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May 27, 2026 Jack Benson, Authorized Agent On-belay Of Minnesota Inc dba Anthony Louis Center 1000 Paul Pkwy N Blaine, MN 55434-3925 License Number 1038850 Report Number 202409903, 202504086, and 202509964 CORRECTION ORDER Dear Jack Benson: On March 30, 2026, Department of Human Services (DHS) licensors conducted a licensing review and licensing investigations at your facility located at 1000 Paul Pkwy N, Blaine, MN 55434-3925. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and chemical dependency treatment program certification standards under Minnesota Rules, parts 2960.0430 through 2960.0500. As a result, DHS is issuing this order which requires you to take the corrective 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 did not meet requirements to the following licensing rules and statutes, as described below. Physical Plant 1. Violation: The physical environment did not meet standards in the following ways: a. It did not provide for the comfort, privacy, and dignity of residents as evidenced by window coverings being broken in many different areas of the program, including window coverings in resident rooms, and one of the bedrooms had soiled mattresses being stored in the room noted while the review took place; and b. The building, structures, or enclosures used by the facility, including walls, floors, ceilings, registers, fixtures, equipment, and furnishings were not kept in good repair as evidenced by floor registers not properly bolted into the floor, as well as lighting fixtures were broken and revealing glass lights and wires in the ceilings. Rule Violated: Minnesota Rules, part 2960.0110, subpart 2 and part 2960.0200, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the physical plant meets all applicable requirements. Within 30 days receipt of this order, submit verification that broken items listed in the violation are fixed. Practices 2. Violation: The license holders Plan for Transfer of Clients and Records Upon Closure did not meet requirements. A controlling individual of the program did not annually review and sign the plan for calendar years 2024 and 2025. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the Plan for Transfer of Clients and Records Upon Closure meets all applicable requirements. 3. Violation: The license holders Program Abuse Prevention Plan did not meet requirements. The license holder’s delegated representatives did not review the Program Abuse Prevention Plan at least annually using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review for calendar years 2024 and 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the Program Abuse Prevention Plan meets all appliable requirements. 4. Violation: The license holders maltreatment of minors internal reviews did not meet requirements. There was no internal review completed for an incident that occurred on August 20, 2024. Statute Violated: Minnesota Statutes, section 245A.66. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of minors internal reviews meet all applicable requirements. 5. Violation: The license holders program outcomes did not meet requirements in the following ways: a. The license holder did not annually evaluate strengths and weaknesses of the program for calendar years 2024 and 2025 in the following ways: i. Accidents; ii. The use of restrictive procedures; iii. Grievances; iv. Adverse findings, allegations of maltreatment under Minnesota Statutes, section 260E, citations, and legal action against the license holder; v. Results of a resident and family satisfaction survey required in part 2960.0140, subpart 1; and vi. Critical incidents b. The board of directors or advisory committee did not meet at least annually; and c. The license holder did not meet at least annually with community leaders representing the area where the facility is located to advise the community leaders about the nature of the program, the types of residents served, the results of the services the program provided to residents, the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A, and subpart 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program outcomes meet all appliable requirements. Personnel Files 6. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements. Staff did not receiving annual training in the following topics: a. Vulnerable adults maltreatment reporting requirements and definitions in sections 262.557 and 262.5572 for calendar year 2024 (personnel files numbered 1 and 3); b. The license holders program abuse prevention plan for calendar year 2024 (personnel files numbered 1 and 3); c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services for calendar year 2024 (personnel files numbered 1 and 3) and 2025 (personnel files numbered 1); d. The maltreatment of minors reporting requirements and definitions in chapter 260E to each mandatory reporter, as described in section 260E.06, subdivision 1 for calendar year 2024 (personnel files numbered 1 and 3) and 2025 (personnel files numbered 1); e. Review of the emergency plan at least once every six months for calendar year 2024 (personnel files numbered 1 and 3); f. The license holder did not document the date and number of hours of training completed by each staff person in each topic area and the name of the entity that provided the training (personnel files numbered 1, 2, and 3); g. Documentation did not demonstrate that staff completed at least 24 hours of in-service training per year for staff who have direct contact with residents for calendar year 2024 and 2025 (personnel files numbered 1); and h. HIV minimum standards training was not provided by license holder at least annually for calendar years 2024 and 2025 (personnel files numbered 1). Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, section 245A.66, subdivision 4, section 245A.19, paragraph (a), and Minnesota Rules, part 2960.0080, subpart 14, part 2960.0100, subpart 3, item A, and subpart 5, and part 2960.0150, subpart 4, item B. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that ongoing training meets all applicable requirements. Resident Files 7. Violation: One of three resident files reviewed for requirements governing admission procedures did not meet requirements. The license holder did not have documentation to demonstrate that they inventoried the resident’s personal property, including clothing (resident files numbered 1). Rule Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1), and Minnesota Rules, part 2960.0070, subpart 4. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that admission procedures meet all appliable requirements. 8. Violation: One of three resident files reviewed for requirements governing initial services plan did not meet requirements in the following ways (resident files numbered 1): a. An initial services plan was not completed during or immediately following the intake interview; and b. The initial services plan did not address what issues are to be addressed in the first treatment sessions. Rule Violated: Minnesota Rules, part 2960.0485. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that initial services plans meet all appliable requirements. 9. Violation: One of three resident files reviewed for requirements governing admission screenings did not meet requirements. The license holder did not complete the gender-specific needs screening for the resident (resident files numbered 1). Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, item B. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that admissions screenings meet all appliable requirements. 10. Violation: One of four resident files reviewed for requirements governing treatment plans did not meet requirements. The individual treatment plan was not signed by a licensed alcohol and drug counselor on 10/23/2025 and 11/12/2025 (resident files numbered 7). Rule Violated: Minnesota Rules, part 2960.0490, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that treatment plans meet all appliable requirements. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 29, 2023. 11. Violation: Three of three client files reviewed for requirements governing required individual treatment plan did not meet requirements (resident files numbered 1, 2, and 3). The progress note was entered in a resident’s file that indicated the type and amount of each service the resident had received bi-weekly instead of weekly.
Rule Violated: Minnesota Rules, part 2960.0490, subpart 4. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that treatment services and documentation meet all appliable requirements. Within 30 days receipt of this order, submit a progress note that demonstrates compliance. 12. Four of four resident files reviewed for requirement governing health care did not meet requirements in the following ways: a. The license holder did not have documentation to demonstrate that they verified with a newly admitted resident’s prescribing medically licensed person regarding: i. The symptoms that the medication will alleviate (resident files numbered 1 and 4); and ii. The symptoms that would warrant consultation with the physician (resident files numbered 1, 2, 3, and 5); b. The license holder did not note for a resident who received prescription drugs at the facility the amount of medication given, dosage, and time when the medication was taken (resident file numbered 5); and i. There was missing dates for medication Sucralfate 1mg, four times daily on April 15-26, and 28; and c. There was no documentation to demonstrate that prescription medication belonging to a resident was given to the resident’s parent or legal guardian upon the residents release from the program (resident files numbered 1). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D, E, and F. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that health care for residents meets all appliable requirements. Within 30 days receipt of this order, submit documentation of contacting a newly admitted resident’s prescribing medically licensed person that demonstrates compliance. 13. Violation: Two of three resident files reviewed for requirements governing no eject did not meet requirements (resident files numbered 1 and 4). The documentation did not demonstrate the license holder complied with the following: a. Conferred with other interested persons to review the issues involved in the decision; b. Determine whether the license holder, treatment team, interested persons, if any, and the resident can develop additional strategies to resolve the issues leading to the discharge and to permit the resident and opportunity to continue to receive services from the license holder; and c. Review the reasons for the decision and the alternatives considered or attempted. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that no eject of residents meets all appliable requirements. Within 30 days receipt of this order, submit no eject documentation that demonstrates compliance. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 29, 2023. 14. Violation: One of three files reviewed for requirements governing discharge procedures did not meet requirements. There was no documentation to demonstrate that the license holder returned all the resident’s personal property to the resident upon discharge (resident files numbered 4). Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that discharge procedures meet all appliable requirements. 15. Violation: Two of two resident files reviewed for requirements governing transition services plans did not meet requirements in the following ways: a. The plan did not recommend ways to meet the resident's needs and identify resources available in the community to address the resident's continuing needs after release from the facility (resident files numbered 2 and 3); b. The plan did not consider the environment into which the resident will return, and recommend how the resident may deal with issues and potential challenges within that environment (resident files numbered 2 and 3); and c. The transition services plan did not include the following elements: i. A budget plan and a description of the residents financial and employment status (resident files numbered 2); and ii. Transportation needs (resident files numbered 2). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that transition services plans meet all appliable requirements. Within 30 days receipt of this order, submit a transition services plan that demonstrates compliance. 16. Violation: Five of five resident files reviewed for requirements governing discharge documentation did not meet requirements in the following ways (resident files numbered 2, 3, and 7): a. Following the resident’s discharge, the license holder did not document the extent to which the resident’s stay in the facility met the goals identified in the resident’s treatment plan; and b. The extent to which the services provided to the resident contributed to achieving the goals and objectives identified in the resident’s treatment plan. Rule Violated: Minnesota Rules, part 2960.0140, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, license holder must ensure that discharge documentation meets all appliable requirements. Within 30 days receipt of this order, submit a discharge summary that demonstrates compliance. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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: Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This children’s chemical dependency residential facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Statutes, section 245A, Minnesota Rules, part 2960.0010 through 2960.0120, Minnesota Rules, parts 2960.0130 through 2960.0220, and Minnesota Rules, parts 2960.0430 through 2960.0500 · 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 651-431-5909. Sincerely, Michael Cihla, Senior Licensor Licensing Division Office of Inspector General
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