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August 19, 2026 Pamela Schmitt, Authorized Agent Family Faith Recovery Center LLC 1303 S Frontage Rd Ste 280 Hastings, MN, 55033 License Number: 1043856 CORRECTION ORDER Dear Pamela: On May 26, 27, 28, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, 1303 S Frontage Rd Ste 280, Hastings, MN, 55033. 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 physical plant postings. The license holder did not have a copy of the program abuse prevention plan posted in a prominent location in the program. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that physical plant postings meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 2. Violation: The license holder did not meet requirements governing service termination policies. The license holder’s policies did not require staff members to assist the client with assessing needs of care or other resources. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 3, clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the service termination policy meets all applicable requirements. Within 30 days of receipt of this order, submit a service termination policy that meets all applicable requirements. 3. Violation: The license holder did not meet requirements governing client rights policies. The license holder’s policies did not include client rights as identified in Minnesota Statutes, section 144.651. Statute Violated: Minnesota Statutes, sections 245G.12, clause (5) and 245G.15, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client rights policies meet all applicable requirements. Within 30 days of receipt of this order, submit a client rights policy that meets all applicable requirements. 4. Violation: The license holder did not meet requirements governing photographs of client. The license holder’s personal electronic device policy did not address the use of any personal electronic device that can record, transmit, or make images of another client. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personal electronic device policy meets all applicable requirements. Within 30 days of receipt of this order, submit a personal electronic device policy that meets all applicable requirements. 5. Violation: The license holder did not meet requirements governing the description of treatment services. a) The license holder’s description of treatment services did not include the following: 1) The amount and type of treatment services provided; and 2) Groups and topics on which a guest speaker could provider under the direct observation of an alcohol and drug counselor; and a) Policy did not identify treatment coordination as a treatment service the program must offer. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 1 and 245G.12, clause (10). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the description of treatment services meets all applicable requirements. Within 30 days of receipt of this order, submit a description of treatment services that meet all applicable requirements. 6. Violation: The license holder did not meet requirements governing the use guest speakers. There was no documentation of the license holder providing the guest speaker with all training required for staff members. Statute Violated: Minnesota Statutes, sections 245G.07, subdivision 3a, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the use of guest speakers meets all applicable requirements. 7. Violation: The license holder did not meet requirements governing client records policies. The license holder’s policies did not include how the program will track and record client attendance at treatment activities, including the date, duration, and nature of each treatment service provided to the client. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b) and 245G.12, clause (8). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the client attendance tracking and records policies meet all applicable requirements. Within 30 days of receipt of this order, submit a client attendance tracking and records policy that meets all applicable requirements. 8. Violation: The license holder did not meet requirements governing description of health services care. The license holder’s description of health care services did not include the program’s procedures for administering opiate antagonist medications. Statute Violated: Minnesota Statutes, sections 245A.242, subdivision 2, paragraph (b), 245G.08, subdivision 3, and 245G.12, clause (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the description of health care services meets all applicable requirements. Within 30 days of receipt of this order, submit a description of health care services that meet all applicable requirements. 9. Violation: The license holder did not meet requirements governing behavioral emergency procedures. The license holder’s behavioral emergency procedure policies did not include: a) Person-centered planning and trauma-informed care; b) Types of procedures that may be used; and c) Staff members authorized to implement behavioral emergency procedures. Statute Violated: Minnesota Statutes, sections 245G.12, clause (7) and 245G.16, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the behavioral emergency procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a behavioral emergency procedures that meets all applicable requirements. 10. Violation: The license holder did not meet requirements governing the program abuse prevention plan. a) The program abuse prevention plan did not include: 1) The evaluation of the location of the program in a particular neighborhood or community; 2) An assessment of the physical plant; and 3) A statement of specific measures to be taken to minimize the risk of abuse; and b) There was no documentation of an annual review of the program abuse prevention plan for the year2024and 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a).
Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan policy meets all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 11. Violation: The license holder did not meet requirements governing vulnerable adult maltreatment reporting policies. The license holder’s policies did not include a requirement to ensure that an internal review is completed within 30 calendar days. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the vulnerable adult maltreatment reporting policy meets all applicable requirements. Within 30 days of receipt of this order, submit a vulnerable adult maltreatment reporting policy that meets all applicable requirements. 12. Violation: The license holder did not meet requirements governing personnel policies and procedures. The personnel policies and procedures did not include: a) Policies prohibiting client abuse described in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572 and chapter 260E; and b) A chart or description of the organizational structure indicating lines of authority and responsibilities. Statute Violated: Minnesota Statutes, section 245G.12, clause (4) and 245G.13, subdivision 1, clauses (4) and (6). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the personnel policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit the policies identified above that meet all applicable requirements. 13. Violation: The license holder did not have a policy for reporting a death in the program. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 16. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policy for reporting a death in the program meets all applicable requirements. Within 30 days of receipt of this order, submit a policy for reporting a death in the program that meets all applicable requirements. 14. Violation: The license holder did not meet requirements governing the plan for transfer of clients and records upon closure. The policy manual did not contain the following: a) A policy for plan of transfer of clients and records upon closure; and b) A signed agreement or other documentation indicating that a county or a similarly licensed provider has agreed to accept and maintain the program’s closed case records and to provide follow-up services as necessary to affected clients. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the policy for plan for transfer of clients and records upon closure meets all applicable requirements. Within 30 days of receipt of this order, submit a policy for plan for transfer of clients and records upon closure that meets all applicable requirements. Personnel Files 15. Violation: Two of two personnel files (personnel files numbered 1 and 2) did not meet requirements governing staff training. There was no documentation of training to the following: a) Annual training for the calendar years 2024 and 2025: 1) Program abuse prevention plan; and 2) HIV minimum standards; and Every 2 year training for emergency procedures for the calendar year 2024 Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (b) through (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the documentation of personnel orientation meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the trainings identified above have been completed. Client Files 16. Violation: Two of three client files reviewed for requirements governing client orientation (client files numbered 1 and 3) did not meet requirements. There was no documentation of orientation to the personal electronic device policy. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 3, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the documentation of client orientation meets all applicable requirements. 17. 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) Status of client’s basic needs (client file numbered 3); b) Client’s perception of the client’s condition (client file numbered 3); c) Client’s description of the client’s symptoms (client file numbered 3); d) Substance use history, including: 1) Duration (client files numbered 1 through 3); 2) Route of administration (client file numbered 3); and 3) Periods of abstinence (client files numbered 1 and 2); e) Client’s relationship with the client’s family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client files 1 through 3); f) Client’s strengths and resources (client files numbered 1 and 3); g) Important developmental incidents in the client’s life (client files numbered 1 and 3); and h) Client’s family health history (client files numbered 1 and 3); 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 30 days of receipt of this order, submit a comprehensive assessment that meets all applicable requirements. 18. 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 American Society of Addiction Medicine (ASAM) level of care (client files numbered 1 and 2). Statute Violated: Minnesota statutes, sections 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 30 days of receipt of this order, submit a treatment plan that meets all applicable requirements. 19. Violation: Two of three files reviewed for requirements governing client records did not meet requirements. Documentation was not completed within 7 days of the treatment service being provided on the following dates: a) April 20, 2026 (client file numbered 1); and b) February 24, 2026 (client file numbered 3). Statute Violated: Minnesota Statute, sections 245G.06, subdivision 2a. Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all client records 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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