August 5, 2025

Sadik Ali, Authorized Agent Pathway to Recovery

900 20th Ave S Minneapolis, MN 55404

License Number: 1120994 (245G)

CORRECTION ORDER

Dear Sadik Ali:

On May 13 through May 16, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Pathway to Recovery located at 900 20th Ave S Minneapolis, MN 55404. 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.

Client Files

1. Violation: One of three client files reviewed for requirements governing initial services plans (client file numbered 2) did not meet requirements. The initial services plan was not completed within 24 hours of the day of service initiation.

Statute Violated: Minnesota Statute, section 245G.04, subdivision 1.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that initial service plans meet all applicable requirements.

2. Violation: One of three client files reviewed for requirements governing vulnerable adult determinations (client file numbered 2) did not meet requirements. The license holder did not determine whether a client is a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21, within 24 hours of the day of service initiation.

Statute Violated: Minnesota Statute, section 245G.04, subdivision 2, paragraph (a).

PO Box 64242 * Saint Paul, Minnesota * 55164-0242 * An Equal Opportunity Employer https://mn.gov/dhs/general-public/licensing/

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that vulnerable adult status determinations meet all applicable requirements.

3. Violation: Two of three client files reviewed for requirements governing comprehensive assessment did not meet requirements. The comprehensive assessment did not contain the following items:

a. The client’s current living situation, including the client’s housing status and household members (client file numbered 2);

b. The client’s education level and employment status (client file numbered 2);

c. The client’s perceptions of the client’s condition (client file numbered 2 and 3);

d. The client’s description of the client’s symptoms (client file numbered 3);

e. The reason for the client’s referral (client files number 2 and 3);

f. Substance use history (client file numbered 2), including:

i. Amounts and types of substances;

ii. Frequency and duration;

iii. Route of administration;

iv. Periods of abstinence; and

v. Circumstances of relapse;

g. A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19 subdivision 1 (client file numbered 2 and 3);

h. Determination of whether the individual screens positive for co-occurring mental health disorders using a screening tool approved by the commissioner pursuant to Minnesota Statutes, section 245.4863 (client file numbered 3); and

i. The client’s relationship with the client’s family and other significant personal relationships, including the client’s evaluation of the quality of each relationship (client file numbered 2).

Statute Violated: Minnesota Statutes, section 245G.05, subdivision 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements.

4. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways:

a. The ITP was not completed by the end of the tenth day on which a treatment session was provided from the day of service initiation (client file numbered 1);

b. The ITP was not signed by the client (client file numbered 2);

c. The ITP was not updated based on information gathered about the client’s condition (client files numbered 1 and 2); and

d. The license holder did not base the client ITP off the client’s comprehensive assessment (client file numbered 3); and

e. The ITP did not document the following:

i. The specific treatment services for which a client has been assessed and the plan to provide the services (client files numbered 1 through 3);

ii. A treatment strategy (client file numbered 2);

iii. Resources to refer the client to when the client’s needs will be addressed concurrently by another provider (client file numbered 2); and

iv. Active interventions to stabilize mental health symptoms (client files numbered 1 through 3).

Statute Violated: Minnesota Statute, sections 245G.06, subdivisions 1 and 1a, clauses (1), (3), and (6), 245G.07, subdivision 1, paragraph (a) and 245G.20.

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 45 days of receipt of this order, submit two individual treatment plans that meet all applicable requirements.

5. Violation: Three of three client files reviewed for requirements governing client record documentation did not meet requirements. Documentation of treatment services did not meet requirements in the following ways:

a. No documentation of client response for the following dates:

i. January 18, 19, 26, February 14, 19, 22, and April 22, 2025 (client file numbered 1);

ii. January 20, 21, 23, 24, February 24, 28, and March 25, 2025 (client numbered 3); and

iii. April 21 and 23, 2025 (client file numbered 2);

b. The provision of the treatment service not documented within 7 days of the serviceon the following dates:

i. November 7, 27, 2025, January 18, 19, 26, February 14, 19, 22, 26, 27, April 6, 10, 13,

14, 15, 18, 26, and 27, 2025 2024 (client file numbered 1);

ii. January 17, 21, 29, February 14, 15, March 25, April 9, 19, 23, and 29, 2025 (client file

numbered 2); and

iii. January 21, 23, February 24, 25, 26, 27, March 24 and 25, 2025 (client file numbered

3);

c. No documentation of the type of service for the following dates:

i. February 24 and 28, 2025 (client file numbered 3); and

ii. April 21, 2025 (client file numbered 2);

d. The documentation did not include the job title or position of the staff person making the entry for the following documents:

i. Diagnostic Assessment (client file numbered 1); and

ii. Individual progress notes on April 21, 2025 (client file numbered 2); and

e. Entries in the client record were not accurate as follows:

i. Peer Recovery Support Service note dated February 14, 2025, was entered into the incorrect client file (client file numbered 1); and

ii. Treatment plan reviews were signed before the end of the review period on the following dates:

a. October 31, November 7 and 20, 2024 (client file numbered 1); and

b. January 16, 22 and 26, and February 5, 2025 (client file numbered 3). Statute Violated: Minnesota Statute, section 245G.06, subdivisions 2a and 2b, paragraph (c).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that all client records meet all applicable requirements.

6. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements in the following ways:

a. The treatment plan review did not include the following:

i. Whether the identified methods continue to be effective for the following treatment plan reviews:

a. January 1, 2025 (client file numbered 2);

b. January 12, 19, 26, February 2, 9, 16 and 23, 2025 (client file numbered 3); and

c. October 31, 2024, and November 20, 2024 (client file numbered 1); and

ii. If changes to the treatment plan are determined to be necessary for the treatment plan review dated January 1, 2025 (client file numbered 2);

b. A treatment plan review was not completed every 30 days for a client receiving ASAM level 2.1 intensive outpatient. The treatment plan review was due on February 14, 2025; however, was not completed until March 13, 2025 (client file numbered 2); and

c. A treatment plan review was not completed weekly for the ten weeks following completion of a treatment plan for a client receiving nonresidential opioid treatment on the following dates:

i. April 13, 20 and 27, 2025 and May 4, 2025 (client file numbered 1);

ii. April 27, 2025 (client file numbered 2); and

iii. February 23, 2025 (client file numbered 3).

Statute Violated: Minnesota Statute, section 245G.06, subdivisions 3 and 3a, paragraphs (e) and (f), clause (1).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that treatment plan reviews meet all applicable requirements. Within 45 days of receipt of this order, submit two treatment plan reviews that meet all applicable requirements.

7. Violation: Three of three client files reviewed for 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 file numbered 6); and

b. The discharge summary did not include:

i. The client’s issues and needs while participating in treatment (client files numbered 4 through 6); and

ii. Continuing care recommendations, including between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to the continuity of care for mental health (client files numbered 4 and 5).

Statute Violated: Minnesota Statute, section 245G.06, subdivision 4, paragraphs (a) and (b), clauses (1) and (6).

Corrective Action Required: Immediately, and on an ongoing basis, the license holder must ensure that service discharge summaries meet all applicable requirements. Within 45 days of receipt of this order, submit two discharge summaries that meet all applicable requirements.

8. Violation: Three of three client files reviewed for requirements governing central registry requirements did not meet requirements. The information submitted to the state central registry did not include the following:

a. Date of admission (client file numbered 2);

b. Date of birth (client file numbered 1); and

c. Current or previous enrollment status in another opioid treatment program (client files numbered 1 through 3).

Statute Violated: Minnesota Statutes, section 245G.22, subdivision 14, paragraph (a), clauses (2), (3), and (5).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure central registry meets all applicable requirements. Within 45 days of receipt of this order submit two central registry documents that meet all applicable requirements.

9. Violation: Three of three client files reviewed for requirements governing the prescription monitoring program (PMP) did not meet requirements. There was no documentation of the following:

a. The PMP data was not reviewed at least every 90 days. The PMP was due March 27, 2025; however, the review was not completed until April 16, 2025 (client file numbered 3);

b. A copy of the PMP data for the report that was reviewed on:

i. April 9, 2025 (client file numbered 1); and

ii. March 26, 2025 (client file numbered 2);

c. The licensed practitioner’s decision for frequency of ongoing PMP checks for the reports dated:

i. April 9, 2025 (client file numbered 1);

ii. March 26, 2025 (client file numbered 2);

iii. April 16, 2025 (client file numbered 3).

Statute Violated: Minnesota Statutes, section 245G.22, subdivision 16, paragraph (b), clauses (2) and (3).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure requirements governing the prescription monitoring program (PMP) are met.

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 substance use disorder treatment program must maintain compliance with the licensing statutes and rules, specifically Minnesota Statute 245G.

· 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 651-431-6698. Sincerely,

Jennifer Eppel, Licensor II Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/