 3) Important developmental incidents in the patient’s life (patient files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245F.06, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. 13. Violation: Four of four patient files reviewed for requirements governing individualized stabilization plans (patient files numbered 1 through 4) did not meet requirements. The stabilization plan did not document: a. Medical needs and goals to be achieved while the patient is receiving services; b. Amount and frequency of services; and c. Participation of others in the stabilization planning process. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that stabilization plans meet all applicable requirements. Within 30 days of receipt of this order, submit two stabilization plans that meet all applicable requirements. 14. Violation: Four of four patient files reviewed for requirements governing progress notes (client files numbered 1, 2, and 3) did not meet requirements. There was no documentation of the patient’s involvement in the stabilization services, including the type and amount of each stabilization service. Statute Violated: Minnesota Statutes, section 245F.07, subdivision 2, clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit two patient progress note documentation that meets all applicable requirements. 15. Violation: Four of four patient files reviewed for requirements governing discharge plans did not meet requirements. There was no documentation of the following: a. The discharge plan was not completed before the patient left the facility and the patient was not provided with a copy of a completed discharge plan (patient files numbered 2, 3, and 4); b. Referral made to other services of agencies at the time of transition (patient file numbered 1); c. The patient’s plan for follow up, aftercare, or other post stabilization services (patient file numbered 1); d. The patient’s participation in the development of the transition plan (patient files numbered 2 and 4); and e. A stabilization summary and final evaluation of the patient’s progress toward treatment objectives (patient file numbered 1). Statute Violated: Minnesota Statutes, section 245F.07, subdivision 3, clauses (1), (2), (3), and (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge plans meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of discharge plans from two patients that meet all requirements. 16. Violation: Three of three patient files reviewed for requirements governing stabilization services did not meet requirements. The following services were not offered and there was no documentation of clinical rationale for not offering: a. Care coordination (patient files numbered 1 and 3); and b. Peer recovery support services (patient files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245F.08, subdivision 1, clauses (4) and (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure stabilization services meet all applicable requirements. Violation: Three of three patient files reviewed for requirements governing patient education did not meet requirements. The license holder did not provide education on the following: a. Substance use disorder, including the effects of alcohol and other drugs (patient files numbered 1, 2, and 3); b. Nicotine cessation options (patient files numbered 1, 2, and 3); and c. Long term withdrawal issues related to use of barbiturates and benzodiazepines (patient files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245F.08, subdivision 4, clauses (1), (5), and (7). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that patient education meets all applicable requirements. 17. Violation: One of three patient files reviewed for requirements governing client property management (patient file numbered 2) did not meet requirements. The license holder did not immediately document disbursement of the person’s property at the time of disbursement, including the person’s signature. 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 meet all applicable requirements. 18. Violation: Three of four patient files reviewed for requirements governing medication administration did not meet requirements. The patient’s use of medication was not recorded, including staff signatures with date and time as follows: a. April 18 through 20, 2026 (patient file numbered 1); b. August 6 and 7, 2025 (patient file numbered 2); and c. June 6 through 11, 2025 (patient file numbered 4). Rule Violated: Minnesota Statutes, section 245F.13, subdivision 1, clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that medication administration 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 Charlene.m.hanson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Char Hanson 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 in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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: Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This withdrawal management program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245F and Minnesota Rules, parts 9530.6590 (Rule 32) · 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 Char Hanson, Licensor, at 651-431-6617. Sincerely,
Char Hanson, Licensor Licensing Division Office of Inspector General
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