|
July 15, 2025 Gerald Powers. Authorized Agent Pathway House, Inc. 3890 Berkshire Road SW Rochester, MN 55902 License Number: 802845 CORRECTION ORDER Dear Gerald, On May 19, 20, and 21, 2025, 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 meet requirements for receiving public funding reimbursement from the commissioner for services provided. There was no documentation that treatment services were provided in the amount billed as follows: a. Ten hours of treatment services were documented for April 11 through April 17, 2025; however, 15 hours were billed for (client file numbered 2); and b. Six hours of treatment services were documented February 14 through February 20, 2025; however, 15 hours were billed for (client file numbered 3). Statute Violated: Minnesota statutes, sections 245A.167 and 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 develop policies and procedures did not contain the following required policies: a. Assessment and treatment planning policies; and b. Maltreatment of minor’s policy per Minnesota Statutes, chapter 260E. Statute Violated: Minnesota statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that provider policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit policy and procedures that meet all applicable requirements. 3. Violation: The license holder’s treatment services description did not meet requirements. The treatment services description as follows: a. There were inconsistencies in the description of treatment services; and b. The treatment services description did not identify which treatment services meet the definition of group counseling. Statute Violated: Minnesota statutes, sections 245G.07, subdivision 4, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that treatment services and description meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that meets all applicable requirements. 4. Violation: The license holder’s internal review of a vulnerable adult maltreatment report dated November 26, 2024, did not include an evaluation of the following: a. Whether Related policies and procedures were followed; b. If the policies and procedures were accurate; c. A need for additional staff training; d. If the reported event is similar to past events with the vulnerable adults or the services involved; and e. A need for any corrective action to be taken by the license holder to protect the health and safety of vulnerable adults. Statute Violated: Minnesota statutes, sections 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that vulnerable adult internal maltreatment reviews meet all applicable requirements. 5. Violation: The license holder did not ensure that client record and treatment service documentation met requirements. Per staff interview, it was the program’s practice to use group sign in sheets as the treatment service documentation. The documentation was not individualized and did not meet requirements on the following dates: a. March 18, 2025, April 1, 2025, April 22, 2025, and May 6, 2025 (client file numbered 1); b. April 14, 2025, April 15, 2025, and April 17, 2025 (client file numbered 2); and c. April 17, 2025, and April 19, 2025 (client file numbered 4). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2a and 2b. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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. Within 30 days of receipt of this order, submit treatment service documentation that meets all applicable requirements. Personnel Files 6. Violation: One of four personnel files reviewed for requirements governing personnel file contents (personnel file numbered 4) did not meet requirements. The personnel file did not contain a written annual review for calendar year 2024. Statute Violated: Minnesota statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all personnel file contents meet all applicable requirements. Client Files 7. Violation: Three of three client files reviewed for requirements governing initial services plan (ISP) (client files numbered 1, 2, and 4) did not meet requirements. The ISP was not person centered and client specific. Statute Violated: Minnesota Statutes, section 245G.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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. 8. Violation: Two of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) (client files numbered 1 and 2) did not meet requirements in the following ways: a. IAPP did not include an assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and self-abuse; and b. IAPP did not include an assessment of the person’s risk of abusing other vulnerable adults. 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, and November 4, 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. Within 30 days of receipt of this order, submit an IAPP that meets all requirements. 9. 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 and did not include the person-centered reason for the delay and the planned completion date (client files numbered 1 and 4); b. The assessment did not include the following: 1) The client’s description of the client’s symptoms (client files numbered 1, 2, and 4); and 2) Substance use history, including route of administration (client file numbered 4); 3) The client’s evaluation of the quality of each family and significant personal relationship (client files numbered 1, 2, and 4); and 4) A determination of whether the individual screens positive co-occurring mental health disorders using a screening tool approved by the commissioner (client files numbered 1 and 4). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1 and 3. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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. 10. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways: a. ITP was not completed within ten days from the day of service initiation (client file numbered 1); b. An ITP was not updated based on new information gathered (client file numbered 2); c. ITP did not include a treatment strategy for accomplishing the client’s treatment goals and objectives (client file numbered 1, 2, and 4); d. The ITP did not document the ASAM level of care (client files numbered 1, 2, and 4); and e. ITP did not identify the participants involved in the clients’ treatment planning (client file numbered 1). Statute Violated: Minnesota statutes, section 245G.06, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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. 11. Violation: One of three client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency (client file numbered 4) did not meet requirements in the following ways: a. TPR was not completed within 30 days for a client receiving residential ASAM 3.1 low intensity services. TPR was due February 7, 2025, and was completed February 11, 2025; b. TPR did not document whether the identified methods continue to be effective; and c. TPR did not document any referrals made. Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3 and 3a, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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 treatment plan reviews meet all applicable requirements. 12. Violation: Three of three client files reviewed for requirements governing medication administration did not meet requirements. There was no documentation of the client’s use of medication including staff signatures with date and time for the following: a. March 19, 2025 through March 28, 2025 (client file numbered 1); b. March 28, 2025, and April 6, 2025 through April 30, 2025 (client file numbered 2); and c. January 1, 2025 through January 31, 2025, and February 1, 2025 through February 27, 2025 (client file numbered 4). Statute Violated: Minnesota statutes, section 245G.08, subdivision 5, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, and November 4, 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. 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
|
