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August 18, 2023 Gerald Powers, Authorized Agent Pathway House Inc 3890 Berkshire Rd SW Rochester, MN 55902 License Number: 809746 Licensing Investigation Number: 202210132
CORRECTION ORDER Dear Gerald Powers, A licensing investigation of Pathway House, located at 103 6th Ave SW, Rochester, MN 55902, was conducted to determine compliance with state and federal laws and rules governing the provision of substance use disorder treatment services under Minnesota Statutes 245G. As a result of this licensing investigation a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Client File 1. Citation: Minnesota Statutes, section 245G.05, subdivision 1, paragraph (a). Violation: One client file was reviewed for the requirements governing comprehensive assessments (C1) and did not meet requirements. The comprehensive assessment did not include the following information about the client’s needs that relate to substance use and personal strengths that support recovery: a. Economic status; b. A description of how the client’s use affected the client’s ability to function appropriately in work and educational settings; and c. Whether the client recognizes needs related to substance use and is willing to follow treatment recommendations. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure comprehensive assessments meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated October 20, 2021. 2. Citation: Minnesota Statutes, section 245G.06, subdivisions 1 and 2. Violation: One client file was reviewed for requirements governing individual treatment plans (C1) and did not meet requirements in the following ways: a. Individual treatment plan dated November 30, 2022 did not include the following: 1. Documentation the individual treatment plan was developed within ten days from the day of service initiation; and 2. Specific goals and methods to address each identified need in the comprehensive assessment summary, including amount and frequency of treatment services. b. The client’s individual treatment plan was not updated based on new information gathered about the client’s condition, the client’s level of participation, and on whether methods identified had the intended effect. Treatment plan review dated December 6, 2022, dimension 4 identified the methods were not effective but that no treatment plan update was needed. Additionally, the client had missed several groups according to documentation and was put on a behavior contact dated December 5, 2022 as a result. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated October 20, 2021. 3. Citation: Minnesota Statues, section 245G.06, subdivision 4, paragraphs (a) and (b). Violation: One client file was reviewed for requirements governing service discharge summary (C1) and did not meet requirements. The discharge summary did not meet requirements in the following ways: a. Completed within five days of the client’s service termination; and b. The client’s strengths and needs while participating in treatment. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure service discharge summary meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated October 20, 2021. If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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 a corrective action ordered must be sent to Ginny Benson: 1. By secure email to: ginny.benson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Ginny Benson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible. Ginny Benson, MH/CRF/SUD Senior Licensor Licensing Division Office of Inspector General
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