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August 3, 2026 Alana Sasaki, Authorized Agent Sasaki Medical LLC dba Kai Shin Clinic 777 Raymond Ave Saint Paul, MN, 55114 License Number: 1110597 CORRECTION ORDER Dear Alana: On April 20, 21, 22, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Kai Shin Treatment located at 7831 Glenroy Rd Ste 145, Minneapolis, MN, 55439. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder treatment under Minnesota Statutes, 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. The license holder did not meet billing requirements for the medical services rate enhancement in accordance with Minnesota Statutes, section 254B.0507, subdivision 5. The license holder did not document the medical services provided in the client’s substance use disorder file when medical services were delivered to the client in the license holder’s separate medical program. 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) A mental health diagnostic assessment completed within 10 days of admission (client files numbered 3); and 2) A multi-disciplinary case review completed monthly for the following months: a) March 2025 through March 2026 (client file numbered 1); b) February 2026 (client file numbered 2); and c) November, December 2025, and January 2026 (client file numbered 3). c. One client file reviewed for requirements governing the provision of telehealth, in accordance with Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c) (client file numbered 3) did not meet requirements. There was no documentation of the following for a treatment service provided on February 26, 2026: 1) The health care provider’s basis for determining that telehealth is an appropriate and effective means for delivering the service to the enrollee; 2) Mode of transmission used to deliver the service through telehealth; and 3) Location of the originating site and the distance site. Statute Violated: Minnesota Statutes, sections 245A.167, 245A.191, paragraph (a), and 245G.07, subdivision 4, paragraph (c). 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 the provision of telehealth services pursuant to Minnesota Statutes, 254B.0625, subdivision 3b, paragraph (c). The policy manual did not contain the following: a. Identified categories or types of services the health care provider will provide through telehealth; b. Policies and procedures specific to services delivered through telehealth; c. Policies and procedures that adequately address patient safety before, during, and after the service is delivered through telehealth; d. Established protocols addressing how and when to discontinue telehealth services; and e. Established quality assurance process related to delivering services through telehealth. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the telehealth services policies meet all applicable requirements. Within 45 days of receipt of this order, submit a telehealth services policy that meets all applicable requirements. Personnel Files 3. Violation: One of five personnel files reviewed for requirements governing background studies did not meet requirements. On April 20, 2025, a DHS licensor determined that the license holder did not initiate a background study on one staff person (SP5) before they began positions allowing direct contact with persons served by the program. a. SP5 began working in a position allowing direct contact with persons served by the program on December 19, 2025; however, the license holder did not initiate a background study to DHS until February 6, 2026. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), the Commissioner shall not issue a fine to a license holder who self-corrects a background study violation before the Commissioner discovers the violation. A license holder who has previously exercised the provision of paragraph (d) to avoid a fine for a background study violation may not avoid a fine for a subsequent background study violation unless at least 365 days have passed since the license holder self-corrected the earlier background study violation. Because the license holder self-corrected the background study violation involving SP5 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP5. Statute Violated: Minnesota Statutes, sections 245A.07, subdivision 3, paragraph (d) and 245C.04, subdivision 1, paragraph (g). Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with the background study requirements in Minnesota Statutes, chapter 245C. 4. Violation: One personnel file reviewed for requirements governing individuals with a temporary permit did not meet requirements. There was no documentation of the amount of supervision provided to an individual with a temporary permit from October 27, 2025, through April 21, 2026 (personnel file numbered 3). 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 required documentation for individuals with a temporary permit meets all applicable requirements. 5. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation of orientation to the following: a. Within 24 working hours of starting: 1) Staff members specific job responsibilities (personnel files numbered 1 and 3 through 5); 2) Policies and procedures (personnel files numbered 1, 3, and 5); 3) Client confidentiality (personnel files numbered 3 and 4); 4) Client needs (personnel files numbered 1 and 3 through 5); and b. Within 72 hours of first providing direct contact services: 1) Reporting requirements and definitions in Minnesota Statutes, sections 245A.65, 626.557 and 626.5572 (personnel files numbered 3 and 4); 2) HIV minimum standards (personnel files numbered 3 and 4); 3) Program abuse prevention plan (personnel files numbered 1 and 3 through 5); 4) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 3 and 5); and c. Before direct client contact: 1) Reporting requirements and definitions in Minnesota Statutes, chapter 260E (personnel files numbered 1, 3 through 5); 2) Emergency overdose treatment (personnel files numbered 3 and 4); and 3) Drug and alcohol policy (personnel files numbered 1 and 5). 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, subdivision 3, 245G.13, subdivisions 1, clause (7) and 2, paragraphs (d) and (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the documentation of personnel orientation meets all applicable requirements. Client Files 6. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements. The CA did not include documentation of the following: a. Substance use history, including (client files numbered 2 and 3): 1) Periods of abstinence; and 2) Circumstances of relapse; and b. A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner (client file numbered 1). 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. 7. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. There was no documentation of the following: a. A treatment strategy (client files numbered 1 through 3); and b. The ASAM level of care (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Within 45 days of receipt of this order, submit an individual treatment plan that meets all applicable requirements. 8. Violation: One of three client files reviewed for requirements governing treatment plan reviews (client file numbered 1) did not meet requirements. A treatment plan review was not completed once every 30 days following the completion of a treatment plan. The treatment plan review was due on December 7, 2025; however, was not completed until January 7, 2026. Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 3a, paragraph (e). Corrective Action: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 9. Violation: One of three client files reviewed for requirements governing service discharge summaries (client file numbered 1) did not meet requirements. The discharge summary did not document the following: a. The client’s progress toward achieving each of the goals identified in the individual treatment plan; and b. The reason for and circumstances of service termination. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service discharge summaries 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
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