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August 14, 2026 CERTIFIED MAIL Christiana Greene, Authorized Agent One Touch of Christ Evangelistic Ministries 5701 Shingle Creek Parkway, Suite 650 Brooklyn Center, MN 55430 License Number 1101002 (245G) ORDER OF LICENSE REVOCATION Dear Christiana Greene: The Department of Human Services (DHS) is revoking your license to provide substance use disorder treatment services at Lifechoices, located at 5701 Shingle Creek Parkway, Suite 650, Brooklyn Park, MN 55430. This revocation is based on failure to comply with licensing laws and rules and commissioner’s evaluation of program. Details of our findings are provided below. Our next steps and your options are also detailed. The revocation goes into effect on August 31, 2026 at 5:00pm to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. LICENSING VIOLATIONS DETERMINED ON MAY 18 AND 19, 2026: DHS determined that your program did not follow licensing rules and statutes, as described below. 1. Violation: The license holder did not meet requirements for receiving public funding reimbursement from the commissioner for services provided in the following ways: a. One hour of individual counseling was billed, however, there was no supporting documentation in the client records on March 17, 2026 (client file numbered 2); b. Documentation of peer recovery services did not meet requirements as a billable treatment service. The documentation did not describe which specific goal in the treatment plan was discussed and addressed or reflect a conversation pertaining to recovery. The documentation only described urinalysis collection, a task that is not defined as a treatment service in Minnesota Statutes, section 245G.07 on: 1) January 5 and 8, 2026 (client file numbered 1); and 2) August 25, 27, 29, 2025, and November 17, 2025 (client file numbered 3); c. Peer recovery services were provided by an individual who did not meet the qualifications as a recovery peer according to the Minnesota Statutes, section 245I.04, subdivision 18 between November 7, 2024, and February 1, 2026 (staff file numbered 1); d. Treatment coordination was provided by an individual who did not meet the qualifications as a treatment coordinator according to Minnesota Statutes, section 245G.11, subdivision 7, paragraph (a) (client file numbered 5) on the following dates: 1) 2 hours on September 7, 2025; 2) 2 hours on September 27, 2025; 3) 30 minutes on October 19, 2025; 4) 2 hours on October 27, 2025; 5) 1 hour on October 28, 2025; and 6) 1 hour on October 30, 2025; e. The license holder did not meet requirements for telehealth services as required by Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c). While on site, a DHS licensor observed group treatment services being provided via telehealth. Per staff interviews with the Authorized Agent and Treatment Director, it was confirmed that telehealth groups are held every Tuesday. This practice was also confirmed through client documentation review (client files numbered 1 through 3). There was no documentation of the following for groups held on August 26, 2025, January 6, March 17, and April 7, 2026: 1) The license holder’s basis for determining that telehealth is an appropriate and effective means for delivering treatment services; 2) The mode of transmission; and 3) The location of the originating site and the distance site; f. The license holder did not meet applicable requirements under Minnesota Statutes, section 254B.0507, subdivision 6, for enhanced rates for services provided to individuals with co-occurring mental health and substance use disorder problems as follows: 1) There was no documentation that co-occurring counseling staff received 8 hours of co-occurring disorder training annually for the following years: a. 2024 and 2025 (personnel file numbered 2); and b. 2026 (personnel file numbered 3); 2) Diagnostic assessments (DA) were not completed within 10 days of admission: a. DA was due on January 4, 2026; however, it was completed on May 17, 2026; 134 days late (client file numbered 1); b. DA was due on February 22, 2026; however, it was completed on May 14, 2026; 82 days late (client file numbered 2); and c. DA was due on July 10, 2025; however, it was not completed at time of discharge on January 27, 2026; 202 days late (client file numbered 3); and 3) There was no documentation of multidisciplinary case reviews for the following months: i. February and April 2026 (client file numbered 1); ii. April 2026 (client file numbered 2); and iii. July through December 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, sections 245A.167, paragraph (a) and 245A.191, paragraph (a). 2. Violation: The license holder did not monitor the implementation of program policies and procedures necessary to maintain compliance with licensing requirements as follows: a. The license holder’s policies titled as follows contained repealed statute language: 1) Comprehensive assessment: 2) Assessment summary; 3) Individual treatment plan; 4) Documentation of treatment services; 5) Discharge summary; 6) Staffing requirements; 7) Reporting prenatal exposure; 8) Maltreatment of minors reporting; and 9) Program Abuse Prevention Plan; a. The policy and procedure manual contained two conflicting service termination policies; b. The treatment service description of peer recovery support services contained information that conflicted with statue requirements including: 1) The staff qualifications to provide peer recovery support services; and 2) The type of services a peer can provide; c. The policy and procedure manual did not contain the following policies: 1) A telehealth services policy as required per Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c); and 2) Personnel policies that describe behavior that constitutes grounds for disciplinary action, suspension, or dismissal, including: i. Policies prohibiting personal involvement with a client in violation of Minnesota Statutes, chapter 604; and ii. Policies prohibiting client abuse described in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 and chapter 260E. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraphs (a) and (b), 245A.65, subdivision 2, 245G.07. subdivision 4, paragraph (c), 245G.12, clauses (1), (4), (8) and (9), 245G.13, subdivision 1, clause (4), and 245G.14, subdivision 1. Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 3. Violation: Thirteen of thirteen client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The client file did not contain an individual treatment plan as follows: 1) The ITP was due by March 20, 2026; however, it was not completed at the time of the licensing review; client received treatment services for approximately 2 months without an ITP (client file numbered 8); 2) The ITP was due November 3, 2024; however, it was not completed as of date of discharge; client received treatment services for approximately 1 year and 2 months without an ITP (client file numbered 10); and 3) The ITP was due February 18, 2026; however, it was not completed at the time of the licensing review; client received treatment services for approximately 3 months without an ITP (client file numbered 12); b. The ITP was not completed by the end of the tenth day on which a treatment session had been provided, not to exceed 30 days, as follows: 1) The ITP was due by January 14, 2026; however, it was not completed until May 19, 2026; 125 days late and completed after the start of the licensing review (client file numbered 1); 2) The ITP was due by February 26, 2026; however, it was not completed until April 27, 2026; 61 days late (client file numbered 2); 3) The ITP was due by July 16, 2025; however, it was not completed until November 20, 2025; 128 days late (client file numbered 3); 4) The ITP was due by April 3, 2026; however, it was not completed until April 24, 2026; 21 days late (client file numbered 4); 5) The ITP was due by November 18, 2022; however, it was not completed until May 13, 2026; 1273 days late (client file numbered 5); 6) The ITP was due by October 11, 2025; however, it was not completed until March 18, 2026; 159 days late (client file numbered 7); 7) The ITP was due by March 15, 2026; however, it was not completed until April 24, 2026; 41 days late (client file numbered 9); 8) The ITP was due by December 5, 2025; however, it was not completed until April 24, 2026; 141 days late (client file numbered 11); and 9) The ITP was due by May 10, 2024; however, it was not completed until March 6, 2026; 666 days late (client file numbered 13); c. The (ITP) was not developed by the alcohol and drug counselor as required. In interviews with staff and clients, it was identified that the peer recovery specialist developed the ITP. The LADC would sign the document after the recovery peer; however, once the recovery peer signed the ITP, it was not editable. This was confirmed through review of client documentation as follows: 1) The ITP was signed by the recovery peer on March 17, 2026, and by the LADC on April 27, 2026 (client file numbered 2); 2) The ITP was signed by the recovery peer on April 20, 2026, and by the LADC on April 24, 2026 (client file numbered 4); 3) The ITP was signed by the recovery peer on March 17, 2026, and by the LADC on May 13, 2026 (client file numbered 5); 4) The ITP was signed by the recovery peer on March 17, 2026, and by the LADC on March 18, 2026 (client file numbered 7); and 5) The ITP was signed by the recovery peer on April 20, 2026, and by the LADC on April 24, 2026 (client file numbered 9); d. The ITP was not signed by the client and did not document the client’s involvement in the development of the plan (client files numbered 1 through 4, 6, 9, 11, and 13); and e. The ITP did not include the following: 1) A treatment strategy (client files numbered 1, 2, and 3); 2) A schedule for accomplishing the client’s treatment goals and objectives (client files numbered 1, 2, and 3); 3) The America Society of Addiction Medicine (ASAM) level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1 and 3); and 4) Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 1 and 1a, paragraph (a). Repeat Violation: You were previously cited for a similar violation in the following orders: · Correction order dated April 11, 2019 · Correction order dated May 10, 2018 4. Violation: The license holder did not meet requirements governing medical emergencies. The license holder did not ensure that at least one staff member on the premises had a current American Red Cross CPR and standard first aid certificate or an equivalent certificate from March 18, 2025, through August 26, 2025. Statute Violated: Minnesota Statutes, section 245G.10, subdivision 5. 5. Violation: Two of four client files reviewed for requirements governing record keeping requirements did not meet requirements. The license holder did not protect client records against unauthorized disclosure according to Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67. During the licensing review, the DHS licensor overheard conversations that were not authorized by a release of information as follows: a. On May 19, 2026, at 11:00 a.m., a staff person and a client had a conversation regarding another client who was not present (client file numbered 2). The conversation included information about the client’s medical condition and current location; b. On May 19, 2026, prior to the start of 9:00 a.m. group, two staff persons and a client had a conversation regarding another client who was not present (client file numbered 4). The conversation included information regarding the client’s absence from treatment, current legal involvement, and plan for treatment discharge; and c. On May 19, 2026, at 12:09 p.m., two staff persons and a client had a conversation regarding another client who was not present (client file numbered 4). This conversation included the status of treatment participation and the client’s significant relationships.
Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (a). 6. Violation: Three of three personnel files reviewed for requirements governing staff orientation did not meet requirements as follows: a. The personnel file was missing documentation of the following orientation: 1) Client needs (personnel files numbered 1 and 3); 2) HIV minimum standards (personnel file numbered 3); 3) Maltreatment of vulnerable adults reporting requirements in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 (personnel file numbered 3); 4) Program abuse prevention plan (personnel files numbered 1 and 3); 5) All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 3); 6) Maltreatment of minors reporting requirements (personnel files numbered 1 and 3); and 7) 12 hours of training in co-occurring disorders (personnel files numbered 2 and 3); and b. Orientation documentation was not completed within the required timeframes. The following orientation documents were completed July 25, 2024; however, the staff person’s date of hire was November 07, 2024 (personnel file numbered 1): 1) Policies and procedures within 24 working hours of employment; 2) HIV minimum standards within 72 hours of employment; and 3) Within 72 hours of first providing direct client contact: i. Maltreatment of vulnerable adult reporting requirements in Minnesota Statutes, section 245A.65, 626.557, and 626.5572; and ii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute Violated: Minnesota Statutes, sections 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) through (f). Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 7. Violation: Three of three personnel files reviewed for requirements governing annual training did not meet requirements. There was no documentation of the following annual training: a. Vulnerable adult maltreatment reporting requirements as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E, including specific training covering the license holder’s policies for obtaining a release of client information for years: 1) 2024 (personnel file numbered 2); and 2) 2025 (personnel files numbered 1, 2, and 3); b. The license holder’s program abuse prevention plan for years: 1) 2024 personnel file numbered 2); and 2) 2025 (personnel files numbered 1, 2, and 3); c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving care for years: 1) 2024 personnel file numbered 2); and 2) 2025 (personnel files numbered 1, 2, and 3); d. Reporting of maltreatment of minors for years: 1) 2024 personnel file numbered 2); and 2) 2025 (personnel files numbered 1, 2, and 3); e. HIV minimum standards, for which the license holder chose to develop their own training instead of using that which is made available by the commissioner, including: 1) HIV Basics for years: a. 2024 personnel file numbered 2); and b. 2025 (personnel files numbered 2, and 3); 2) HIV transmission and prevention for years: a. 2024 personnel file numbered 2); and b. 2025 (personnel files numbered 2, and 3); 3) Substance use and HIV for years: a. 2024 (personnel file numbered 2); and b. 2025 (personnel files numbered 1, 2, and 3); 4) Opioid overdose prevention for years: a. 2024 personnel file numbered 2); and b. 2025 (personnel files numbered 1, 2, and 3); 5) Resources for support with HIV or SUD for years: a. 2024 personnel file numbered 2); and b. 2025 (personnel files numbered 2, and 3); 6) Program’s policies and procedures for working with HIV-infected clients and referring clients to individual HIV counseling and services when needed for years: a. 2024 personnel file numbered 2); and b. 2025 (personnel files numbered 2, and 3). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b) and 245G.13, subdivision 2, paragraphs (c) and (d). 8. Violation: Four of four client files reviewed for requirements governing client orientation did not meet requirements as follows: a. The client file did not contain documentation of the following orientation: 1) Client rights and responsibilities in Minnesota Statutes, sections 144.651 and 148F.165 (client files numbered 1 through 4); 2) Grievance procedure (client files numbered 1 through 4); 3) Opioid education material approved by the commissioner (client files numbered 1 through 4); 4) HIV minimum standards (client files numbered 1 through 4); 5) Tuberculosis (client files numbered 1 through 4); 6) Personal electronic device policy (client file numbered 3); 7) Maltreatment of vulnerable adults internal and external reporting policies (client files numbered 1 through 4); and 8) The program abuse prevention plan (client files numbered 3 through 4); and b. Orientation to the program abuse prevention plan was completed late. Orientation was due on December 26, 2025; however, it was not completed until December 31, 2025; 5 days late (client file numbered 1); Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 3, 245G.04, subdivision 3, 245G.09, subdivision 3, paragraph (a), and 245G.15. 9. Violation: Three of three client files reviewed for requirements governing initial service plans (ISP) did not meet requirements as follows: a. The ISP was not completed within 24 hours of the day of service initiation: 1) The ISP was due on December 27, 2025; however, it was not completed until January 14, 2026; 18 days late (client file numbered 1); and 2) The ISP was due February 13, 2026; however, it was not completed at the time of the licensing review; 94 days late (client file numbered 2); and 3) The ISP was due on July 1, 2025; however, it was not completed until July 23, 2025; 22 days late (client file numbered 3); b. The ISP was not person-centered and client-specific (client files numbered 1 and 3); and c. The ISP did not identify needs to be addressed during the time between the day of service initiation and the development of the individual treatment plan (client files numbered 1 and 3). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 10. Violation: Three of three client files reviewed for requirements governing vulnerable adult determinations did not meet requirements. The vulnerable adult determination was not completed within 24 hours of the day of service initiation as follows: a. The vulnerable adult determination was due December 27, 2025; however, it was not completed until January 14, 2026; 18 days late (client file numbered 1); b. The vulnerable adult determination was due February 13, 2026; however, it was not completed until March 17, 2026; 32 days late (client file numbered 2); and c. The vulnerable adult determination was due July 1, 2025; however, it was not completed until July 23, 2025; 22 days late (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 2, paragraph (a). 11. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements as follows: a. A comprehensive assessment was not completed by the end of the fifth day on which a treatment service was provided as follows: 1) The comprehensive assessment was due on January 5, 2026; however, it was not completed until January 14, 2026; 5 days late (client file numbered 1); 2) The comprehensive assessment was due on February 21, 2026; however, it was not completed until March 17, 2026; 21 days late (client file numbered 2); and 3) The comprehensive assessment was due on July 8, 2025; however, it was not completed until July 23, 2025; 9 days late (client file numbered 3); b. A person-centered reason for the delay and the planned completion date was not documented in the client file (client files numbered 1, 2, and 3); and c. The comprehensive assessment did not contain the following: 1) The status of the client’s basic needs (client files numbered 1, 2, and 3); 2) Immediate risks including behavioral and emotional symptoms (client files numbered 1, 2, and 3); 3) The client’s perception of the client’s condition (client files numbered 1, 2, and 3); 4) The client’s description of the client’s symptoms (client files numbered 1, 2, and 3); 5) The client’s history of mental health and substance use disorder treatment (client file numbered 3); 6) Substance use history, including: a. Amount of substance (client files numbered 1 through 3); b. Frequency (client files numbered 1 through 3); c. Duration (client files numbered 1 through 3); d. Route of administration (client file numbered 3); and e. Circumstances of relapse (client file numbered 1); 7) The client’s evaluation of each significant personal relationship (client file numbered 1 and 3); 8) The client’s resources (client files numbered 1, 2, and 3); 9) Important developmental incidents in the client’s life (client file numbered 1 and 3); 10) Family health history (client file numbered 2 and 3); 11) A determination of whether the individual screened positive for co-occurring mental health disorders (client files numbered 1, 2, and 3); 12) A summary to support the risk rating within each dimension listed in Minnesota Statutes, section 254B.04, subdivision 4, paragraphs (b) through (g) (client file numbered 3); and 13) Recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245G.05 subdivisions 1, paragraphs (a) and (c), and 3. Repeat Violation: You were previously cited for a similar violation in the following orders: · Correction order dated April 11, 2019 · Correction order dated May 10, 2018 12. Violation: Four of four client files reviewed for requirements governing documentation of treatment services did not meet requirements in the following ways: a. Client documentation did not record: 1) Type of treatment service: a. January 7, 2026 (client file numbered 1); b. August 25, 2025 and November 19, 2025 (client file numbered 3); and c. A note on September 27, 2025 identified the treatment service as both peer support and treatment coordination (client file numbered 5); 2) Amount of treatment service: a. January 5 and 6, 2026 (client file numbered 1); b. March 16, 17, 18, 19, April 7, 8, and 9, 2026 (client file numbered 2); and c. August 25, 26, 27, 28, November 17, 19, and 20, 2025 (client file numbered 3); 3) Client response to a service provided on March 18, 2026 (client file numbered 2); and b. Documentation was not signed within 7 days of providing the treatment service on the following dates: 1) January 7, 2026 (client file numbered 1); and 2) October 30, 2025 (client file numbered 4); c. Documentation did not include the job title or position of the staff member making the entry on the following dates: 1) January 4, 5, 8, and April 15, 2026 (client file numbered 1); 2) March 15, 21, April 7 and 10, 2026 (client file numbered 2); 3) August 25, 29, November 18 and 22, 2025 (client file numbered 3); and 4) September 7, 27, 2025, October 27, 28, and 30, 2025; and d. Peer recovery support services entries contained a templated note which did not describe services provided. During staff interviews, it was confirmed the note was copied and pasted and not reflective of the services provided on the following dates: 1) April 15, 2026 (client file numbered 1); and 2) March 15, 17, 21, April 7, and 10, 2026 (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivisions 2a and 2b, paragraph (c). 13. Violation: The license holder did not meet requirements governing the program abuse prevention plan (PAPP) as follows: a. The PAPP did not document an evaluation of factors which may encourage or permit abuse, including: 1) Age; 2) Gender; 3) Mental functioning; 4) Physical & emotional health or behavior of clients; 5) Need for specialized programs of care for clients; 6) Need for training of staff to meet identified individual needs; and 7) Knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; and b. The PAPP did not document specific measures to be taken to minimize the risk of abuse. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. 14. Violation: The license holder’s treatment service description did not include the following: a. Type of service provided: and b. Which services meet the definition of group counseling. Statute Violated: Minnesota Statutes, section 245G.12, clause (10).
15. Violation: The license holder did not meet requirements governing client rights protection. The license holder’s client rights policy did not include client rights as identified in Minnesota Statutes, sections 144.651 and 253B.03 Statute Violated: Minnesota Statutes, sections 245G.12, clause (5) and 245G.15, subdivision 1. 16. Violation: The license holder did not meet requirements governing grievance procedures. The license holder’s grievance procedure did not include the following: a. The address and phone number for the Board of Behavioral Health and Therapy; and b. A statement that the client may bring the grievance to the highest level of authority in the program if not resolved by another staff member. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2, clause (2) and (3). 17. Violation: The license holder did not meet requirements governing emergency overdose treatment. The license holder did not maintain a written standing order protocol for intramuscular naloxone maintained on site. Statute Violated: Minnesota Statutes, sections 245A.242, subdivision 2, paragraph (a) and 245G.08, subdivision 3. 18. Violation: The license holder did not meet requirements governing HIV minimum standards. The license holder did not maintain written policies and procedures consistent with HIV minimum standards contained in the HIV-1 guidelines for substance use disorder treatment and care programs in Minnesota. Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (a) and 245G.12, clause (1). Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 19. Violation: The license holder did not meet requirements governing personnel policies and procedures as follows: a. There was no written plan that included orientation within 24 working hours to policies and procedures, client needs, HIV minimum standards; and client confidentiality; and b. The alcohol and drug policy did not prohibit license holders, employees, subcontractors, and volunteers from abusing prescription medications. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245G.12, clause (4), and 245G.13, subdivision 1, clauses (5) and (7). 20. Violation: One personnel file reviewed for requirements governing every two year training (personnel file numbered 2) did not meet requirements. There was no documentation of training on client rights as specified in Minnesota Statutes, sections 144.651, 148F.165, and 253B.03 for the year 2024. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 2, paragraph (b). 21. Violation: One of three personnel files reviewed for requirements governing personnel file contents (personnel file numbered 2) did not meet requirements. The license holder did not document an annual job performance evaluation for the year 2024. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1, clause (3). Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 22. Violation: Two of four client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements as follows: a. TPR was due on July 30, 2025; however, the file did not include documentation of a TPR (client file numbered 3); and b. The TPR was signed on April 24, 2026, prior to the completion of the ITP on April 27, 2026. (client file numbered 2). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3a, paragraph (e). Repeat Violation: In a correction order dated May 10, 2018, you were previously cited for a similar violation. 23. Violation: One client file reviewed for requirements governing discharge summaries (client file numbered 3) did not meet requirements. The discharge summary did not document the client’s strengths and needs while participating in treatment, including services provided.
Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4, paragraph (b). 24. Violation: One client file reviewed for requirements governing the drug and alcohol abuse normative evaluation system (DAANES) (client file numbered 3) did not meet requirements. There was no documentation that information about the client to DAANES. During an exit interview, the license holder confirmed that the program is not submitting DAANES information for any client at admit or discharge.
Statute Violated: Minnesota Statutes, section 245G.17. REASON FOR LICENSE REVOCATION 1. Failure to comply with licensing laws and rules DHS determined that your program failed to fully comply with the laws and rules that apply to licensed Substance Use Disorder Treatment programs. DHS has also considered the nature, chronicity, and severity of the violations and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that revocation of your license is appropriate. Nature and severity of licensing violations determined Many of the violations cited in the Order of Revocation are violations impacting the health, safety, or rights of individuals served by the program. The violations include: § Three violations related to client assessment and treatment planning were determined (violations 1, 3, and 11). These violations were found in all the client files reviewed. None of the comprehensive assessments reviewed were completed within the required timeframe. A review of all current clients was completed for treatment plans and only one file had a treatment plan completed within the required timeframe. Treatment plans were completed after the license holder received notification on March 12, 2026, of the upcoming licensing review. Additionally, it was confirmed through staff interviews that not all treatment plans were completed by qualified staff. Lack of timely assessments and treatment plans completed by qualified staff makes it difficult to determine the appropriateness of services provided to clients. § Three violations related to the documentation and provision of treatment services were determined (violations 1, 8, and 12) . These violations were found in all client files reviewed. As a SUD treatment license holder, you are required to provide person-centered treatment services based on recommendations from the client’s comprehensive assessment. Further, services provided were not consistent with what was reimbursed through public funding. § Eight violations related to maintaining compliant policies and procedures were determined (violations 2 and 13 through 19). Staff interviewed during the licensing review provided conflicting information regarding your policies and practices, and noncompliant policies and procedures present significant risk regarding client rights, health and safety, and program integrity. Noncompliant policies and procedures also demonstrate the license holder’s lack of competent knowledge related to Minnesota Statutes, chapters 245A and 245G. § One violation related to the unauthorized disclosure of client records was determined (violation 5), in violation of the Code of Federal Regulations, title 42. Failure to protect client rights in this manner is an egregious breach of trust and could negatively impact client participation in treatment. § Two violations related to staffing requirements and qualifications were determined (violations 1 and 4). Staff providing treatment services in an SUD treatment program must be qualified to do so, and you did not verify that staff were qualified. You allowed unqualified staff to provide peer support and treatment coordination services. During interviews, the Authorized Agent and Treatment director were unable to speak to the statute requirements for staff qualifications. Further, you did not ensure that there was a staff member on site when clients were present that was CPR and first aid trained. This presents a significant safety risk to clients. § Three violations related to staff orientation and development were determined (violations 6, 7, and 20) . None of the personnel files reviewed for requirements governing staff orientation and ongoing staff development had documentation of trainings completed within the statue timeframe, with many of the trainings not completed at all. A risk to the health and safety of your clients is compromised when staff are not trained on items such as emergency procedures, maltreatment reporting, and the program abuse prevention plan. Chronicity Your program received its license on February 3, 2020, and the May 2026 licensing review noted in this order was the first licensing review of license 1101002, Lifechoices. From January 2017 to February 2020, you were a controlling individual and the Authorized Agent of Life Choices Chemical Health, a nonresidential substance use disorder treatment program that was licensed under Minnesota Statutes, chapter 245G, at the same location as license 1101002. Life Choices Chemical Health’s license was closed in February 2020. The history of noncompliance of that program was taken into consideration, including a correction order issued on April 11, 2019, that cited seven violations and a correction order issued on May 10, 2018, that cited 17 violations. Additionally, eight violations determined on May 18 and 19, 2026, in the current order are repeat violations that were previously cited in the May 10, 2018, correction order and/or the April 11, 2019, correction order. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1). 2. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of persons served by your program, information about the qualifications of staff persons that are working in your program, and the license holder’s ability to demonstrate competent knowledge of the applicable requirements of statutes and rules. As a license holder, you are enrolled to receive public funding reimbursement for services. You must comply with enrollment requirements as licensing standards. You have egregiously violated these standards as described in violation number one above. You additionally have not engaged in person centered treatment planning as demonstrated by not developing individualized treatment plans in a timely manner or completing treatment plan reviews. The health and safety of clients was put in jeopardy, as you did not ensure that staff on site with clients were trained in CPR and first aid. Further, the numerous violations related to noncompliance of policies and failure to ensure staff were qualified to provide treatment services indicate a lack of competency related to statutory requirements governing substance use disorder treatment programs. DHS has determined that revocation of your license is appropriate based on the Commissioner’s evaluation of the program. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Substance Use Disorder treatment services is revoked. YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: 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 10 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 Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must comply with the conditions described below. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license. If you continue to operate pending the outcome of your appeal, you must comply with the following conditions: 1. While operating pending appeal, you cannot apply for or be issued an additional DHS License; 2. Within 14 days of filing an appeal, you must notify current clients and all parties who refer individuals to your program of the status of your license: revoked operating under appeal. While operating pending appeal, you must notify new clients and referral sources that the license is revoked and operating under appeal before they begin receiving services. A copy of the notice with client and/or legal representative(s) signature must be maintained in the client file.
3. Within 14 days of filing an appeal, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of owner, treatment director or authorized agent. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor: a. Two years of professional experience in the following: 1) A regulatory or compliance position; 2) Involved in direct care as a providing substance use disorder services in a DHS Licensed substance use disorder licensed program, or 3) If applicable, the development and implementation of substance use disorder treatment planning in a DHS licensed substance use disorder licensed program. b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and Minnesota Statutes, Chapter 245G, Substance Use Disorder Licensed Treatment Facilities; and c. A bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology, or a related field may substitute for one year of professional experience. 4. Within 30 days of compliance officer approval, you must implement DHS Licensing’s self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapter 245A and 245G. This includes an assessment of staff implementing the policies and procedures. Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan, discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the appeal or otherwise determined by DHS licensing. 5. Within 30 days of filing an appeal within the timeframes described above, you must submit documentation to demonstrate all violations identified above have been corrected. This includes verification of staff training, revising non-compliant policies and procedures, etc. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. · The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). · Minnesota Statutes, section 245.095 defines which programs administered by DHS are included in the exclusion provision, and further defines “excluded,” “individual,” and “provider.” · License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. · If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. · Under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (b), the commissioner may include terms the license holder must follow pending a final order on appeal. Questions If you have any further questions regarding this matter, you may contact Maura McGarry, Supervisor, at 651-431-6671. Sincerely,
Katie Leuer, Manager Licensing Division Office of Inspector General
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