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April 9, 2026 Gerald Powers. Authorized Agent Pathway House, Inc. 3890 Berkshire Road SW Rochester, MN 55902 License Number: 802845 License investigation number: 202509267, 202600654, 202504250 CORRECTION ORDER Dear Gerald, On February 9, 10, 11 and 12, 2026, a Department of Human Services (DHS) licensor conducted a licensing review and investigation 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 monitor the implementation of their policy and procedures in the following ways: a. The discharge policy did not include all current requirements; and b. The controlled drug policy and procedure for storage of medications was not followed. There was no documentation that controlled medications were counted and administered as required (client file numbered 1). Statute Violated: Minnesota statutes, sections 245A.04, subdivision 14, paragraph (b), clause (3), 245G.06, subdivision 4, and 245G.08, subdivision 6, clause (2). 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 a discharge policy that meets all applicable requirements. 2. Violation: The license holder did not determine an acceptable group size based on each client’s needs. Group counseling documentation exceeded 16 clients on September 30, 2025. Statute Violated: Minnesota statutes, section 245G.10, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder will ensure that staff requirements meet all applicable requirements. 3. Violation: The license holder did not ensure that treatment service documentation met requirements. Per staff interview and confirmed through client chart reviews, it was the program’s practice to use group sign in sheets as the treatment service documentation. The documentation did not include the client’s response, was not individualized and did not meet requirements on the following dates: a. September 20, 2025 (client files numbered 1 and 2); and b. January 27, 2026 (client file numbered 3). Statute Violated: Minnesota statutes, section 245G.06, subdivisions 2a. Repeat Violation: In a Conditional Order that DHS issued on October 26, 2023, and Correction Order on November 4, 2024, and July 15, 2025, 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 service documentation meets all applicable requirements. Personnel Files 4. Violation: Two of two personnel files reviewed for requirements governing staff orientation did not meet requirements. There was no documentation within 24 working hours of the following: a. The staff members specific job responsibilities (personnel file numbered 4); and b. Emergency overdose treatment (personnel files numbered 3 and 4). Statute Violated: Minnesota statutes, sections 245G.08, subdivision 3, and 245G.13, subdivision 1. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all staff orientation meet all applicable requirements. 5. Violation: One of two personnel files reviewed for requirements governing annual training (personnel file numbered 2) did not meet requirements. There was no documentation for calendar year 2025 of the following: a. Mandatory reporting requirements as specified in Minnesota Statutes, sections 245A.65, 626.557, 626.5572, and chapter 260E; b. Program abuse prevention plan; c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and d. HIV minimum standards. Statute Violated: Minnesota statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 3, and 245G.13, subdivision 2, paragraphs (c) and (d). Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all annual training meet all applicable requirements. Within 30 days of receipt of this order, submit annual training documentation for personnel file numbered 2 that demonstrates compliance. 6. Violation: Three of four personnel files reviewed for requirements governing personnel file contents did not meet requirements. There was no documentation of: a. A completed application for employment signed by the staff member and containing the staff member’s qualifications for employment (personnel file numbered 2); b. An inquiry required by Minnesota Statutes, sections 604.20 to 604.205 made to the staff member’s former employers regarding substantiated sexual contact with a client (personnel file numbered 4); and c. A written job performance evaluation for calendar years 2024 and 2025 (personnel files numbered 1 and 2). Statute Violated: Minnesota statutes, section 245G.13, subdivisions 1 and 3. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all personnel file contents meet all applicable requirements. Within 30 days of the receipt of this order, submit documentation of (b) and (c) that demonstrate compliance. Client Files 7. Violation: Four of five client files reviewed for requirements governing client orientation did not meet requirements. There was no documentation of orientation to the following within 24 hours: a. A written statement of the client rights and responsibilities as identified in Minnesota Statutes, sections 144.651, 148F.165 (client file numbered 4); b. Grievance procedure (client file numbered 4); c. Opioid education material (client file numbered 4); d. Maltreatment of vulnerable adults (client file numbered 4); e. Program abuse prevention plan (client files numbered 1, 2, 3, and 4); f. Within 72 hours of admission: 1) HIV minimum standards (client file numbered 4); 2) Tuberculosis (client file numbered 4); and g. Personal electronic device (client file numbered 4); and h. Consent to the disclosure of suspected maltreatment from the client (client file numbered 4). Statute Violated: Minnesota Statutes, sections 245A.19, paragraph (b), 245A.65, subdivision 1, paragraph (c), 245G.04, subdivision 3, 245G.09, subdivision 3, clause (1), and 245G.15. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure client orientation meets all applicable requirements. 8. Violation: Four of four client files reviewed for requirements governing initial services plan (ISP) did not meet requirements in the following ways: a. An ISP was not completed within 24 hours of the day of service initiation (client file numbered 4); and b. The 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, November 4, 2024, and July 15, 2025, 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. 9. Violation: Three of five client files reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements in the following ways: a. IAPP was not developed as part of the initial service plan within 24 hours of the day of service initiation (client file numbered 4); and 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 files numbered 3 and 5). 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, November 4, 2024, and July 15, 2025, 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. 10. Violation: Three of four client files reviewed for requirements governing comprehensive assessments did not meet requirements. The assessment did not include the following: a. The client’s description of the client’s symptoms (client file numbered 2); b. Substance use history, including route of administration (client file numbered 3); c. The client’s evaluation of the quality of each family and significant personal relationship (client files numbered 1, 2, and 3); and d. ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client file numbered 1). Statute Violated: Minnesota Statutes, sections 245G.05, subdivisions 1 and 3. Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, November 4, 2024, and July 15, 2025, 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. 11. Violation: Three of four 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. ITP was not signed by the client and did not document the client’s involvement in the development of the plan (client file numbered 1); c. ITP did not include how the family or others will be involved in the client’s treatment (client file numbered 1); d. ITP did not include a treatment strategy (client file numbered 1, 2, and 3); and e. ITP did not identify 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, section 245G.06, subdivisions 1 and 1a, clauses (2), (3), (5) and (6). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, November 4, 2024, and July 15, 2025, 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. 12. Violation: Three of three 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 within 24 hours of the event (client file numbered 1); b. Medical appointment the client attended (client file numbered 2); c. Concerns related to medications that were not documented in the medication administration record (client file numbered 1); and d. Each entry in a client’s record did not include: 1) The staff member’s title: i. August 29, 2025, September 5, 24, 2025, October 13, 2025, November 12, 2025, and December 5, 2025 (client file numbered 2); and ii. January 8, 14, 2025, and February 3, 2026 (client file numbered 3); 2) Staff signature on January 28, 2025 (client file numbered 3). Statute Violated: Minnesota statutes, sections 245G.06, subdivision 2b. Corrective Action Required: Immediately and on an on-going basis, the license holder must ensure all client record documentation meets all applicable requirements. 13. Violation: One of three client files reviewed for requirements governing treatment plan reviews (TPR) and their frequency (client file numbered 3) did not meet requirements. TPR was not completed within 30 days for a client receiving residential ASAM 3.1 low intensity services. Statute Violated: Minnesota statutes, section 245G.06, subdivisions 3a, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, November 4, 2024, and July 15, 2025, 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. 14. Violation: One of three client files reviewed for requirements governing medication administration (client file numbered 1) did not meet requirements. There was no documentation of the client’s use of medication including staff signatures with date and time for October 1, 2, 4, and 5, 2025. Statute Violated: Minnesota statutes, section 245G.08, subdivision 5, paragraph (c), clause (7). Repeat Violation: In a Correction Order that DHS issued on February 29, 2024, November 4, 2024, and July 15, 2025, 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. 15. Violation: Three of four client files reviewed for requirements governing discharge summaries did not meet requirements. There was no documentation of the following: a. The discharge summary completed within five days of the client’s service termination (client file numbered 6); b. The service discharge summary recorded in the six dimensions listed in Minnesota Statutes, section 254B.04, subdivision 4 (client file numbered 1); c. The client’s issues, strengths, and needs while participating in treatment (client files numbered 1 and 2); d. Services provided (client file numbered 1); e. The client’s progress toward achieving each of the goals identified in the individual treatment plan (client file numbered 1); f. A risk rating and description for each of the ASAM six dimensions (client file numbered 1); and g. The client’s living arrangements at service termination (client file numbered 1). Statute Violated: Minnesota statute, section 245G.06, subdivision 4, clauses (1), (2), (3), and (5). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. Within 30 days of receipt of this order, submit a discharge summary that 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
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