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April 10, 2025 Randy Smith, Authorized Agent Path to Recovery 11990 Jonquil St. NW Coon Rapids, MN 55433 License Number: 1119978 Report Number: 202407582, 202409068 CORRECTION ORDER Dear Randy: On February 10, 11, and 12, 2025, Department of Human Services (DHS) licensors conducted a licensing review and licensing investigation at your facility, Path to Recovery located at 4555 Erin Drive Suite 120, Eagan, MN 55122. 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, Practices, and Procedures 1. Violation: The license holder submitted requests for payment of public funds for treatment services (client file numbered 1) that did not meet requirements. Treatment services were not documented in the client file; however, services were billed on May 2, 2024, for 30 minutes of treatment coordination and on May 6, 2024, for 4 hours of group counseling. Statute Violated: Minnesota Statute, section 245A.191. 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 monitor the implementation of their policy and procedures for guest speakers. Treatment service documentation on June 26, 2024 (client file numbered 2) and October 18, 2024 (client file numbered 3) indicated guest speakers were used, however, documentation did not contain the name of the speaker or the specific topic of the group. Additionally, the license holder did not have a personnel record that contained documentation of completed orientation trainings as required. Statute Violated: Minnesota Statute, section 245A.04, subdivision 14, paragraph (b) and 245G.07, subdivision 3a, paragraph (d). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure use of guest speakers meets all applicable requirements. 3. Violation: During a licensing investigation, it was determined the license holder did not meet requirements for the following: a. Additional treatment services, example: living skills development, employment or education services to help the client become more financially independent were not conducted by a qualified staff; and b. The license holder did not have a personnel record that contained a job description, documentation of completed orientation and training, and the staff member qualifications (personnel file numbered 4). Statute Violated: Minnesota Statute, sections 245G.07. subdivision 3 and 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that counselors and personnel policy and files meet all applicable requirements. Personnel Files 4. Violation: Two of four personnel files reviewed for requirements governing staff qualifications did not meet requirements in the following ways: a. There was no documentation of the following (personnel file numbered 2): 1) For the treatment director: i. At least one year of work experience in direct service or management to an individual with substance use disorder; ii. Baccalaureate degree or three years of work experience in administration or personnel supervision in human services; and iii. Demonstration of knowledge and implications of 245G, sections 626.557 and 626.5572, and chapters 245A and 260E; and 2) Three or more years’ experience providing individual and group counseling to individuals with substance use disorder for the alcohol and drug counselor supervisor. Statute Violated: Minnesota statutes, section 245G.11, subdivisions 3 and 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications meet all applicable requirements. Prior to changing licensing state from pending reopening to active, license holder must submit staff qualifications for key positions that meet requirements. 5. Violation: Four of four personnel files reviewed for requirements governing staff orientation did not meet requirements. Documentation did not include the following orientation: a. Staff members specific job responsibilities within 24 working hours of hire (personnel file numbered 1); b. Maltreatment of vulnerable adults reporting requirements in Minnesota Statutes, section 245A.65 within 72 hours of first providing direct contact services (personnel files numbered 1, 2, and 3); and c. Maltreatment of minors reporting requirements and definitions in Minnesota Statutes, chapter 260E before direct contact (personnel files numbered 1, 2, and 3). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraph (e). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets all applicable requirements. Within 30 days after license becomes active, submit a staff orientation that demonstrates compliance. 6. Violation: Three of four personnel files reviewed for requirements governing additional training (personnel files numbered 1, 2, and 3) did not meet requirements. Documentation did not include emergency overdose treatment training. Statute Violated: Minnesota statutes, sections 245A.242 and 245G.08, subdivisions 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure additional trainings meet all applicable requirements. 7. Violation: Three of three personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of the following: a. A completed application or resume for employment signed by the staff member containing qualifications for employment (personnel file numbered 2 and 3); b. The first date of direct contact with persons served (personnel file numbered 1); and c. An inquiry requires 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 1 and 3). Statute Violated: Minnesota statutes, sections 245A.041, subdivision 6 and 245G.13, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel file contents meet all applicable requirements. Client Files 8. Violation: Two of four client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation to the following: a. On the day of service initiation: 1) Client rights (client files numbered 1 and 3); and 2) Grievance procedure (client file numbered 3); and b. HIV minimum standards completed within 72 hours of admission (client files numbered 1 and 3); and c. Internal and external maltreatment of vulnerable adults reporting policies completed within 24 hours of admission (client files numbered 1 and 3). Statute Violated: Minnesota statutes, sections 245A.19, 245A.65, subdivision 1, paragraph (c), 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. 9. Violation: Two of four client files reviewed for requirements governing initial service plans (ISP) and vulnerable adult determination did not meet requirements. The ISP and vulnerable adult determination were not completed within 24 hours of the day of service initiation (client files numbered 1 and 2). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1a, paragraph (a), 245G.04, subdivisions 1 and 2, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans and vulnerable adult determination meet all applicable requirements. 10. Violation: Four of four client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements in the following ways: a. There was no documentation of: 1) The client’s description of the client’s symptoms (client file numbered 2), 2) The reason for the client’s referral (client files numbered 1 and 2); 3) The client’s history of mental health treatment (client file numbered 2); and b. The comprehensive assessment did not include or identify which of the following topics will require further assessment during the course of the client’s treatment: 1) The client’s evaluation of the quality of each relationship (client file numbered 2); 2) The client’s resources (client file numbered 3); 3) Potential brain injuries the client has suffered (client file numbered 1); 4) The client’s family health history (client files numbered 2, 3, and 4); 5) A determination of whether the individual screens positive for co-occurring mental health disorders (client file 2); and 6) A recommendation for the ASAM level of care identified in section 254B.19, subdivision 1 (client files numbered 1 through 4). Statute Violated: Minnesota statutes, sections 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 after license becomes active, submit a client comprehensive assessment that demonstrates compliance. 11. Violation: Five of five client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. ITP was not completed until after the client discharged (client files numbered 2 and 4); b. ITP was not completed by the end of the tenth day on which a treatment session has been provided from the day of service initiation (client files numbered 1 and 5); c. The ITP was not signed by the client and did not document the client’s involvement in the development of the plan (client files numbered 1 and 6); d. The ITP was not based on the client’s comprehensive assessment (client file numbered 1); e. The ITP contents did not include: 1) Treatment goals in relation to any or all the applicable ASAM six dimensions identified in section 254B.04, subdivision 4, to ensure measurable treatment objectives (client files numbered 1); 2) A treatment strategy (client files numbered 1 and 2); 3) A schedule for accomplishing the client’s treatment goals and objectives (client file numbered 1); 4) Documentation of the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1, under which the client is receiving services (client files numbered 1, 2, and 6); 5) The participants involved in the client’s treatment planning (client file numbered 6); and 6) Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 1). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 1a, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meets all applicable requirements. Within 30 days after license becomes active, submit a client treatment plan that demonstrates compliance. 12. Violation: Four of four client files reviewed for requirements governing treatment services did not meet requirements. There was no documentation of the following: a. The type of treatment services provided to the client: 1) May 2, 3, and 14, 2024 (client file numbered 1); 2) June 11, 2024 through July 2, 2024 (client file numbered 2); 3) October 21 and 23, 2024 (client file numbered 3); and 4) June 11 and 12, 2024, and August 1 and 6, 2024 (client file numbered 4); and b. The client response to each treatment service: 1) May 3, 2024 (client file numbered 1); and 2) June 25, 2024 (client file numbered 2); and c. Documentation of a treatment service within seven days of providing the treatment service (client file numbered 1): 1) May 2, 2024 group note signed May 28, 2024; 2) May 3, 2024 group note signed May 23, 2024; and 3) May 14, 2024 group note signed May 28, 2024. Statute Violated: Minnesota statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment service documentation meets all applicable requirements. Within 30 days after license becomes active, license holder must submit a treatment service note that meets requirements. 13. Violation: Four of four client files reviewed for requirements governing client record documentation did not meet requirements. There was no documentation of the following: a. A significant event that occurred at the program within 24 hours of the event (client file numbered 3); b. The client record being signed by the staff member making the entry: 1) August 19, 2024 (client file numbered 4); and 2) June 21, 2924 (client file numbered 2); and c. The client record did not include the job title or position on September 9, 2024 individual note and October 17, 2024 treatment coordination note (client file numbered 1); and d. ITP and treatment plan reviews did not document the correct date of service initiation (client file numbered 1). Statute Violated: Minnesota statutes, sections 245G.06, subdivision 2b and 245G.09, subdivision 1, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client record documentation meets all applicable requirements. 14. Violation: One of two client files reviewed for requirements governing treatment plan reviews (TPR) (client file numbered 1) did not meet requirements. There was no documentation of the following: a. The span of time covered by the review on August 15, 2024 and September 12, 2024; and: b. August 16, 2024, and September 12, 2024 TPRs did not contain: 1) The client goals addressed and whether the identified methods continue to be effective; 2) Monitoring of any physical and mental health problems; and 3) Whether the client agrees with the change to the treatment plan; and 4) Referrals made since the previous treatment plan review; and c. Whether the client agrees with the change to the treatment plan dated August 16, 2024; and d. The October 12, 2024, treatment plan review was completed five days late. Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3 and 3a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 15. Violation: Nineteen of twenty-five client files reviewed for requirements governing discharge summaries did not meet requirements in the following ways: a. The service discharge summary was not completed within five days of the client’s service termination (client files numbered 1, 2, 5 through 10, 12 through 15, 18, 20 through 25); b. The discharge summary did not include the following information: 1) The client’s issues, strengths, and needs while participating in treatment (client files numbered 2 and 3); 2) The client’s progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 2); 3) A risk rating and description of each of the ASAM six dimensions (client file numbered 4); 4) The reasons for and circumstances of service termination (client file numbered 2); 5) Continuing care recommendations (client file numbered 2); and 6) Service termination diagnosis (client file numbered 3). Statute Violated: Minnesota statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries 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 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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