|
July 9, 2026 Terri Senkow, Authorized Agent Metro Treatment of Minnesota LP 2500 Maitland Center Pkwy Ste 250 Maitland, FL 32751 License Number: 1035458 CORRECTION ORDER Dear Terri: On March 23, 24, 25, and 26, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, St. Cloud Metro Treatment Center located at 524 25th Ave N, Saint Cloud, MN 56303. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under MN 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 governing medical services. There was no documentation of a registered nurses’ supervision monthly for the following months: 1) March, 2024; 2) November, 2024; 3) December, 2024; 4) January, 2025; 5) February 2025; 6) March, 2025; and 7) May, 2025. Statute Violated: Minnesota Statutes, section 245G.08, subdivision 5, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the registered nurse supervision policies meet all applicable requirements. 2. Violation: The license holder did not meet requirements governing personnel policy requirements. There was no policy describing behavior that constitutes grounds for disciplinary action, suspension, or dismissal, including policies prohibiting personal involvement with a client in violation of Minnesota Statutes, chapter 604, and policies prohibiting client abuse described in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572, and chapter 260E. Statute Violated: Minnesota Statutes, sections 245G.13, subdivision 1, clause (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies meet all applicable requirements. Within 60 days of receipt of this order, submit updated personnel policies that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing quality improvement plan requirements. There was no documentation of the quality improvement plan updated at least annually to include new or continued goals based on an updated evaluation of services for the calendar year 2026. Statute Violated: Minnesota Statutes, sections 245G.22, subdivision 18, clause (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies meet all applicable requirements. Personnel Files 4. Violation: Staff Person 3 (SP3) began a position allowing direct contact with persons served by the program on December 28, 2022. At the time of the licensing review, it was noted that SP3 had a legal name change since the background study was initiated on October 29, 2020. The license holder did not initiate a new background study or notify the commissioner of the name change for SP3. Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 7, paragraph (a). Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Client Files 5. Violation: Seven of seven client files reviewed for requirements governing client orientation files (client files numbered 1 through 7) did not meet requirements. There was no documentation of orientation to the program abuse prevention plan within 24 hours of admission. Statute Violated: Minnesota Statutes, sections 245A.65, subdivision, paragraph (a), clause (4), 245G.09, subdivision 3, paragraph (a), clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 60 days of receipt of this order, submit a document that demonstrates orientation to the program abuse prevention plan that meets all applicable requirements. 6. Violation: Seven of seven client files reviewed for requirements governing initial services plans (ISP) and vulnerable adult determination did not meet requirements in the following ways: a) The ISP and vulnerable adult determination were not completed within 24 hours of the day of service initiation (client file numbered 7); and b) The ISP was not person-centered and client specific (client files numbered 1 through 6). Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1 and 245G.09, subdivision 3, paragraph (a), clause (2). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. Within 60 days of receipt of this order, submit an initial service plan that meets all applicable requirements. 7. Violation: Seven of seven client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not include documentation of the following: a. Client’s household members (client file numbered 7); b. Status of the client’s basic needs (client files numbered 1 through 7); c. Client’s education level (client file numbered 2); d. Client’s employment status (client files numbered 1 through 7); e. The client’s perceptions of the client’s condition (client files numbered 3 through 5); f. Cultural influences on the client (client files numbered 1 through 5); g. Substance use history, including: i. Amounts and types of substances (client file numbered 4); ii. Frequency and duration (client file numbered 4); iii. Route of administration (client files numbered 2 and 4); iv. Periods of abstinence (client files numbered 1, 3 through 7); and v. Circumstances of relapse (client files numbered 1 through 5); h. Important developmental incidents in the client’s life (client files 1 through 7); i. Potential brain injuries (client files numbered 1 through 5); j. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner (client files numbered 1 through 7); and k. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1 through 7). Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Within 60 days of receipt of this order, submit a comprehensive assessment that meets all applicable requirements. 8. Violation: Four of seven client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not completed within 14 days from the day of service initiation (client file numbered 4); and b. There was no documentation of the ASAM level of care (client file numbered 1 through 7). Statute Violated: Minnesota Statutes, sections 245G.06, subdivisions 1 and 1a, clause (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 60 days of receipt of this order, submit an individual treatment plan from a recent client that meets all applicable requirements. 9. Violation: Three of three client files reviewed for requirements governing the provision of telehealth, pursuant to Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c) did not meet requirements. There was no documentation of the following: a) The health care provider’s basis for determining that telehealth is an appropriate and effective means for delivering the service to the enrollee on: 1) October 16, 23, and 30, November 6, and December 11, 2025, and January 29 (client file numbered 4); 2) February 5, 2025 (client file numbered 6); and 3) January 6 and 13, 2026 (client file numbered 7). b) Mode of transmission used to deliver the service through telehealth and records evidencing that a particular mode of transmission was utilized on: 1) October 16, 23, and 30, November 6, and December 11, 2025, and January 29, 2026 (client file numbered 4); and 2) January 13, 2026 (client file numbered 7); and c) Location of the originating site and the distance site for the dates: 1) October 16, 23, and 30, November 6, and December 11, 2025, and January 29, 2026 (client file numbered 4); 2) February 5, 2025 (client file numbered 6); and 3) January 6 and 13, 2026 (client file numbered 7). 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 for clients receiving telehealth services the records meet all applicable requirements. 10. Violation: One of seven client files reviewed for requirements governing client record documentation (client file numbered 3) did not meet requirements. Entries in the client record were not accurate. The discharge summary had an inaccurate discharge date. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2b, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 11. Violation: Four of six client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways: a) The treatment plan review did not indicate the span of time covered by the review for the dates signed: 1) January through April, 2025 (client file numbered 1); 2) October through December, 2025 (client file numbered 2); and 3) October, 2025 through February 2026 (client file numbered 4); and b) Treatment plan reviews were not completed weekly for the ten weeks following the completion of a treatment plan: 1) Treatment plan reviews were due on February 27, March 6 and 13, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 1); 2) Treatment plan review was due on October 21, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 2); 3) Treatment plan reviews were due on November 26, December 3 and 10, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 3); and 4) Treatment plan reviews were due on November 5, 19, 26, December 3, 10, 17, and 24, 2025; however, there was no treatment plan review documentation in the chart (client file numbered 4). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 3 and 3a, paragraph (f), clause (1). Corrective Action: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 12. Violation: Four of four client files were reviewed (client files numbered 1 through 4) for requirements governing service discharge summaries did not meet requirements. The discharge summary was not completed within five days of service termination. Statute Violated: Minnesota statute, section 245G.06, subdivision 4, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service discharge summaries meet all applicable requirements. 13. Violation: Four of five client files reviewed for requirements governing nonmedication treatment services did not meet requirements. The license holder did not meet requirements in the following ways: a) The program did not offer at least 50 consecutive minutes of individual or group therapy treatment services weekly, for the first ten weeks following the day of service initiation for the following weeks: 1) October 21, 2025 (client file numbered 2); 2) November 26, December 3, and 10, 2025) (client file numbered 3); 3) November 3, 17, 24, December 1, and 8, 2025 (client file numbered 4); and 4) December 17, 24, 31, 2025, January 7 21, February 11, and 18, 2026 (client file numbered 7). b) Following the first ten weeks following the day of service initiation, the program did not offer at least 50 consecutive minutes of individual or group therapy for the month of January 2026 (client file numbered 4). Statute Violated: Minnesota statute, section 245G.22, subdivision 15, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure nonmedication treatment services meet all applicable requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely,
David Her, Licensor Licensing Division Office of Inspector General
|
