August 24, 2026                      

Yussuf Shafie, Authorized Agent

Alliance Wellness Center

8040 Old Cedar Ave S, Suite 101

Bloomington, MN 55425

License Number: 1077449, 1121235, 1116958

CORRECTION ORDER

Dear Yussuf:

On June 1, 2, and 3, 2026, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Alliance Wellness Center located at:

· 8040 Old Cedar Ave S., Suite 101, Bloomington, MN (1077449)

· 7170 Bryant Lake Drive, Eden Prairie, MN (1121235)

· 1400 Energy Park Drive, Suite 21, St. Paul, MN (1116958)

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. Three hours of group was billed on April 13, 15, and 21, 2026; however, there was two hours of group documented (client file numbered 1);

b. Three hours of group was billed on February 2, 3, 4, 5, and 9, 2026; however, there was two hours of group documented (client file numbered 2);

c. One hour of individual counseling was billed on February 7, 2026; however, there was 30 minutes of individual counseling documented (client file numbered 2);

d. Six hours of group was billed on November 17 and 20, 2025 and January 12, 13, and 14, 2026; however, there was five hours of group documented (client file numbered 4);

e. Five hours of group was billed on November 18 and 19, 2025 and January 15, 2026; however, there was four hours of group documented (client file numbered 4);

f. Three hours of group was billed on November 21, 2025; however, there was two hours of group documented (client file numbered 4); and

g. 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 1 and 5); and

2) A multi-disciplinary case review completed monthly for the following:

i. April and May 2026 (client file numbered 1);

ii. December 2025, January, February, and March 2026 (client file numbered 2);

iii. February, March, April, and May 2026 (client file numbered 3); and

iv. October, November, and December 2025, January and February 2026 (client file numbered 4).

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 service initiation policy and procedures. The policy did not ensure that the specific service initiation criteria included adolescents.

Statute Violated: Minnesota Statute, section 245G.14, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation meets all applicable requirements. Within 30 days of receipt of this order, submit a service initiation policy that meets all applicable requirements.

3. Violation: The license holder did not meet requirements governing grievance procedures. The policy did not ensure that the grievance procedure is made available upon a former client’s request.

Statute Violated: Minnesota Statute, section 245G.15, subdivision 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that grievance procedures meets all applicable requirements. Within 30 days of receipt of this order, submit a grievance procedure that meets all applicable requirements.

4. Violation: The license holder did not meet requirements governing physical plant postings (1077449). The program abuse prevention plan, grievance procedure, and maltreatment of vulnerable adults reporting policies were not posted in a prominent location.

Statute Violated: Minnesota Statute, sections 245A.65, subdivision 2, paragraph (a), 245G.14, subdivision 1, 245G.15, subdivision 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that physical plant postings meets all applicable requirements. Corrected on site.

5. Violation: The license holder’s description of treatment services did not meet requirements. It did not contain:

a. The type of treatment services provided; and

b. Which services meet the definition of group counseling under Minnesota Statutes, section 245G.01, subdivision 13a; and

c. 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 policies and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a description of treatment services that meets all applicable requirements.

6. Violation: The license holder’s provider policy and procedures did not meet requirements. The policy did not include the target population served.

Statute Violated: Minnesota Statute, section 245G.12, clause (13).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that provider policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a policy and procedure that meets all applicable requirements.

7. Violation: The license holder did not meet requirements governing the provision of telehealth per Minnesota Statutes, section 256B.0625, subdivision 3b, paragraph (c). The telehealth policy did not include the following:

a. Categories or types of services the health care provider will provide through telehealth;

b. Written policies and procedures specific to services delivered through telehealth that are regularly reviewed and updated;

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. An established quality assurance process related to delivering services through telehealth.

Statute Violated: Minnesota Statute, section 245G.07, subdivision 4, paragraph (c).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that telehealth policies meet all applicable requirements. Within 30 days of receipt of this order, submit a telehealth policy that meets all applicable requirements.

8. Violation: The license holder did not meet requirements governing HIV minimum standards. The policy did not include procedures for working with HIV-infected clients and referring clients to individual HIV counseling and services.

Statute Violated: Minnesota Statute, section 245A.19, paragraph (d).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that HIV minimum standards meets all applicable requirements. Within 30 days of receipt of this order, submit the policy identified above that meet all applicable requirements.

9. Violation: The license holder did not meet requirements governing the program abuse prevention plan (PAPP). The PAPP (1121235 and 1116958) did not include an annual review by the governing body or delegate for calendar years 2024 and 2025.

Statute Violated: Minnesota Statute, section 245A.65, subdivision 2, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program abuse prevention plans meets all applicable requirements.

10. Violation: The license holder did not meet requirements governing emergency overdose treatment. Documentation did not contain a written standing order protocol that permits the license holder to maintain a supply of opiate antagonists on site.

Statute Violated: Minnesota Statute, section 245A.242, subdivision 2, paragraph (a), and 245G.08, subdivision 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that emergency overdose treatment procedures meet all applicable requirements. Corrected on site.

11. 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 standard first aid certification or an equivalent during 8am-4:30pm for daytime services and 3:30pm-9pm for evening groups. It was identified that the license holder had select staff certified in CPR, however, the certification did not include first aid.

Statute Violated: Minnesota Statute, section 245G.10, subdivision 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements governing medical emergencies meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that at least one staff member on the premises has the required certifications on all shifts for a two week period.

Personnel files

  Personnel files reviewed are identified in the following manner:

· Personnel files numbered 1, 3, 4 and 6 (1077449)

· Personnel file numbered 2 and 6 (1116958)

· Personnel file numbered 5 and 6 (1121235)

12. Violation: One of six personnel files reviewed for requirements governing staff qualifications did not meet requirements. There was no documentation that a recovery peer had a minimum of one year in recovery from substance use disorder (personnel file numbered 3).

Statute Violated: Minnesota Statutes, section 245G.11, subdivision 8, clause (1).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications meet all applicable requirements.

13. Violation: Two of five 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 (personnel file numbered 2):

1) Staff members specific job responsibilities;

2) Policies and procedures;

3) Client confidentiality; and

4) Client needs;

b. Within 72 hours of employment (personnel file numbered 2):

1) HIV minimum standards;

2) Maltreatment of vulnerable adults reporting requirements;

3) Program abuse prevention plan; and

4) Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and

c. Before direct contact:

1) Maltreatment of minors reporting requirements (personnel file numbered 2); and

2) Emergency overdose treatment (personnel files numbered 1 and 2).

Statute Violated: Minnesota Statute, sections 245A.19, paragraph (b), 245A.65, subdivision 3 and 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 staff orientation meets all applicable requirements.

14. Violation: One of five personnel files reviewed for requirements governing staff development (personnel file numbered 5) did not meet requirements. There was no documentation of the following annual training for the year 2026:

a. Vulnerable adult maltreatment reporting requirements as specified in Minnesota Statutes, sections 245A.65, 626.557, and 626.5572;

b. Program abuse prevention plan;

c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services;

d. Maltreatment of minors reporting requirements; and

e. HIV minimum standards.

Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff training meets all applicable requirements.

15. Violation: Three of six personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following:

a. The first date that a background study subject had direct contact (personnel file numbered 1);

b. An inquiry required by sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel file numbered 4); and

c. A written annual job performance evaluation for the year 2026 (personnel file numbered 5).

Statute Violated: Minnesota Statute, sections 245A.041, subdivision 6 and 245G.13, subdivision 1, clause (3).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel file contents meets all applicable requirements.

Client files

  Client files reviewed are identified in the following manner:

· Client files numbered 1 and 2 (1077449)

· Client files numbered 3 and 5 (1121235)

· Client file numbered 4 (1116958)

16. Violation: Five of five client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation:

a. On the day of service initiation:

1) Client rights and responsibilities, as identified in Minnesota Statutes, section 148F.165 (client file numbered 1);

2) Grievance procedure (client file numbered 1); and

3) Opioid educational material (client files numbered 1 through 5);

b. Within 72 hours of admission:

1) HIV minimum standards (client file numbered 1);

2) Information on tuberculosis and tuberculosis screening (client file numbered 1);

3) Internal and external maltreatment of vulnerable adult reporting policies (client file numbered 1); and

4) Program abuse prevention plan (PAPP) (client files numbered 1, 3, 4, and 5).

Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, 245G.04, subdivision 3, 245G.09, subdivision 3, paragraph (a), and 245G.15, subdivisions 1 and 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client orientation meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for a client from each licensed location where the PAPP was reviewed at orientation.

17. Violation: Three of five client files reviewed for requirements governing initial services plan (ISP) and VA determination (client files numbered 3, 4, and 5) did not meet requirements. The ISP and VA determination was not completed within 24 hours of the day of service initiation.

Statute Violated: Minnesota Statute, section 245G.04, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial service plan and VA determination meets all applicable requirements. Within 30 days of receipt of this order, submit two client ISP and VA determinations that demonstrate compliance.

18. Violation: Five of five client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements as follows:

a. The CA was not reviewed and updated by a qualified staff member by the end of the fifth day on which a treatment service had been provided (client file numbered 5); and

b. The CA did not include the following:

1) The status of the client’s needs (client file numbered 3);

2) The client’s perceptions of the client’s condition (client file numbered 3);

3) The client’s strengths and resources, including the extent and quality of the client’s social networks (client files numbered 2 and 4);

4) Important developmental incidents in the client’s life (client files numbered 2 and 4);

5) Maltreatment, trauma, potential brain injuries, and abuse that the client has suffered (client file numbered 4);

6) Brain injuries (client file numbered 2);

7) The client’s family health history (client file numbered 4);

8) A determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (client files numbered 1 and 3); and

9) The American Society of Addiction Medicine (ASAM) level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 2, 4, and 5).

Statute Violated: Minnesota Statute, section 245G.05.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that meets all applicable requirements.

19. Violation: Five of five client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows:

a. The ITP was not completed by the end of the tenth day on which a treatment session had been provided from the day of service initiation (client files numbered 1, 2 and 4);

b. The ITP did not use a person-centered, culturally appropriate planning process (client file numbered 4);

c. The ITP did not include how the family or others will be involved in the client’s treatment (client file numbered 2); and

d. The ITP did not document (client files numbered 2 through 5):

1) A treatment strategy; and

2) 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, section 245G.06, subdivisions 1 and 1a, paragraph (a.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan that demonstrates compliance.

20. Violation: Five of five client files reviewed for requirements governing treatment service and client record documentation did not meet requirements in the following ways:

a. Treatment service documentation did not include:

1) The type of treatment service:

i. April 13, 15, 16, 21, and 22, 2026 (client file numbered 1);

ii. February 2, 3, 4, 5, and 9, 2026 (client file numbered 2);

iii. January 2, 4, 5, 6, 7, and 21, 2026, and March 9, 10, 11, 12, and 13, 2026 (client file numbered 3);

iv. November 17, 18, 20, and 21, 2025, and January 12, 13, 14, 15, and 16, 2026 (client file numbered 4); and

v. May 4, 5, 6, 7, and 8, 2026 (client file numbered 5);

2) The amount of each treatment service provided:

i. January 4, 2026 (client file numbered 3; and

ii. May 5, 6, and 7, 2026 (client file numbered 5);

3) The client’s response to the treatment service on April 13, 15, 16, 21, and 22, 2026 (client file numbered 1); and

4) Late entry for May 5, 2026 (client file numbered 5).

b. Telehealth documentation did not include the mode of transmission used to deliver the service and the location of the originating site and the distance site on February 2, 3, and 4, 2026 (client file numbered 2); and

c. Client record entries did not include:

1) Staff title:

I. March 9, 2026 group note (client file numbered 3); and

II. October 14, 2025 comprehensive assessment and treatment plan (client file numbered 4); and

2) Accurate documentation for November 18, 2025 and January 15, 2026 group note (client file numbered 4).

Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 2a, 2b, paragraph (c), and 245G.07, subdivision 4, paragraph (c).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment service and client record documentation meets all applicable requirements. Within 30 days of receipt of this order, submit two client treatment service documentation that demonstrates compliance.

21. Violation: Five of five client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency did not meet requirements as follows:

a. TPR was not completed once every 30 days for a client receiving ASAM level 1.0 outpatient or 2.1 intensive outpatient services:

1) Due May 15, 2026, review not signed and dated (client files numbered 1 and 5);

2) January 7, 2026, completed late (client file numbered 2); and

3) Due December 26, 2026, review not signed and dated, and February 2, 2026, completed late (client file numbered 4).

b. The TPR did not document the following:

1) The span of time covered by the review:

I. January 7, 2026, February 6, 2026, and February 27, 2026 (client file numbered 2); and

II. November 26, 2026 (client file numbered 4);

2) Whether the identified methods continue to be effective for April 20, 2026 (client file numbered 5);

3) Monitoring of any physical and mental health problems including toxicology results:

I. January 7, 2026 and February 6, 2026 (client file numbered 2);

II. February 1, 2026, May 4, and 31, 2026 (client file numbered 3); and

III. November 26, 2026, and February 2, 2026 (client file numbered 4);

4) Staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change for November 30, 2025, and February 27, 2026 (client file numbered 2); and

5) Any referrals made since the previous treatment plan review for November 25, 2025 (client file numbered 2).

Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 3, clauses (1), (3), and (4), and 3a, paragraphs (a) and (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.

22. Violation: Three of five client files reviewed for requirements governing record keeping requirements (client files numbered 3, 4, and 5) did not meet requirements. The license holder did not ensure that the client records were protected against unauthorized disclosure according to Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67. Per staff interview and client documentation, the license holder was communicating with the client’s housing manager without a release of information on file. Client documentation includes the following:

a. May 4, and 31, 2026 TPRs (client file numbered 3);

b. November 26, 2025, and February 2, 2026 TPRs (client file numbered 4); and

c. Unsigned TPRs created on April 29, 2026 and May 25, 2026 (client file numbered 5).

Statute Violated: Minnesota Statute, section 245G.09, subdivision 1, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that record keeping meets all applicable requirements.

23. Violation: Two of two client files reviewed for requirements governing discharge summaries did not meet requirements as follows:

a. The discharge summary was not completed within five days of the client’s service termination (client file numbered 2); and

b. The discharge summary did not document the client’s progress toward achieving each of the goals identified in the individual treatment plan (client files numbered 2 and 4).

Statute Violated: Minnesota Statute, section 245G.06, subdivision 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge summaries meets all applicable requirements. Within 30 days of receipt of this order, submit a discharge summary that demonstrates compliance.

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

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/