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November 4, 2024 Gerald Powers. Authorized Agent Pathway House, Inc. 613 2nd St SW Rochester, MN 55902 License Number: 802845 CORRECTION ORDER Dear Gerald, On September 16, 17, and 18, 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Pathway House located at 613 2nd St. SW, Rochester, MN 55902. 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, Practices and Procedures 1. Violation: The license holder did not update the primary person to whom internal reports may be made within their posted maltreatment of vulnerable adult policy. Posting listed two individuals as the primary person. Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1, paragraph (d) and 245G.12. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that internal maltreatment reporting meets all applicable requirements. Violation corrected on site. 2. Violation: The license holder did not monitor the implementation of their policy and procedure for client attendance at treatment activities. Documentation did not include dates, time frame specific to each group session and when the client arrived late to the group, did not specifically list the time. Statute Violated: Minnesota statutes, sections 245A.04, subdivision 14, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that client attendance tracking meets all applicable requirements. Within 30 days of receipt of this order, submit attendance documentation that demonstrates compliance. 3. Violation: The license holder did not meet staff requirements in the following ways: a. The license holder did not ensure that group counseling did not exceed 16 clients as evidenced by sign in sheets for July 10, 18 and August 1, 14, 26 and 24, 2024; and b. The license holder failed to ensure that when clients were present at least one staff person on the premises had a current American Red Cross standard first aid certificate or an equivalent certificate and at least one staff member on the premises who has a current American Red Cross community, American Heart Association, or equivalent CPR certificate. There was no documentation that staff were CPR and first aid certified on the overnight shift of 7/11/24 and 7/12/24, and the PM shift on 7/10/24. Statute Violated: Minnesota statutes, section 245G.10, subdivisions 4 and 5. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that staff qualifications meet all applicable requirements. 4. Violation: The license holder did not monitor the implementation of their policies and procedures to ensure client rights were protected under MN Statute 144.651, subdivision 23. Per client interview and observation, household chores are part of the client statuses as Pathway House protocol, and this includes cleaning staff and client bathrooms, grounds keeping, cleaning the kitchen, etc. Individual treatment plans did not reflect these tasks to be a client specific goal. Statute Violated: Minnesota statutes, sections 245A.04, subdivision 14, paragraph (b) and 245G.12. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that client rights protection meets all applicable requirements. 5. Violation: The license holder did not offer treatment services to address issues related to co-occurring disorders. Documentation did not include a co-occurring group as part of their curriculum. Statute Violated: Minnesota statutes, section 245G/07, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure treatment services meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment services curriculum that includes a group for co-occurring disorders. 6. Violation: The license holder did not comply with the terms of the conditional license in three out of three client files reviewed for client notification of the program’s conditional license status (client files numbered 1, 2, and 3). The license holder did not include documentation that a copy or an offer to provide a copy of the conditional order was provided upon the client’s request. Statute Violated: Minnesota Statutes, section 245A.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all clients are notified of the programs’ conditional license status and are provided or offered a copy of the conditional order. Personnel Files 7. Violation: One of two personnel files reviewed for requirements governing background studies (personnel file numbered 1) did not meet requirements. There was no documentation of the following: a. Being affiliated under the correct roster; and b. The date staff first had direct contact. Statute Violated: Minnesota statutes, sections 245C.07, paragraph (a), and 245G.20, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all background studies meet all applicable requirements. 8. Violation: Two of four personnel files reviewed for requirements governing staff qualifications did not meet requirements. No documentation of the following: a. Current licensure in file (personnel file numbered 4); and b. The amount of supervision on a weekly basis the supervising licensed alcohol and drug counselor provided to an alcohol and drug counselor (ADC-T) (personnel file numbered 6). Statute Violated: Minnesota statutes, section 245G.11, subdivisions 5, paragraph (a) and 11. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff qualifications meet all applicable requirements. Violation corrected on site. 9. Violation: One of two personnel files reviewed for requirements governing staff orientation (personnel file numbered 1) did not meet requirements. Orientation was not completed within 24 hours for the staff members specific job responsibilities. Statute Violated: Minnesota statutes, section 245G.13, subdivision 1, paragraph (7). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure that staff orientation meets all applicable requirements. 10. Violation: Two of two personnel files reviewed for requirements governing annual training did not meet requirements. No documentation of annual training for August 2024 (personnel file numbered 3) and June 2024 (personnel file numbered 5) of the following: a. Vulnerable adult maltreatment; b. Obtaining a release of client information; c. Program abuse prevention plan; d. Internal policies and procedures related to the prevention and reporting of maltreatment; e. Maltreatment of minors reporting; f. Reporting of prenatal exposure to controlled substances; g. HIV minimum standards; and h. Programs policies and procedures for working with HIV infected clients and referring clients to services when needed. Statute Violated: Minnesota statutes, 245G.13, subdivision 2, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure annual training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff listed above have completed the required trainings. Client Files 11. Violation: Three of three client files reviewed for requirements governing initial services plan (ISP) did not meet requirements in the following ways: a. ISP was not completed within 24 hours of the day of service initiation (client file numbered 2); and b. ISP was not person centered and client specific (client files numbered 1, 2, and 3). Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial services plans meet all applicable requirements. Within 30 days of receipt of this order, submit an ISP that meets all requirements. 12. Violation: Two of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways: a. IAPP was not completed within 24 hours of the day of service initiation (client file numbered 2); b. IAPP did not include an assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and self-abuse (client file numbered 3); c. IAPP did not include an assessment of the person’s risk of abusing other vulnerable adults (client file numbered 3); and d. IAPP did not document that the person receiving services participated in the development of the IAPP (client file numbered 2). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and 245G.04, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual abuse prevention plans meet all applicable requirements. 13. Violation: Three of three client files reviewed for requirements governing comprehensive assessments did not meet requirements in the following ways: a. The comprehensive assessment was not completed within 5 calendar days on which a treatment service had been provided from the day of service initiation (client files numbered 2 and 3); b. The comprehensive assessment did not include the person-centered reason for the delay and the planned completion date (client files numbered 2 and 3); c. The assessment did not include information about the client’s current life situation, including the following information: 1) The status of the clients’ basic needs (client files numbered 1, 2, and 3); 2) The clients’ perceptions of the client’s condition (client files numbered 1, 2, and 3); 3) The client’s description of the client’s symptoms, including the reason for the client’s referral (client files numbered 1, 2, and 3); 4) The client’s history of mental health treatment (client files numbered 1, 2, and 3); 5) Cultural influences on the client (client files numbered 1, 2, and 3); 6) Substance use history, including amounts and types of substances (client file numbered 3); and d. The assessment did not include information related to the following topics: 1) The client’s evaluation of the quality of each family and significant personal relationship (client files numbered 1, 2, and 3); 2) The client’s resources (client files numbered 1, 2, and 3); 3) Important developmental incidents in the client’s life (client files numbered 1, 2, and 3); 4) The client’s and family’s health history, including the client’s physical health history (client files 1, 2, and 3); 5) A screening tool approved by the commissioner for co-occurring mental health disorders (client files numbered 1, 2, and 3); and 6) A risk rating and summary to support the risk ratings within each of the dimensions (client file numbered 2). Statute Violated: Minnesota Statutes, sections 245G.05, subdivision 1, and 245I.10, subdivision 6, paragraphs (b) and (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. 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 requirements. 14. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. An ITP was not updated based on new information gathered (client files numbered 2 and 3); b. ITP did not include how the family or others will be involved in the client’s treatment planning or the reasons why natural supports were not involved (client files numbered 1, 2, and 3); c. ITPs did not use a person-centered, culturally appropriate planning process (client files numbered 1, 2, and 3); d. ITP did not include a schedule for accomplishing the client’s treatment goals and objectives (client file numbered 3); e. The ITPs did not document the ASAM level of care (client files numbered 1, 2, and 3); and f. ITPs did not identify the participants involved in the clients’ treatment planning (client files numbered 1 and 3). Statute Violated: Minnesota statutes, section 245G.06, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. 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 an individual treatment plan that meets all requirements. 15. Violation: Three of three client files reviewed for requirements governing client record and treatment service documentation did not meet requirements in the following ways: a. No documentation of all treatment services provided (client files numbered 1, 2 and 3); b. Documentation did not record the date, type, and amount of each treatment service provided to the client and the client’s response to each treatment service within seven days of providing the treatment service (client files numbered 1, 2, and 3); c. No documentation of the following: 1) Concerns related to medications were not documented in the medication administration record (client file numbered 3); and 2) Concerns related to attendance for treatment services, including the reason for any client absence from the treatment service (client file numbered 2); d. Each entry in the client’s record did not include a signature date and title or position of the staff person that made the entry (client files 1, 2, and 3). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2a and 2b. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record and treatment service documentation meets all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing treatment plan reviews (TPR) did not meet requirements in the following ways: a. TPR did not indicate the span of time covered by the review (client file numbered 3); b. TPR did not document whether the identified methods continue to be effective (client file numbered 2); c. TPR did not document the participation of others involved in the individual’s treatment planning (client file numbered 1); d. TPR did not document staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change (client file numbered 2); and e. TPR did not include a review and evaluation of the individual abuse prevention plan (client file numbered 2). Statute Violated: Minnesota statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 17. Violation: Three of three client files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. Documentation did not include staff signatures (client files numbered 1, 2 and 3); and b. The client’s use of the medication was not recorded for all medications administered (client files numbered 1 and 2). Statute Violated: Minnesota statutes, section 245G.08, subdivision 5, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication administration meets all applicable requirements. 18. Violation: One of two client files reviewed for requirements governing discharge summaries (client file numbered 1) did not meet requirements. Documentation of the risk rating and descriptions did not match for dimensions 1, 3, and 4. Statute Violated: Minnesota statutes, section 245G.06, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. RECOMMENDATIONS The following recommendation(s) are not requirements of the licensing rules and statutes that govern your services or facility. DHS has provided the recommendations below to call your attention to areas where your facility is in minimum compliance with the requirements of applicable rules or statutes. DHS recommends that you comply with the following recommendations to ensure that you continue to meet the requirements of applicable licensing rules and statutes. Your failure to follow these recommendations will not result in a fine or action against your license at this time. However, should your failure to follow these recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and DHS could issue a fine or other licensing action. 1. Recommendation: When reviewing client files, it was identified that a client was presented with a behavioral contract after an incident of yelling, inappropriate interactions with staff, and overall anger issues. It was not clear if this was considered a significant event, requiring documentation to be completed within 24 hours of the occurrence. It is recommended that you define “significant event” in your policy and indicate how that event may impact the client’s relationship with other clients, staff, or the client’s family, or the client’s treatment plan. Statute: Minnesota statutes, section 245G.06, subdivision 2. 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
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