MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”

License Number and Program Type:

1102156-H_CRS (Home and Community-Based Services-Community Residential Setting)
1079030-HCBS (Home and Community-Based Services)

Investigator(s):

Marie Tierney
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
(651) 431-6573

Suspected Maltreatment Reported:

Allegation One: It was reported that a staff person (SP1) hit a vulnerable adult (VA1) in the genitals.

Allegation Two: It was reported that SP1 touched a vulnerable adult (VA2) in unwanted ways including rubbing VA2’s stomach, “smacking” VA2’s buttocks, and poking VA2. During the investigation, information was received that SP1 also touched VA1 in a similar manner.

Allegation Three: It was reported that SP1 often “talked dirty” about adults and children of another gender around VA2. When VA2 told SP1 that s/he did not like this, SP1 told VA2 s/he “must be gay.” During the investigation, information was received that SP1 talked similarly around VA1 which caused VA1 to feel uncomfortable.

Allegation Four: It was reported that on one occasion, SP1 refused to drive VA2 from St. Paul back to the facility. VA2 had to wait over ten hours alone in St. Paul before another staff person drove him/her back to the facility.

Allegation Five: It was reported that a staff person (SP2) often slept in a vacant bedroom while s/he was on duty. When VA1 and VA2 asked SP2 for assistance, s/he came out of the bedroom, yelled at VA1 and VA2, and walked around the facility wearing his/her undergarments. It was also reported that on one occasion, SP2 had sexual contact with an unidentified staff person (SP3) at the facility, which was overheard by VA2.

Allegation Six: It was reported that a staff person (SP4) told VA1, “Battle lines drawn,” during a disagreement, which caused VA1 to feel uncomfortable when SP4 was working.

Allegation Seven: It was reported that the facility was infested with mold which caused eye and respiratory illness in VA1, and “mold on the lungs” in VA2. VA1 moved out of the facility and was living in his/her vehicle to avoid the mold.

Allegation Eight: It was reported that VA2 used crack cocaine at the facility and staff persons did not address the concern.

Allegation Nine: It was reported that VA2 was unable to attend funerals for his/her grandparent, sibling, and other family members because the facility did not supply transportation.

Allegation Ten: It was reported that staff persons did not cook or clean at the facility, and that VA2 often asked VA1 to cook for him/her because staff refused to cook.

Allegation Eleven: It was reported that facility staff persons “lost” approximately $140 in cash belonging to VA2.

Allegation Twelve: It was reported that on two occasions, VA2 paid for fuel (a total of approximately $40) for a facility vehicle when staff persons were unable to get the facility credit card to work. VA2 was not reimbursed for the purchases.

Allegation Thirteen: It was reported that VA2 was employed by the facility as a maintenance worker, and his/her paychecks were often missing hours worked, or paid VA2 less than his/her agreed-upon wage. It was reported that the facility owed VA2 $470 in back wages.

Allegation Fourteen: During the investigation, information was received that a staff person (SP5) drove VA1 to SP5’s family member’s home, where SP5 used marijuana. SP5 proceeded to drive VA1 while under the influence of marijuana.

Date of Incident(s): Multiple, many unspecified

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clauses (1) and (2); and subdivision 2, paragraph (c); and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a):

Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to:

· Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.

· The use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.

Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast.

In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult.

The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on November 17, 2021; from documentation at the facility, law enforcement records, medical records, and records from Chisago county licensing; and through 20 interviews conducted with VA1, VA2, a facility resident (R1), a resident from a different facility operated by Bridges MN (R2), VA1’s case manager (CM1), VA2’s case manager (CM2), SP1, SP2, SP4, SP5, and ten current and former staff persons (P1 – P10), including supervisory and administrative staff persons. SP3’s identity was not determined.

The DHS investigator scheduled an interview with a former supervisory staff person at the facility (P11). However, P11 did not answer his/her phone at the appointed time, and did not respond to subsequent voice mail messages. Therefore, P11 was not interviewed.

Facility records documented that VA1 was a “good cook” who enjoyed fishing and other outdoor activities and who wanted to be thought of as a “nice” person. VA1’s diagnoses included anxiety, substance use disorder, blood clotting disorder and diabetes. VA1 was subject to a civil commitment order. VA1 had a history of paranoia, including a belief that others were trying to harm him/her. VA1 needed supports to gain social skills, learn to manage his/her emotions, stabilize his/her addictions, manage his/her medications, and stabilize his/her mental health.

Facility records documented that VA2 was a “friendly” and “helpful” person who was “extremely motivated to work.” VA2’s diagnoses included schizophrenia, bipolar disorder, traumatic brain injury, delusional disorder, and substance use disorders. VA2 wanted to become more independent in his/her daily living skills, get his/her driver’s license, and further his/her education.

The facility’s internal reviews noted that VA1 and VA2 each had a history of inaccurate reporting. However, this information was not documented or addressed in VA1’s or VA2’s individualized plans that were supplied to the DHS investigator.

The facility was a five bedroom, two bathroom multi-level home located in a rural area. Two or more staff persons were scheduled to work at the facility at all times, with awake overnight staff persons. The allegations investigated in this report spanned an unspecified time period during which there were periods when VA1 and VA2 were the only persons served at the facility, as well as periods when other individuals (including R1) lived at the facility.

Allegation One: It was reported that SP1 hit VA1 in the genitals.

Facility records showed that VA1 might display verbal and physical aggression, including a reported history of assaulting staff persons at previous facilities. If VA1 displayed verbal or physical aggression, staff persons were to attempt to de-escalate VA1 and redirect him/her to a preferred activity or space. VA1 was also vulnerable to physical abuse because s/he might provoke abuse by others and/or not know how to respond to abuse if it occurred. If VA1 experienced abuse staff persons were to provide first aid as needed and report the incident as required.

VA1 provided the following information during his/her interview:

· On an unspecified date, VA1 walked into a staff office where SP1 was lying on a couch. VA1 asked SP1 if s/he wanted to go for a walk and SP1 said, “No,” “kind of smiled at [VA1],” then “popped” VA1 in the genitals with the back of SP1’s hand. VA1 doubled over in pain and asked SP1, “What the fuck is your problem?” and SP1 laughed. VA1 stood up and SP1 hit him/her in the genitals a second time with the back of SP1’s hand, then VA1 “socked” SP1 in the face. SP1 began bleeding near the side of SP1’s eye and VA1 began to worry that s/he would get in trouble.

· VA2 witnessed the incident and called law enforcement. SP1 told law enforcement that “nothing happened.”

· SP1 told VA1 that if anyone asked, VA1 should say s/he and SP1 were “just playing around, nothing happened.”

· Initially, VA1 followed SP1’s instruction to tell others that s/he was “just playing around” with SP1 during the incident. However, after thinking about it more, VA1 decided s/he should not let SP1 “get away” with hitting people, and VA1 told others that the incident started with SP1 hitting VA1.

· VA1’s genitals were “really sore” for at least one month after the incident. VA1 sought medical attention for his/her genital pain.

The DHS investigator requested VA1’s medical records. However, as of the date this report was completed, they had not yet been received.

VA2 provided the following information during his/her interview:

· On an unspecified date, VA1 and SP1 returned to the facility from an outing. VA1 and SP1 began “horsing around” and “fake wrestling,” then VA1 “clocked [SP1] for real,” and SP1 punched and kicked VA1 in the groin “as far as [s/he] can.”

· VA2 called law enforcement and VA1 and SP1 told law enforcement that they were “just playing around.”

P1 provided the following information during his/her interview:

· Initially, when P1 and P11 asked VA1 and SP1 about the incident, VA1 and SP1 told P1 and P11 that they knew one another from “years back” and were very close. VA1 said s/he and SP1 were “horse playing around.” VA1 said VA2 saw them and thought they were having a “serious” fight, but VA1 assured P1 and P11 that they were “just goofing around.”

· Days later, VA1 told P1 that SP1 hit VA1 and “beat [VA1] up,” and that VA1 wanted to file a police report. P11 asked VA1 if s/he was referring to the same incident s/he previously described as “just goofing around,” and VA1 said yes.

· P1 never had concerns about the way s/he observed SP1 interact with VA1, VA2, R1, or other persons served at the facility.

Law enforcement records regarding this incident were requested. However, as of the date this report was completed, they had not yet been received.

An Incident Report documented the following:

· On October 18, 2021, VA2 told P11 that on October 16, 2021, VA1 and SP1 “got into a physical altercation.” VA2 said VA1 tapped SP1 on the shoulder repeatedly and SP1 asked VA1 to stop several times. SP1 lay back on a couch and lifted his/her leg to block VA1. VA1 then punched SP1 “very hard” in the shoulder, and SP1 “retaliated by punching [VA1] in the genitals.” Next, VA1 punched SP1 in the eye and made him/her bleed. VA2 called law enforcement and when they arrived SP1 told law enforcement “everything was okay.”

· On October 18, 2021, SP1 and VA1 each told P11 that they were “just horse playing” and VA1’s fingernail caught the corner of SP1’s eye and caused bleeding.

· On October 29, 2021, VA1 approached P11 and told him/her that SP1 punched him/her in the genitals twice during the incident, and said s/he did not feel safe around SP1. VA1 said after SP1 punched him/her in the genitals, s/he retaliated by punching SP1 in the face. VA1 said s/he previously said s/he was “horse playing” with SP1 because SP1 told him/her to say that.

SP1 provided the following information during his/her interview with the DHS investigator:

· On an unspecified date in autumn of 2021, SP1 took VA1 fishing. When they returned to the facility, SP1 sat on a low sofa in a staff office.

· VA1 approached SP1 and asked him/her to go outside to smoke with VA1. SP1 declined, but VA1 proceeded to repeatedly ask SP1 to go outside to smoke with him/her. VA1 began to pull SP1’s hand and suggested they go for a walk. SP1 said s/he was tired and needed to rest for a while and would “get back to” VA1. VA1 continued to make requests of SP1, pulling SP1’s hand and getting closer to SP1.

· SP1 “got serious” and said to the VA, “Stop, get away from me, stop doing this.” VA1 then took hold of SP1’s head with two hands and pulled SP1’s head toward VA1. SP1 tried to push VA1 off him/her, making contact with VA1’s lower “belly.” The SP said, “It took a good 30 to 40 seconds to push [him/her] to give me some breathing space, [his/her] big weight was on me basically, my seat was so low, my head was at like [VA1’s] belly button level, when I pushed [him/her] in the belly or gut area, I don’t really remember if I touched [his/her] genitals but I pushed [him/her] off me,” and VA1 stopped. During this interaction, VA1’s fingernail scratched the side of SP1’s face, causing bleeding that got on SP1’s sweater.

· SP1 washed his/her sweater and put it in his/her vehicle. When s/he returned inside the facility VA2 had called law enforcement to report the SP1 and VA1 were “fist fighting,” and VA1 was “freaking out, crying and sobbing.” SP1 told law enforcement “nothing like fist fighting happened.”

· A few days later, SP1 was with VA1 in the community when VA1 repeatedly touched a community person’s service dog, despite the owner asking VA1 not to several times. VA1 “made a scene” and SP1 told VA1 his/her behavior was “not okay.” Shortly after that incident, VA1 started telling others that SP1 hit VA1 in the genitals.

· SP1 denied intentionally hitting VA1’s genitals and thought VA1 might say SP1 hit his/her genitals because s/he was upset about being held accountable during the incident with the service dog.

SP1 provided information for the facility’s internal investigation that was mostly consistent with the information s/he provided to the DHS investigator. However, there were some differences. SP1 told facility investigators that after making repeated requests of SP1, VA1 touched SP1’s head three to four times. Then SP1 “gently” pushed VA1 away from him/her with the back of his/her hand. VA1 then scratched SP1 near the eye and SP1 began to bleed, and then SP1 told VA1 to stop using a more stern tone of voice.

On October 16, 2021, SP1 wrote in VA1’s progress notes, “[VA1] got up at 9 a.m. and took a shower. Took only morning injection and refused other meds. Around 1 pm [s/he] went to fish at the lake.” There was no mention of a physical altercation or law enforcement involvement.

The facility’s Employee Conduct and Work Rules policy stated that staff persons were expected to follow rules of conduct that will protect the interests and safety of all staff persons, service recipients, and others. Conduct that may result in disciplinary action included fighting, threatening violence, and boisterous or disruptive activity.

The facility’s Reporting and Review of Maltreatment of Vulnerable Adults policy stated that staff persons were required to conduct themselves in a supportive and respectful manner which did not maltreat vulnerable adults.

The facility’s personnel files and training records documented that SP1 was trained on positive behavior supports, the facility’s policies and procedures, the Reporting of Maltreatment of Vulnerable Adults Act, and on VA1’s individualized plans prior to the incident. There was no information that SP1 received any corrective action related to the October 16, 2021, incident.

Conclusion for Allegation One:

A. Maltreatment:

VA1 said SP1 punched him/her in the genitals two times before VA1 punched SP1 in the face, and VA2 said VA1 hit SP1 first, then SP1 punched and kicked VA1 in the genitals “as far as [s/he] can.” SP1 denied intentionally hitting VA1 in the genitals, and said “It took a good 30 to 40 seconds to push [him/her] to give me some breathing space, [his/her] big weight was on me basically, my seat was so low, my head was at like [VA1’s] belly button level, when I pushed [him/her] in the belly or gut area, I don’t really remember if I touched [his/her] genitals but I pushed [him/her] off.”

Given the conflicting information provided, credibility was a determining factor:

· VA1 initially told P1, P11, and law enforcement that s/he and SP1 were “horse playing,” but a few days later told P1 that the incident actually began with SP1 punching VA1 in the genitals. VA1 said s/he provided incorrect information at first because SP1 told him/her to do so, but later s/he decided that s/he could not let SP1 “get away” with hitting people. Subsequently, VA1 provided consistent information that SP1 hit him/her in the genitals. However, SP1 said s/he thought VA1 was angry with SP1 over being held accountable during an incident days later, and then began telling people SP1 hit him/her.

· VA2 provided consistent information over time, and to multiple individuals that during the incident VA1 punched SP1 and SP1 retaliated by hitting VA1 in the genitals.

· SP1 did not document that any incident occurred on October 16, 2021. The Incident Report stated that on October 18, 2021, when asked about the incident, SP1 told P11 s/he and VA1 were “just horse playing” and VA1’s fingernail caught the corner of SP1’s eye, causing bleeding. For the facility’s internal investigation, SP1 said VA1 touched his/her head three or four times, then the SP “gently” pushed VA1 away with the back of his/her hand. SP1 told the DHS investigator that VA1 took hold of his/her head with both hands and pulled it toward VA1, then SP1 tried to push VA1 off him/her for 30 to 40 seconds, during which VA1’s fingernail scratched VA1’s face, causing bleeding. SP1 said s/he did not remember whether s/he made contact with VA1’s genitals during this physical interaction.

Given the above, it was determined that VA2’s account of the incident was the most credible, and therefore, there was a preponderance of the evidence that VA1 hit SP1, and SP1 then hit VA1 in the genitals. Although VA1’s interaction with SP1 might have needed intervention, SP1 was lying down at a time when s/he was responsible to provide care and services to VA1 which VA1 had requested. SP1’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and were not accidental or therapeutic conduct. VA1 said s/he “doubled over in pain” when s/he was hit, and it could also reasonably be expected to produce physical pain or emotional distress to be hit in the genitals by a caregiver.

It was determined that physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

SP1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s individualized plans prior to the incident. SP1 was responsible for maltreatment of VA1.

C. Recurring and/or Serious Maltreatment:

See part C of conclusion for Allegation Three.

Allegation Two: It was reported that SP1 touched VA2 in unwanted ways including rubbing VA2’s stomach, “smacking” VA2’s buttocks, and poking VA2. During the investigation, information was received that SP1 also touched VA1 in a similar manner.

VA2 was vulnerable to physical and sexual abuse because s/he might cooperate with an abusive situation, s/he was unable to “deal with” verbally and physically aggressive persons, and s/he might provoke abuse by others. Staff persons were to teach VA2 what abuse might look like and what to do if s/he experienced abuse. In addition, staff persons were to report any known or suspected abuse as required.

VA1 was vulnerable to physical abuse (as described in allegation one). VA1 was also vulnerable to sexual abuse because in the past s/he had presented nude in shared and public areas. If staff persons suspected or observed sexual abuse, they were to redirect VA1 to safety and report the suspected or observed abuse as required.

VA2 provided the following information during his/her interview with the DHS investigator:

· “A few times,” SP1 touched VA2 in unwanted ways including rubbing VA2’s shoulder, rubbing VA2’s belly, poking VA2, and “smacking” VA2’s buttocks.

· When this happened VA2 felt “upset” and “got in a fight with [SP1] I yelled at [him/her] and almost hit [him/her] twice.”

· VA2 “reported to the office” about SP1’s conduct and told unspecified facility management that s/he did not feel comfortable with SP1 working at the facility, but “they still sent [SP1] out here for almost half a year.”

VA1 provided the following information during his/her interview with the DHS investigator:

· Sometimes while VA1 was out on walks with SP1, SP1 touched VA1 in unwanted ways including poking, pinching, grabbing and hitting the sides and front of VA1’s stomach.

· SP1 touched VA2’s stomach and called VA2 “buddy.” VA2 “made a fit about it” and said, “No, don’t be touching me.” (VA1 did not say how s/he knew this.)

P3 (who was a supervisory staff person at the time) said that in late summer or early autumn of 2021, VA1 and VA2 “accused [SP1] of touching them sexually” including touching and hitting VA2’s “butt” and touching VA1’s leg while VA1 was sitting down. P3 notified a facility administrator (P4) of the allegations. P3 was told s/he did not need to document the allegations because s/he did not directly witness it, and when s/he asked VA1 and VA2 if they wanted to file a report, each declined.

P4 said that when the facility investigated the October 16, 2021, incident involving SP1, “a lot of things came out about [SP1] being inappropriate . . . like the baseball butt tap thing that [s/he] would do.” P4 elaborated that VA1 and VA2 said SP1 “smacked” their buttocks “and things like that.” P4 said s/he was not aware of this prior to investigating the October 16, 2021, incident.

The facility’s internal review regarding this allegation stated, “There have been no reports of this to upper management and no knowledge of this occurring.”

SP1 denied ever poking, rubbing, or touching VA1’s or VA2’s buttocks, shoulders, or stomach.

The facility’s Professional Boundaries policy stated that staff persons were expected to “respect clients’ physical, emotional and cultural boundaries,” and, “teach our clients how to develop appropriate boundaries for themselves and with other clients and staff.” The facility’s Employee Conduct and Work Rules policy stated that conduct that may result in disciplinary action included sexual or other unlawful or unwelcome harassment.

The facility’s personnel files and training records documented that SP1 was also trained on VA2’s individualized plans prior to the incidents.

Conclusion for Allegation Two:

A. Maltreatment:

SP1 denied poking, rubbing, or touching VA1’s or VA2’s buttocks, shoulders, or stomach. However, VA1 and VA2 provided consistent information to the DHS investigator and to P3 that on multiple occasions SP1 touched VA1’s and VA2’s in unwanted and unnecessary ways including rubbing, poking, “smacking,” pinching, grabbing, and hitting various parts of VA1’s and VA2’s bodies (including VA2’s buttocks).

Therefore, there was a preponderance of the evidence that on multiple occasions, SP1 touched VA1’s and VA2’s bodies (including VA2’s buttocks) in unwanted and unnecessary ways. It was not determined whether SP1’s intent was sexual or aggressive, and therefore it was not determined whether sexual abuse occurred. However, being repeatedly touched in unwanted ways by a caregiver could reasonably be expected to produce emotional distress, and VA2 said s/he felt “upset” to the point that s/he tried to “fight” SP1.

It was determined that emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult).

It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast.)

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(2) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(3) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(4) whether the facility or individual followed professional standards in exercising professional judgment.

SP1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s and VA2’s individualized plans prior to the incident. SP1 was responsible for maltreatment of VA1 and VA2.

C. Recurring and/or Serious Maltreatment:

See part C of conclusion for Allegation Three.

Allegation Three: It was reported that SP1 often “talked dirty” about adults and children of another gender around VA2. When VA2 told SP1 that s/he did not like this, SP1 told VA2 s/he “must be gay.” During the investigation, information was received that SP1 talked similarly around VA1 which caused VA1 to feel uncomfortable.

During his/her interview, VA2 said SP1 “always” talked “sexual talk” about other staff members and community persons of another gender. Sometimes VA2 told SP1 s/he did not like talking about this topic, and SP1 told VA2 s/he “must be gay.” VA2 felt “upset” and wanted to fight SP1 when this happened.

During his/her interview, VA1 said on multiple occasions, SP1 talked about “getting with” 15 and 18 year old persons of another gender “because they’re young.” VA1 said s/he tried to “blow it off.” However, VA1 was a child sexual abuse survivor and, “I don’t want to hear that shit,” and afterward VA1 perceived SP1 as unsafe due to his/her comments.

P3 (a supervisory staff person at the time) said, “[SP1] treated [persons of another gender] as objects and nothing more than sexual gratification and I’m sure when I wasn’t around [SP1] would say it to [VA1 and VA2].” SP1 texted another staff person, “You’re nothing more than a hole,” and, “You’re disgusting that’s why your [spouse] used to beat you.” P3 was “appalled” by SP1’s conduct toward the other staff person and reported it to facility management and human resources and stopped scheduling SP1 to work at the facility. P3 said, “I would rather work 70 to 90 hours a week just to make it so residents didn’t have to work with really crappy staff like [SP1].”

P5 said s/he heard SP1 talk about persons of another gender in “sexualized” ways, including, “Something about wanting to be with like 15 year old or 18 year old bitches and something about never being married because[SP1] was going to treat [persons of another gender] dirty.” P5 said SP1’s conduct made him/her “uncomfortable” and s/he suggested SP1 not talk about such topics in the workplace.

SP5 said s/he worked one or two shifts with SP1 and SP1 was “[boy/girl] crazy” and talked about dating and dating apps with SP5. SP1 talked about staff persons of another gender “not in the nicest way.” For example, SP1 said a staff person s/he was “talking to” “Looked like [s/he] did drugs.”

SP1 denied talking about persons of another gender with VA1 and VA2.

The facility’s internal review for this allegation stated, “There have been no reports of this to upper management and no knowledge of this occurring.”

There was no information that SP1 received any corrective action related to the comments described by P3.

Relevant Statute:

Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states that a person’s protection-related rights include the right to be treated with courtesy and respect.

Conclusion for Allegation Three:

A. Maltreatment:

SP1 denied talking about persons of another gender with VA1 and VA2. However, VA1 and VA2 each provided consistent information that on multiple occasions, SP1 talked about persons of another gender in a sexual way around them including “getting with” 15 and 18 year old persons of another gender “because they’re young.” VA2 said when s/he told SP1 s/he did not want to talk about this, SP1 told VA2 s/he “must be gay,” which made VA2 feel “upset;” and VA1 said that s/he was a child sexual abuse survivor and s/he perceived SP1 as “unsafe” after such conversations. P3, P5, and SP5 each provided corroborating information that SP1 talked in a similar manner around them which corroborated VA1’s and VA2’s accounts. SP1’s interactions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; were in violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6); and were not accidental or therapeutic conduct. There was a preponderance of the evidence that SP1 talked about adults and children of another gender in a sexual way around VA1 and VA2 on multiple occasions; which caused emotional distress to both VA1 and VA2.

It was determined that emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(3) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(4) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(5) whether the facility or individual followed professional standards in exercising professional judgment.

SP1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s and VA2’s individualized plans prior to the incident. SP1 was responsible for maltreatment of VA1 and VA2.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.”  Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.  Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury.  For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment.  For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke.  Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated physical abuse of VA1 (Allegation One) and emotional abuse of VA1 and VA2 (Allegations Two and Three) for which SP1 was responsible did not meet the statutory definition of serious maltreatment as outlined above. However, SP1 was responsible for the physical and/or emotional abuse of two vulnerable adults which was recurring maltreatment. SP1 was disqualified from providing direct contact services.

Allegation Four: It was reported that on one occasion, SP1 refused to drive VA2 from St. Paul back to the facility. VA2 had to wait over ten hours alone in St. Paul before another staff person drove him/her back to the facility.

VA2 said during his/her interview that around the end of October or beginning of November 2021, an unidentified staff person drove VA2 to St. Paul around noon. When it was time to return to the facility, the staff person got into an argument with VA2 and VA2 told the staff person s/he would not get into the facility van “until you get someone else to come get me.” The staff person called law enforcement and VA2 had to wait until 10:30 p.m. for another staff person to pick him/her up and drive him/her back to the facility. VA2 said while s/he waited s/he visited friends, family, and neighborhood churches. There was no harm to VA2.

Information from facility records, P6, and law enforcement records was consistent that on October 30, 2021, P6 drove VA2 to St. Paul at VA2’s request. P6 dropped VA2 off at 11:45 a.m. and agreed to pick VA2 up at 12:45 p.m. at a specific location (VA2 was authorized to spend one hour in the community without supervision). However, VA2 did not show up at the agreed upon time and place. P6 looked for VA2 on foot, then contacted supervisory staff persons. At 4:05 p.m. P6 called 9-1-1 to report VA2 as a missing person to law enforcement. Law enforcement and P6 looked for VA2 until 6 p.m., when P6 returned to the facility. At 10:19 p.m. VA2 called the facility and asked for a ride home. A staff person picked VA2 up and drove him/her to the facility. There was no information that VA2 was harmed.

SP1 said s/he was not aware of any incident where VA2 had to wait in St. Paul for several hours.

The facility’s internal review for this allegation stated, “There have been no reports of this to upper management and no knowledge of this occurring.”

Conclusion for Allegation Four:

It was reported that SP1 refused to drive VA2 from St. Paul back to the facility, and VA2 had to wait over ten hours alone in St. Paul before another staff person drove him/her back to the facility. However, VA2 said s/he got into an argument with an unidentified staff person and refused to get into the facility van. Further, information from facility records, P6 and law enforcement records was consistent that on October 20, 2021, P6 drove VA2 to St. Paul and dropped him/her off around 11:45 a.m. VA2 did not meet P6 at an agreed upon time and place and P6 subsequently looked for VA2 on foot, contacted supervisory staff persons, and reported VA2 as a missing person to law enforcement. At 10:19 p.m., VA2 called the facility and asked for a ride home. There was no information that VA2 was harmed.

Therefore, there was a preponderance of the evidence that when P6 suspected VA2 was missing, P6 took reasonable and necessary action by searching for VA2, contacting facility supervisors, and reporting VA2 as a missing person to law enforcement.

It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Allegation Five: It was reported that SP2 often slept in a vacant bedroom while s/he was on duty. When VA1 and VA2 asked SP2 for assistance, s/he came out of the bedroom, yelled at VA1 and VA2, and walked around the facility wearing his/her undergarments. It was also reported that on one occasion, SP2 had sexual contact with SP3 at the facility, which was overheard by VA2.

VA2’s bedroom was on a lower level of the facility. There was a vacant bedroom adjacent to VA2’s bedroom.

SP1, VA1, VA2, and R1 were all the same gender.

VA1 said that every time SP2 worked, SP2 went into the vacant bedroom to sleep. When VA1 or VA2 knocked on the door to ask for assistance, SP2 came out of the vacant room wearing only undergarments and yelled at VA1 and VA2, saying things like, “Do you think this job is easy?” “Leave me alone!” and, “What is [VA2’s] problem?”

VA2 said a staff person, possibly P6 but s/he was not sure, often walked around the facility wearing only his/her undergarments. On one occasion the staff person had sexual contact with another staff person whose name VA2 did not know. When asked how s/he knew they had sexual contact, VA2 said, “You can hear it. You know, then they come out of the room together and [one staff person] is in [his/her undergarments], what else am I supposed to think?”

R1 did not provide pertinent information about Allegation Five during his/her interview with the DHS investigator.

P1 (a supervisory staff person at the time) said on an unspecified date, R1 told him/her that the previous night, SP2 was working, but R1 could not find SP2 in the house. R1 then went outside the house and began looking into windows, and R1 saw SP2 sleeping in the vacant bedroom. R1 “scared” SP2, and SP2 jumped up and said, “What are you doing?” R1 said, “Aren’t you supposed to be awake?” R1 then went back inside the house and SP2 came out of the vacant bedroom wearing only his/her undergarments. VA2 also told P1 that SP2 came out of the vacant bedroom wearing only his/her undergarments. SP2 denied sleeping on the job and denied wearing only his/her undergarments. P1 said s/he reported this information to facility management.

P4 said P11 told him/her that facility residents said SP2 was sleeping while s/he was working, and on one occasion s/he was wearing only his/her undergarments. P4 did not have information about what happened if residents asked SP2 for assistance. P4 said SP2 received “corrective action” for sleeping on the job.

P5 said “many” staff persons slept on the job and on one occasion VA2 told P5 that SP2 was wearing only his/her undergarments at the facility. P5 also “heard” that SP2 had a community person visit him/her at the facility. SP2 never saw the community person in the facility, but on one occasion when P5 worked with SP2, SP2 sat outside the facility and talked with the community person for the full duration of SP2’s shift. P5 also witnessed SP2 “yell at” VA2 in a manner P5 described as “rude” and “not very nice.”

P7 said there was one occasion when VA1 and VA2 said SP2 was sleeping in a different room at the facility, and came out wearing only his/her undergarments, and they also said SP2 had sexual contact with an unidentified staff person. SP2 denied the allegations. SP2 was transferred to a different facility.

SP2 denied ever sleeping while on duty, denied ever wearing only his/her undergarments at the facility, and denied having sexual contact with anyone while s/he was at the facility. SP2 said one night, R1 was looking for SP2 and saw SP2, but R1 still called a supervisory staff person and told him/her SP2 was missing. The supervisor called the facility and SP2 answered to confirm s/he was present. R1 then “made up” that SP2 was “naked.”

The facility’s internal review for this allegation stated that facility management was only aware of reports of SP2 allegedly sleeping, but had not previously been made aware of allegations that SP2 wore only his/her undergarments, nor that SP2 allegedly had sexual contact with another staff person at the facility. SP2 denied the allegations. Although the facility determined there was “no evidence” that SP2 was sleeping on the job, SP2 received corrective action “to make it clear that sleeping during their shift will not be tolerated.”

The facility’s Program Abuse Prevention Plan stated that the facility was staffed with awake support staff at all times.

The facility’s Employee Conduct and Work Rules policy stated that sleeping on the job and disrespectful conduct were each prohibited.

The facility’s Professional Boundaries policy stated that staff persons were to provide positive role models to residents; respect residents’ physical, emotional and cultural boundaries; teach residents how to develop appropriate boundaries for themselves and with other clients and staff; and treat clients with respect at all times.

The facility’s personnel files and training records documented that SP2 was trained on the facility’s policies and procedures, the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s and VA2’s individualized plans prior to the incidents.

Relevant Statutes:

Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3), states that the license holder shall monitor implementation of policies and procedures by program staff.

Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection-related rights include the right to be treated with courtesy and respect.

Conclusion for Allegation Five:

SP2 denied sleeping on the job, denied wearing only his/her undergarments at the facility, and denied having sexual contact while at the facility. However, R1, VA1 and VA2 provided consistent information to multiple persons over time and to this investigator that SP2 slept in the vacant bedroom and wore only his/her undergarments. In addition, VA1 and P5 each provided information that SP2 yelled at VA1 and VA2. There was a preponderance of the evidence that SP2 slept in the vacant bedroom on multiple occasions, wore only his/her undergarments on at least one occasion, and yelled at VA1 and VA2.

Although sleeping on the job was inconsistent with facility expectations and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, there was no information that VA1 or VA2 were harmed by SP2 sleeping, and SP2 was ultimately responsive when VA1 or VA2 asked for assistance. Wearing his/her undergarments was not professional and represented a violation of facility policies and procedures, which was a violation of Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3). However, given that SP2 was the same gender as VA1, VA2, and the R, and that it was not determined whether SP2 wore only his/her undergarments on more than one occasion, it was unclear whether this conduct caused or could reasonably be expected to cause emotional distress.

Regarding yelling at VA1 and VA2, VA1 said SP2 said things such as “Do you think this job is easy?” “Leave me alone!” and, “What is [VA2’s] problem;” and P5 said s/he witnessed SP2 “yell” at VA2 in a manner that was “rude and “not very nice.” SP2’s conduct was inconsistent with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Services, and was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given the information available, it was not determined whether SP2’s conduct caused or could reasonably be expected to cause emotional distress.

It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening).

Allegation Six: It was reported that SP4 told VA1, “Battle lines drawn,” during a disagreement, which caused VA1 to feel uncomfortable when SP4 was working.

Information from VA1, P2, law enforcement records, and facility documentation was consistent that on the night of October 29 - 30, 2021:

· VA1 was upset with P2 because P2 would not take him/her into the community (according to P2 s/he was unable to do so due to staffing and supervision needs of other persons living at the facility). Eventually P11 took VA1 into the community.

· After VA1 left, R1 began arguing with SP4 about SP4 using his/her phone while R1 watched television. VA1 returned to the facility during the argument and went to his/her room, and R1 followed him/her. Minutes later, VA1 and R1 returned to a common area and yelled at SP4. VA1 brought up his/her anger with P2 about previously “denying [VA1’s] rights” by not taking him/her into the community, and threatened to call law enforcement.

· P2 said something to VA1 during the incident that included the words, “battle lines drawn,” or, “You have drawn your battle lines.”

· VA1 and R1 continued to yell at SP4 and P2 called law enforcement. Law enforcement responded to the facility but there was no investigation and no charges.

R1 did not provide pertinent information about Allegation Six during his/her interview with the DHS investigator.

VA1 said SP4 and P2 were “argumentative” during the incident and that s/he felt “unsafe” after P2 said, “Battle lines drawn.”

SP4 did not recall many details about the incident. SP4 did not hear P2 say “battle lines drawn,” but VA1 said P2 said this, and VA1 was “mad” about it. SP4 denied saying “battle lines drawn.”

P2 said s/he remained calm during the incident and his/her comment to VA1 was intended as “normal talk” to VA1.

The facility’s personnel files and training records documented that SP4 and P2 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s individualized plans prior to the incidents.

Conclusion for Allegation Six:

Information from all sources was consistent that during an incident on the night of October 29 – 30, 2021, P2 said something to VA1 that included the words “battle lines drawn” or, “You have drawn your battle lines.” Although VA1 said P2 was “argumentative” during the incident and that s/he felt “unsafe” after the incident, P2 said s/he was calm during the incident, and that s/he intended his/her words toward VA1 to be “normal talk.”

Although P2’s comments to VA1 were neither therapeutic nor consistent with the role of a professional caregiver in a program licensed by the Department of Human Services, there was a preponderance of the evidence that a single incident of saying “battle lines drawn” would not reasonably be expected to produce emotional distress.

It was determined that emotional abuse did not occur (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening).

Allegation Seven: It was reported that the facility was infested with mold which caused eye and respiratory illness in VA1, and “mold on the lungs” in VA2. VA1 moved out of the facility and was living in his/her vehicle to avoid the mold.

VA1 said during his/her interview that multiple areas of the facility were infested with mold. VA1 supplied photographs to the DHS investigator, but it could not be determined whether mold was depicted in the photographs. VA1 said s/he hired a mold remediation company to test the mold and it was determined to be penicillum aspergillus. VA1 said the mold caused illness to VA1, VA2, and multiple staff persons. VA1 said his/her illness included nausea, vomiting, respiratory congestion, “coughing up chunks of skin,” defecating blood, and an eye infection. VA1 said saw three health care professionals about his/her mold-related illness. The first did not identify a problem, the second told VA1 s/he needed remove him/herself from the mold-infested environment, and the third gave VA1 an antibiotic for an eye infection. VA1 moved out of the facility against the advice of his/her interdisciplinary team and was living in his/her vehicle in order to avoid exposure to the mold.

VA1 declined to show or send documentation of the mold testing to the DHS investigator or to the facility.

The DHS investigator requested VA1’s medical records for his/her visits related to mold exposure. However, as of the date this report was completed, no such records were received.

VA2 said s/he had chest x-rays that showed s/he had mold “on my lungs” due to mold infestation at the facility. VA2 said his/her health care professionals “keep giving me more antibiotics” to clear the mold from his/her lungs.

VA2’s medical records documented the following:

· On May 17, 2021, VA2 was seen for pityriasis versicolor (a common yeast infection of the skin) and foot callouses. It was noted that VA2 had “coarse ronchi and expiratory wheezing” in his/her left lung that cleared with coughing. VA2 received an antifungal medication to treat the pityriasis versicolor.

· On June 10, July 23, August 13, November 5, and December 7, 2021, VA2 reported coughing and/or “concerns of mold from living environment” with productive cough, wheezing, shortness of breath, and lung pain. At each visit, VA2’s lung sounds were clear; and at each visit except the June 10, 2021, visit, a chest x-ray was completed which was “clear” with “no acute infectious process noted.” There were no treatments prescribed for VA2’s respiratory concerns.

· On January 31, 2022, VA2 was seen by a health care professional for various concerns. VA2 did not mention any respiratory concerns at that time and his/her lung sounds were clear.

The DHS investigator asked P1 – P10 and SP1, SP2, SP5, and SP6 whether they had any concerns of mold at the facility. Each said that VA1 believed there was a mold infestation at the facility, but VA1 did not supply evidence of this to others, and each person said they did not have concerns about a possible mold infestation.

The Chisago County adult foster care licensor conducted inspections at the facility on August 24 and October 25, 2021, and issued citations related to several physical plant concerns. However, no concerns of mold were noted.

The facility’s internal review stated that facility maintenance did not identify any signs of mold at the facility, so no mold testing or mitigation was completed. P7 told facility investigators that VA1 believed there was mold at the facility and was trying to convince VA2 and R1 that there was mold present.

Conclusion for Allegation Seven:

VA1 told the DHS investigator that s/he hired a mold remediation company to test the facility and penicillum aspergillum was detected at the facility. In addition, VA1 and VA2 each stated that they experienced mold-related illness that required medical care; VA2’s medical records showed VA2 had persistent respiratory problems from May through December of 2021; and VA1 said s/he had to move out of the facility to live in his/her vehicle in order to avoid exposure to the mold.

However, VA1 declined to provide documentation of the alleged mold testing; VA2’s medical records showed that s/he did not receive any treatments for any mold related illness; and VA1’s medical records were not received. Further, the facility provided information that facility maintenance found no signs of mold present, the county licensor did not identify any mold-related concerns, and no staff person interviewed said they had concerns about mold. Therefore, there was a preponderance of the evidence that the facility was not infested with mold and that VA1 and/or VA2 did not have any illnesses related to mold.

It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Allegation Eight: It was reported that VA2 used crack cocaine at the facility and staff persons did not address the concern.

The facility’s record for VA2 documented that VA2 had a history of substance abuse (methamphetamines and marijuana) that resulted in criminal charges for VA2. VA2 was on provisional discharge from a civil commitment order. VA2’s health care professional recommended VA2 limit alcohol consumption to one or two beers one or two days per week. Any suspicion of substance use beyond this was to be reported to VA2’s interdisciplinary team. If a staff person suspected substance use, they were to contact a supervisory staff person (P3 or P11) for guidance on how to proceed. VA2 was authorized to spend time in the community without supervision (the amount of time varied over time).

VA1 said s/he believed VA2 used crack cocaine at the facility because whenever VA2 received money, VA2 first asked VA1 for a ride into the community, then if VA1 refused VA2 asked staff persons for a ride into the community. As soon as VA2 returned to the facility, s/he went into his/her bedroom and closed the door, then VA1 smelled a “chemical smell” that extended throughout the facility’s lower levels and went up into VA1’s upper level bedroom. VA1 said s/he was sure staff persons could also smell the chemical odor, but they did not intervene.

R1 said VA1 used marijuana at the facility but s/he did not have any reason to think VA2 used any illegal substances.

VA2 denied using crack cocaine at the facility. VA2 acknowledged that s/he used CBD and marijuana at the facility on “a couple” occasions.

CM2 said when staff persons suspected VA2 possessed or used illegal drugs, they passed the information on to CM2 and VA2’s legal guardian.

P5 said reports that VA1 and VA2 were suspected of using illegal drugs “seem like they go nowhere” and P2 said when s/he told P11 about a suspicion that VA1 and VA2 used marijuana P11 said, “There’s nothing we can do about it anyway.” However, the remaining staff persons interviewed stated that when staff persons suspected facility residents used illegal drugs, they called law enforcement, documented the incident, and/or notified a supervisory staff person. In addition, the facility supplied Incident and Emergency Reports that documented incidents of suspected drug use by VA2 and showed that case managers and VA2’s legal guardian were notified.

There was no information that VA2 was seriously harmed by any illegal drug use at the facility.

The facility’s internal review for this allegation stated that there were no reports or concerns of VA2 using crack cocaine. When VA2 was suspected of using marijuana, it was “addressed.”

Conclusion for Allegation Eight:

VA1 said s/he believed VA2 used crack cocaine at the facility and staff persons did not intervene. In addition, P1 and P5 provided information that facility management did not respond to concerns about VA1 and VA2 using illegal drugs. However, CM2 and the remaining staff persons interviewed stated that when staff persons suspected VA2 used illegal drugs, they called law enforcement, documented the incident, and/or notified a supervisory staff person. In addition, Incident and Emergency Reports documented that incidents of suspected drug use by VA2 were reported to VA2’s case managers and legal guardian and there was no information that VA2 was seriously harmed by any illegal drug use at the facility. Therefore, there was a preponderance of the evidence that there was not a failure to supply VA2 with reasonable and necessary care and services.

It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Allegation Nine: It was reported that VA2 was unable to attend funerals for his/her grandparent, sibling, and other family members because the facility did not supply transportation.

The facility’s record for VA2 stated that the facility was responsible to provide transportation to allow VA2 to access the community.

VA2 said during his/her interview that seven or more of his/her family members died during the time VA2 lived at the facility, but VA2 was unable to attend their funerals because the facility did not supply transportation and because the facility “had policies saying this and that and you have to be in this house this long before you can go off grounds.” VA2 was unsure of the dates of the funerals s/he missed.

VA2 provided the names of some, but not all of the family members who died. However, the DHS investigator was not able to identify the dates or locations of the funerals VA2 described.

VA1 said VA2 told him/her that s/he chose not to attend one family member’s funeral. VA1 was unaware of other funerals.

SP5 said VA2 talked about family members dying, but, “Staff just kept telling me they don’t think it’s real.” SP5 said s/he was not aware of VA2 attending any funerals of family members who passed away and said, “If [the funerals] were real, it’s because [staff] didn’t take [VA2] . . . they made it seem like they didn’t believe [VA2] at all.”

P1 said VA2’s parent died approximately November of 2021. P1 said VA2 wanted to attend the funeral, so P1 got an oil change and filled the gas tank on a facility vehicle and scheduled an extra staff person to drive VA2 to the funeral and back. However, when the time came to leave for the funeral, VA2 said s/he changed his/her mind and no longer wanted to attend.

P3 said two of VA2’s family members died sometime between August 2020 and 2021. SP1 transported VA2 to one of the funerals. VA2 did not attend the other because some of VA2’s family members informed him/her that s/he was not welcome to attend.

SP1 said one of VA2’s family members died in June or July 2021, but VA2 was not able to attend the funeral because it was out of state.

P5 said two or three of VA2’s family members died in approximately 2021. VA2 attended one funeral and missed another, but P5 did not know why VA2 did not attend.

P7 said one of VA2’s family members died “a couple months back.” P7 requested extra staffing to allow VA2 to attend the funeral, but s/he was not sure whether VA2 actually attended it.

The facility’s internal review for this allegation stated that extra staffing was provided to allow VA2 to visit with family after a family member passed away, and the facility was unaware of VA2 missing any funerals.

Conclusion for Allegation Nine:

VA2 provided information that s/he missed the funerals of several family members because the facility did not supply transportation, or because facility policies prevented him/her from leaving the facility. In addition, SP5 provided information that staff persons did not believe VA2 about the deaths of his/her family members. However, VA2 did not supply specific information about the funerals s/he allegedly missed; staff persons provided information that on at least some occasions, extra staffing was supplied to allow VA2 to attend funerals; there were other factors that could have affected VA2’s ability to attend the funerals (such as whether s/he was welcome and the location); and VA1 and P1 each said that VA2 chose not to attend at least one funeral. Therefore, there was not a preponderance of the evidence as to whether the facility failed to supply reasonable and necessary care and services to VA2.

It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Allegation Ten: It was reported that staff persons did not cook or clean at the facility, and that VA2 often asked VA1 to cook for him/her because staff refused to cook.

Facility records showed that the facility was responsible to supply VA1 and VA2 with three meals and healthy snacks each day, and to maintain a clean and safe home.

VA1 provided information that staff persons often refused to cook for VA1, VA2, and other household members, resulting in missed meals; and that staff persons failed to clean the facility to the point that it was “nasty,” “disgusting,” and “filthy.”

The other individuals who provided information about this allegation said that VA1 enjoyed and was skilled at cooking and often chose to cook for him/herself and others; that VA2 sometimes chose to cook with staff assistance; and that staff persons cooked meals if and when VA1 and VA2 chose not to, although sometimes VA1 and VA2 chose not to eat the food that staff persons prepared. No other individual was aware of any missed meals.

Some persons interviewed said the facility was not always clean. However, others said they did not have concerns about the cleanliness of the facility.

The facility received correction orders from the county licensor on August 24 and October 25, 2021, for unclean conditions.

During the site visit on November 17, 2021, the DHS investigator did not have concerns related to cleanliness.

There was no information that VA1 and/or VA2 were harmed by the unclean conditions.

Conclusion for Allegation Ten:

VA1 said staff persons refused to cook meals for VA1 and VA2, resulting in missed meals; and that the facility was not clean. However, all other persons interviewed who provided information about this allegation said that they were not aware of any missed meals due to any staff persons’ refusal to cook, although sometimes VA1 and VA2 chose not to eat food prepared by staff persons. In addition, although information from the county licensor’s correction order and other individuals supported VA1’s account that the facility was not clean, there was no information that VA1 or VA2 were harmed by unclean conditions. The facility received correction orders from the county licensor on August 24 and October 25, 2021, regarding the unclean conditions, and the DHS investigator did not have concerns related to cleanliness during the November 17, 2021, site visit. However, there was not a preponderance of the evidence as to whether the facility failed to supply reasonable and necessary care and services to VA1 and VA2.

It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Allegation Eleven: It was reported that facility staff persons “lost” approximately $140 in cash belonging to VA2.

Information from interviews and facility records was consistent that VA2 had a representative payee who managed VA2’s finances. VA2’s representative payee placed funds into a debit card account for VA2, and VA2 independently withdrew cash using the debit card. VA2 stored and managed his/her cash independently and staff persons had no role in storing or safeguarding VA2’s cash.

VA2 said s/he gave $140 in cash to staff persons to hold on to for him/her, and when s/he asked for the cash later on, staff persons told him/her that they did not know where it was or that VA2 did not give cash to staff persons; and the $140 was never returned to VA2. VA2 did not provide information about which staff person(s) s/he gave the cash to, nor when s/he did so.

Information from all other persons interviewed who had information about this allegation was consistent that no other person recalled VA2 asking a staff person to safeguard his/her cash.

The facility’s internal review for this allegation noted that it would be unusual for VA2 to have $140 in cash, as s/he usually had smaller amounts available to him/her, and that VA2 had a history of telling others that s/he did not have money “as a way to get things from others.”

Conclusion for Allegation Eleven:

VA2 said s/he gave $140 in cash to staff persons to hold on to for him/her, and the $140 was never returned to him/her. However, VA2 did not provide information as to which staff person(s) s/he gave the cash to, nor when s/he did so, information from all other sources was consistent that staff persons had no role in storing or safeguarding VA2’s cash, and no other person recalled VA2 ever asking any staff person(s) to safeguard his/her cash. Therefore, there was not a preponderance of the evidence as to whether a staff person willfully used, withheld, or disposed of VA2’s funds.

It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult).

Allegation Twelve: It was reported that on two occasions, VA2 paid for fuel (a total of approximately $40) for a facility vehicle when staff persons were unable to get the facility credit card to work. VA2 was not reimbursed for the purchases.

The facility’s record for VA2 documented that the facility was responsible to provide transportation to VA2 to allow VA2 to access the community, visit friends and family, and attend his/her job.

Information from VA2 and P7 was consistent that on two or three occasions, VA2 paid for fuel for a facility vehicle when staff persons either forgot to bring the facility fuel card with them on an outing, or when staff persons were not able to get the fuel card to work. P4 was aware of one of these occasions.

During VA2’s interview on November 11, 2021, VA2 said s/he paid a total of approximately $40 (approximately $20 on each of two occasions) and that s/he was never reimbursed for this expense. During a follow up interview on February 22, 2022, VA2 said s/he had since been reimbursed.

P7 said each time VA2 purchased fuel for a facility vehicle, VA2 “usually” saved the receipt for purchase and told P7 about it. P7 told VA2 to ask staff persons to reimburse VA2 from the facility’s petty cash, and to his/her knowledge VA2 was reimbursed. However, there were no receipts for VA2’s reimbursements.

P5 said s/he was not aware of any instances of a facility resident paying for fuel for a facility vehicle. P5 said the facility had a “gas card” that was stored in the facility vehicle at all times and it was neither necessary nor appropriate for a resident to pay for fuel. Sometimes a staff person paid for fuel for a facility vehicle, and then the staff person was reimbursed later on.

The facility’s internal review for this allegation said “a long time ago” VA2 told P7 that s/he lent $20 to a staff person for fuel because the staff person did not have the facility’s fuel card with him/her. VA2 was subsequently reimbursed. The facility determined that no corrective action was needed to protect the health and safety of persons served by the facility.

Relevant Statutes:

Minnesota Statutes, section 245A.04, subdivision 13, paragraphs (b) and (d) state that the license holder must ensure separation of funds of persons served by the program from funds of the license holder, the program, or program staff; and license holders and program staff must not borrow money from a person served by the program, or use funds of persons served by the program to purchase items for which the facility is already receiving public or private payments.

Conclusion for Allegation Twelve:

Information from VA2, P7, and P4 was consistent that on at least one occasion, and likely two to three occasions, VA2 purchased fuel for a facility vehicle and was later reimbursed which was a violation of Minnesota Statutes, section 245A.04, subdivision 13, paragraphs (b) and (d). VA2 was reimbursed in some amount, after an unknown period of time elapsed. However, due to the absence of related documentation, it could not be determined whether VA2 was reimbursed in full for these expenditures, nor the timeline of his/her reimbursement. Therefore, there was not a preponderance of the evidence whether a person willfully used, withheld, or disposed of VA2’s funds.

It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult).

Allegation Thirteen: It was reported that VA2 was employed by the facility as a maintenance worker, and his/her paychecks were often missing hours worked, or paid VA2 less than his/her agreed-upon wage. It was reported that the facility owed VA2 $470 in back wages.

Facility records documented the following:

· The facility provided both residential services (community residential setting, CRS) and employment support services (ES) to VA2.

· VA2 was scheduled to work two days per week, supported by the facility’s ES services.

· The CRS facility was responsible to provide transportation to VA2, and ES staff persons were responsible to support VA2 in his/her employment.

· One of VA2’s ES goals was to attend work 100% of the time, for every scheduled shift, with two or less verbal cues. Another of VA2’s ES goals was to work three days per week.

The distance between the CRS facility and the ES facility was approximately 45 miles. Although VA2 had the skills needed to use public transportation, metro mobility, and similar services; public transportation was not available from the CRS facility, so s/he was reliant on staff persons to drive him/her to work.

VA2 said s/he worked “for Bridges” and that his/her paychecks from Bridges were often missing hours, or s/he was not paid his/her agreed-upon wage. As a result, VA2 said s/he was owed approximately $470 in back wages.

P10 said s/he was aware that VA2 believed s/he was missing money from his/her pay checks. P10 compared VA2’s time cards from his/her employers, documentation for shifts VA2 missed work, and VA2’s pay checks. P10 did not identify any pay discrepancies in VA2’s pay checks. P10 said that although VA2 was scheduled to work two days per week, sometimes VA2 missed work and when that happened, VA2’s pay checks were smaller than s/he expected, but it was because VA2 did not work as many hours as usual. P10 said VA2 missed work due to lack of transportation to work and illness, “but mostly transportation.”

CM2, P4, and P7 each said the CRS facility struggled with staffing which resulted in VA2 missing some shifts at work, since there weren’t enough staff to transport VA2 from the CRS facility to the ES facility.

The facility’s internal review for this allegation stated that the facility reviewed VA2’s records and did not identify any occasions where VA2 was not paid for all hours worked at the agreed upon wage. P10 told facility investigators that VA2 missed “a lot” of work and was not paid for shifts s/he did not work, which was likely why VA2 thought s/he was not being paid as much as s/he should be. The facility shared VA2’s time cards with VA2’s representative payee for transparency.

Relevant Statutes:

Minnesota Statutes, section 245D.07, subdivision 1, states that the license holder must provide services as assigned in the coordinated service and support plan.

Conclusion for Allegation Thirteen:

Information from various sources showed that VA2 missed an unknown number of shifts due in part to the CRS facility’s failure to supply VA2 with transportation to work, which was a violation of Minnesota Statutes, section 245D.07, subdivision 1. Although VA2 said that s/he was owed $470 in back wages from his/her job through ES, P10 provided consistent information to the DHS investigator and to facility investigators that s/he compared the hours VA2 worked with his/her pay checks and did not identify any discrepancies. Therefore, there was a preponderance of the evidence that a person did not willfully use, withhold, or dispose of VA2’s funds.

It was determined that financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult).

Allegation Fourteen: During the investigation, information was received that SP5 drove VA1 to SP5’s family member’s home, where SP5 used marijuana. SP5 proceeded to drive VA1 while under the influence of marijuana.

Facility records documented that VA1 “struggled with sobriety.” VA1 was subject to civil commitment and staff persons were to report any illegal drug use to VA1’s case managers, who could make recommendations for substance use disorder treatment if needed. VA1’s mental health “can deteriorate rapidly in the context of relapse on mood altering substance.” Staff persons were to encourage VA1 to remain sober and substance free.

During VA1’s interview, VA1 spontaneously provided the following information:

· SP5 brought cocaine and marijuana to the facility.

· During an outing, SP5 drove VA1 to SP5’s family member’s (FM’s) home, saying s/he needed to pick up “some gas money.” SP5 went inside the home and VA1 waited outside in the vehicle. When SP5 returned to the vehicle s/he smelled like marijuana. VA1 asked SP1, “Did you pick up some weed,” and SP5 said, “Yeah, just a little bit.” VA1 said, “[SP1] played it off like [s/he] did nothing wrong.”

· VA1 provided the accurate city for the FM’s home, which was approximately 33 miles away from the facility.

· VA1 said, “It was really hard for me . . . trying to be without anxiety. . . when as soon as I got there I’m being offered marijuana not just from [VA2] but from staff.”

During the investigation of report #202109523 (regarding a separate facility operated by Bridges MN), a resident of that facility (R2) stated that SP5 brought R2 to the FM’s home (providing accurate information about the location and landmarks near the FM’s home,); and that SP5 purchased, used, and was under the influence of cocaine on multiple occasions while providing services to the R; including driving R2 while under the influence of cocaine.

R2 and VA1 did not know one another.

SP5 denied ever taking any Newberry residents to his/her family member’s home. When asked how a Newberry resident would know where SP5’s family member lived, SP5 said s/he took Newberry residents to a mall near the FM’s home one time, and “might have” told them, “I’m by [the FM’s] house.” SP5 also denied using any illegal drugs while working with facility residents.

The facility’s Drug and Alcohol Free Work Environment policy stated, “being under the influence of alcohol or illegal drugs, including marijuana, while on the job poses serious health and safety risks to employees and others, which is not tolerated.” The use, abuse, and being under the influence of illegal drugs was “expressly prohibited” at any time an employee was on duty or conducting facility business.

The facility’s Vehicle Safety policy stated that staff persons were to obey all traffic laws while driving with facility residents in the vehicle.

The facility’s personnel files and training records documented that SP5 was trained on VA1’s plans, the facility’s policies and procedures in general, and on the facility’s Vehicle Safety policy. The facility did not supply evidence that SP5 was trained specifically the facility’s policies and procedures for reporting suspected vulnerable adult maltreatment, nor any other module related to vulnerable adult maltreatment.

The facility’s failure to train SP5 on the Reporting of Maltreatment of Vulnerable Adults Act was a violation of Minnesota Statutes, section 245D.09, subdivision 4, clause (5), which states in relevant part that within 72 hours of first providing direct contact services, the license holder must provide and ensure completion of orientation to the Reporting of Maltreatment of Vulnerable Adults Act, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment.

Conclusion for Allegation Fourteen:

A. Maltreatment:

SP5 denied taking VA1 to the FM’s home and using illegal drugs while working with facility residents. However, VA1 said SP5 brought cocaine and marijuana to the facility, took VA1 to the FM’s home, and used marijuana while providing services to VA1, including driving VA1 while SP5 was under the influence of marijuana. This information was corroborated by information provided by R2, who did not know VA1 but said SP5 also drove R2 to the FM’s home and purchased, used, and was under the influence of illegal drugs while providing services to R2, including driving R2. Using and being under the influence of illegal drugs while driving and providing other services to VA1 both involved VA1 in illegal activities and endangered VA1 when SP5 drove under the influence. Further, VA1 “struggled” to maintain sobriety and staff persons were supposed to encourage him/her to avoid illegal drug use. Therefore, there was a preponderance of the evidence that SP5 failed to provide VA1 with reasonable and necessary care and services when s/he used illegal drugs while providing services to VA1 and drove VA1 while under the influence of marijuana.

It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(4) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(5) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(6) whether the facility or individual followed professional standards in exercising professional judgment.

The facility lacked evidence that SP5 was oriented specifically to the facility’s policies and procedures for reporting suspected vulnerable adult maltreatment, or any other modules related to vulnerable adult maltreatment, which was a violation as outlined above. Although SP5 may not have received this training, SP5 was trained on VA1’s plans, the facility’s policies and procedures in general, as well as on the facility’s Vehicle Safety policy. In addition, it is generally understood that the use of illegal drugs, and driving while under the influence of marijuana, are illegal activities and present a risk to others in the vehicle. Therefore, the facility’s responsibility was mitigated and it was determined that SP5 was responsible for the neglect of VA1.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious;” and whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. 

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury.  For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment.  For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke.  Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP5 was responsible in this report did not meet the definition of serious or recurring maltreatment because VA1 did not sustain an injury that required the care of a physician and VA1 stated that SP5 drove VA1 intoxicated on one occasion. However, information maintained by the Department of Human Services, in combination with this report, resulted in SP5 being disqualified for recurring maltreatment. SP5 was disqualified from providing direct contact services.

Action Taken by Facility:

The facility completed an internal review for each allegation and determined that for each allegation, policies and procedures were adequate and were followed, there was no need for additional staff training, the incident was similar to past events or complaints with the persons or services involved (the internal review noted that VA1 and VA2 each had a history of inaccurate reporting), and there was no need for corrective action to be taken by the license holder to protect the health and safety of the persons served by the facility.

Action Taken by Department of Human Services, Office of Inspector General:

SP1 and SP5 were each disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that SP1 and SP5 were each responsible for maltreatment and the disqualifications of SP1 and SP5 are each subject to appeal.

On June 27, 2022, based on the nature severity, and chronicity of licensing violations an Order of License Revocation was also issued. The revocation is subject to appeal.

In addition, it was determined that facility mandated reporters had knowledge of two alleged incident and did not report the incidents as required. The license holder was not fined $400 ($200 for each occurrence) for failure to report maltreatment because a more serious licensing action was taken.

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