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July 30, 2026 Ashley Kjos, Authorized Agent Woodland Centers 1125 6th St SE Willmar, MN 56201 License Number: 830946 CORRECTION ORDER Dear Ashley: On May 11, 12, 13, and 14, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Woodland Centers located at 1125 6th St. SE, Willmar, MN 56201. 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 for receiving public funding reimbursement from the commissioner for services provided as follows: a. Two hours of group counseling were billed for on February 23, 2026; however, the supporting documentation indicated one hour was provided (client file numbered 3); and b. The license holder did not meet billing requirements for individuals with co-occurring disorders in accordance with Minnesota Statutes, section 254B.0507, subdivision 6. There was no documentation of the following: 1) Co-occurring staff received 8 hours of training on co-occurring disorders annually for calendar year 2025 (personnel file numbered 3); and 2) A multi-disciplinary case review completed monthly for December 2025, January, February, March and April 2026 (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.167, paragraph (a) and 245A.191, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure and document that services are provided in the amount and type for which they were billed. Additionally, 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 service; disenrollment in the public payment program; or other administrative, civil, or criminal penalties as provided by law. 2. Violation: The license holder did not meet requirements governing client rights protection, as follows: a. The license holder’s client’s right policy did not include client rights as identified in Minnesota Statutes, sections 148F.165; and b. There was no documentation that the response to the client’s grievance occurred within three days of the staff members’ receipt of the grievance received on May 29, 2025. Statute Violated: Minnesota Statute, section 245G.15, subdivisions 1 and 2, clause (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client rights protection meets all applicable requirements. The license holder’s client’s right policy was corrected on site. 3. Violation: The license holder’s service initiation and termination policy did not meet requirements. There was no documentation of: a. A protocol for assisting clients in need of care not provided by the license holder; b. A procedure for a service termination and denial of service initiation that poses an immediate threat to the health of any individual or requires immediate medical intervention; and c. Procedures staff must follow when a client leaves against medical advice; including a policy that requires staff members to assist the client with assessing needs of care or other resources. Statute Violated: Minnesota Statute, section 245G.14, subdivisions 2, paragraphs (a) and (b), and 3, clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation and termination policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a service initiation and termination policy that demonstrates compliance. 4. Violation: The license holder’s treatment services policy did not meet requirements. The policy did not include the following: a. A description of how each treatment service will be provided, including the amount and type; b. Which services meet the definition of group counseling under Minnesota Statutes, section 245G.01, subdivision 13a; c. Groups and topics on which a guest speaker could provide under the direct observation of an alcohol and drug counselor; and d. The program’s treatment week. Statute Violated: Minnesota Statute, section 245G.12, clause (10). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment services description meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that demonstrates compliance. 5. Violation: The license holder’s program abuse prevention plan (PAPP) did not meet requirements in the following ways: a. The population assessment did not include the age of clients; and b. The assessment of the environment of the facility did not include the type of internal programming. Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a), clauses (1) and (3). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program abuse prevention plans meet all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 6. Violation: The license holder did not monitor the implementation of policies and procedures necessary to maintain compliance with licensing requirements. The policies and procedures contained repealed statute language for assessment and treatment planning. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), and 245G.12, clause (1). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that written policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit an assessment and treatment planning policy and procedure that demonstrates compliance. Personnel files 7. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements as follows: a. There was no documentation within 24 working hours of the following: 1) Staff members specific job responsibilities (personnel files numbered 1 and 2); 2) Policies and procedures (personnel files numbered 1 and 2); 3) Client confidentiality (personnel file numbered 1); and 4) Client needs (personnel files numbered 1 and 2); b. There was no documentation within 72 hours of the following: 1) Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 (personnel file numbered 2); 2) Program abuse prevention plan (personnel files numbered 1 and 2); and 3) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 and 2); c. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E before direct contact (personnel file numbered 2); and d. 12 hours of training in co-occurring disorders within six months of employment (personnel files numbered 1 and 2). Statute Violated: Minnesota Statute, sections 245A.65, subdivision 3, and 245G.13, subdivisions 1, clause (7) and 2, paragraphs (e) and (f). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff orientation meets all applicable requirements. 8. Violation: Three of three personnel files reviewed for requirements governing staff development did not meet requirements. There was no documentation of annual training for the following: a. The license holder’s policies for obtaining a release of client information for calendar years: 1) 2024 (personnel file numbered 3); 2) 2025 (personnel file numbered 3); and 3) 2026 (personnel files numbered 1 and 2); b. Program abuse prevention plan for calendar years: 1) 2024 (personnel file numbered 3); 2) 2025 (personnel file numbered 3); and 3) 2026 (personnel files numbered 1 and 2); and c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar years: 1) 2024 (personnel file numbered 3); 2) 2025 (personnel file numbered 3); and 3) 2026 (personnel files numbered 1 and 2). Statute Violated: Minnesota Statute, sections 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for the staff members listed above that demonstrates compliance. 9. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following: a. The staff member’s qualifications for employment (personnel file numbered 2); and b. A written job performance evaluation for: 1) Calendar years 2024 and 2025 (personnel file numbered 3); and 2) Calendar year 2026 (personnel files numbered 1 and 2). Statute Violated: Minnesota Statute, section 245G.13, subdivisions 1, clause (3) and 3, clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for the staff members listed above that demonstrates compliance. Client files 10. Violation: Three of three client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation to the following: a. Staff review of the written statement of client rights and responsibilities with the client on the day of service initiation (client file numbered 1); b. Within 72 hours of admission (client file numbered 2): 1) HIV minimum standards; 2) Information on tuberculosis and tuberculosis screening; 3) Internal and external maltreatment of vulnerable adult reporting policies; and 4) Program abuse prevention plan; and c. Personal electronic device (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.09, subdivision 3, paragraph (a), clause (1) and 245G.15, subdivisions 1 and 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meet all applicable requirements. 11. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not include the following: a. The client’s household members (client file numbered 1); b. Substance use history, including: 1) Duration (client file numbered 3); and 2) Route of administration (client files numbered 1 and 2); and c. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 2 and 3). Statute Violated: Minnesota Statute, sections 245G.03, subdivision 1, paragraph (c), and 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 12. Violation: Two of three client files reviewed for requirements governing individual treatment plans (ITP) (client files numbered 2 and 3) did not meet requirements. There was no documentation of the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services. Statute Violated: Minnesota Statute, sections 245G.03, subdivision 1, paragraph (c), and 245G.06, subdivision 1a, paragraph (a), clause (4). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. 13. Violation: Two of two client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency did not meet requirements as follows: a. The TPR did not document the following: 1) The span of time covered by the review: i. January 2, 30, 2026, February 27, 2026 and March 27, 2026 (client file numbered 1); and ii. February 27, 2026, and March 27, 2026 (client file numbered 3); 2) The participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others on January 2, 30, 2026, February 27, 2026 and March 27, 2026 (client file numbered 1); and b. A treatment plan review was not completed once every 30 days for ASAM level 1.0 or 2.1 by April 27, 2026 (client file numbered 3). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 3, and 3a, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plan reviews and their frequency meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan review that meet all 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 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 651-431-6617 or at Charlene.m.hanson@state.mn.us. Sincerely, Char Hanson, Licensor Licensing Division Office of Inspector General
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