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August 12, 2025 Gerald Powers, Authorized Agent Pathway House 3890 Berkshire Rd SW Rochester, MN 55902 License Number: 809746 CORRECTION ORDER Dear Gerald: On May 19, 20, and 21, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Pathway House located at 103 6th Ave 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, Procedures, and Practices 1. Violation: The license holder did not meet requirements governing grievance procedures. The license holder’s grievance procedure did not include the current address and phone number of the Department of Health Facilities Complaints. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the grievance procedure meets all applicable requirements. Within 45 days of receipt of this order, submit an updated grievance procedure that meets all applicable requirements. 2. Violation: The license holder’s treatment services description did not meet requirements 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, section 245G.12. Repeat Violation: In a Correction Order that DHS issued on October 20, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the treatment services description meets all applicable requirements. 3. Violation: The license holder’s practices regarding vulnerable adult internal review requirements did not meet requirements. There was no documentation of an internal review done within 30 calendar days for a report received on April 20, 2025. Statute Violated: Minnesota Statutes, sections 245A.65 subdivision 1, paragraph (b), clause (1). Repeat Violation: In a Correction Order that DHS issued on October 20, 2021, you were previously found in violation of this same statute. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the vulnerable adult internal review requirement practices meet all applicable requirements. Client Files 4. Violation: Three of three client files reviewed for requirements governing initial service plans (ISP) (client files numbered 1 through 3) did not meet requirements. The ISP was not person centered and client specific. Statute Violated: Minnesota statutes, section 245G.04, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure initial service plans meet all applicable requirements. 5. Violation: Three of three client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways: a. The IAPP did not include an individual assessment of the person’s susceptibility to abuse by others (client files numbered 1 and 3); and b. The IAPP did not include an assessment of the person’s risk of abusing other vulnerable adults (client files numbered 1, 2, and 3). Statute Violated: Minnesota statutes, sections 245A.65, subdivision 2, paragraph (b), clause (1), 245G.04, subdivision 2, paragraph (b), and 245G.21, subdivision 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure IAPPs meet all applicable requirements. 6. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements as follows: a. CA was not completed within 5 calendar days from day of service initiation, and there was no documentation of the person-centered reason for the delay and planned completion date (client file numbered 2); and b. CA did not include documentation of the following: 1) Status of the client’s basic needs (client files numbered 2 and 3); 2) Client's health history and the client's family health history, including the client's physical, chemical, and mental health history (client files numbered 2 and 3); and 3) A 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 1). Statute Violated: Minnesota Statutes, section 245G.05. Repeat Violation: In a Correction Order that DHS issued on October 20, 2021, 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. 7. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements as follows: a. The ITP was not completed within ten days from the day of service initiation (client files numbered 1, 2, and 3); b. The ITP was not person centered (client files numbered 1 and 3); and c. There was no documentation of the following: 1) A treatment strategy (client files numbered 1, 2, and 3); 2) The ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 2 and 3); and 3) Resources to refer the client to when needs will be addressed concurrently by another provider (client file numbered 3). Statute Violated: Minnesota statutes, sections 245G.06, subdivisions 1 and 1a, paragraph (a), clauses (2) through (4) and (6). Repeat Violation: The license holder was previously found in violation of the same statute in the following orders: · Correction Order dated August 18, 2023 · Correction Order dated October 20, 2021 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. 8. Violation: Three of three client files reviewed for requirements governing client record documentation did not meet requirements in the following ways: a. Entries did not include the job titles or position of the staff that made the entry: 1) April 9, 15, 16, 21, 23, 24, 26 and May 1, 4, 7, 11, and 12, 2025 (client file numbered 1); 2) January 13 through 15, 18 through 20, 22, 24, 28, 29, February 4 through 6, 11, 14, 17, 19 through 21, 24, 25, 27, and March 4, 6, 7, 10 through 12 and 15 through 17, 2025 (client file numbered 2); and 3) December 4, 9 through 11, 13, 14, 19, 21, 26thorugh 28, 2024, January 1, 3 through 5, 7, 15, 19 through 21, 24, 27, 28, and February 4, 5, 10, 14, 16, 17, 19, and 20, 2025 (client file numbered 3); and b. Entries were not signed for notes dated: 1) April 11, 2025 (client file numbered 1); 2) January 17, March 9, 14, and 23, 2025 (client file numbered 2); and 3) December 30, 2024 (client file numbered 3). Statute Violated: Minnesota statutes, section 245G.06, subdivision 2b, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on October 20, 2021, 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 documentation meets all applicable requirements. 9. Violation: Three of three client files reviewed for requirements governing treatment plan reviews did not meet requirements as follows: a. There was no documentation of the following: 1) Client goals addressed since the last treatment plan review and whether the identified methods continue to be effective for treatment plan reviews dated March 3 and 17, 2025 (client file numbered 2) and February 18, 2025 (client file numbered 3); 2) Monitoring of any physical and mental health problems for treatment plan review dated March 17, 2025 (client file numbered 2); 3) The participation of others involved in the individual’s treatment planning for treatment plan review dated May 02, 2025 (client file numbered 1); and 4) The span of time covered by the review for treatment plan review dated March 17, 2025 (client file numbered 2); and b. Treatment plan reviews were not completed once every 30 days for client’s receiving residential ASAM level 3.1 low-intensity services as follows: 1) Treatment plan review was due on February 16, 2025; however, was completed on February 20, 2025 (client file numbered 2); and 2) Treatment plan review was due on January 12, 2025; however, was completed on January 29, 2024 (client file numbered 3). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3 and 3a, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plan reviews meet all applicable requirements. 10. Violation: Two of two client files reviewed for requirements governing service discharge summaries (client files numbered 2 and 3) did not meet requirements as follows: a. The discharge summary was not completed within five days of service termination; and b. Progress toward achieving each goal identified in the treatment plan was copy and pasted from the last treatment plan review. Statute Violated: Minnesota statute, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service discharge summaries meet all applicable requirements. Within 45 days of receipt of this order, submit a service discharge summary that demonstrates compliance. 11. Violation: Three of three client files reviewed for requirements governing medication administration did not meet requirements. The client’s use of medication was not recorded, including staff signatures with date and time as follows: a. April 11 through 15, and 18, 2025 (client file numbered 1); b. February 02, 2025 (client file numbered 2); and c. December 10, 29, 30, 2024, January 01, 19, 30, 31, February 05, 14, 16 and 22, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.08, subdivisions 5, paragraph (c), clause (7) and 6, clause (3) and 245G.21, subdivision 8. Repeat Violation: In a Correction Order that DHS issued on October 20, 2021, 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 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 david.her@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: David Her 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 651-431-7229 or at david.her@state.mn.us. Sincerely, David Her, Licensor Licensing Division Office of Inspector General
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