|
MALTREATMENT INVESTIGATION MEMORANDUM 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: 1088207-H_CRS (Home and Community Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Marci Sparrow Suspected Maltreatment Reported: It was reported that on April 6, 2022, a staff person (SP) did not supervise a vulnerable adult (VA) resulting in the VA choking on food. When the VA was found on the floor, the SP called 9-1-1 but did not initiate cardiopulmonary resuscitation. The VA was transported by emergency personnel to a hospital, admitted to the hospital, and placed on a ventilator. The VA died on April 16, 2022. Date of Incident(s): April 6, 2022 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 17, paragraph (a): 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 April 27, 2021; from documentation at the facility and hospital medical records; and through eight interviews conducted with the VA’s guardian (G) and facility staff persons (SP1, SP2, and P1-P5). The VA liked dogs, reading, and being outside. The VA also enjoyed watching game shows such as Jeopardy and Wheel of Fortune. The VA’s diagnoses included mild developmental disability, atypical autism, anxiety disorder, intermittent explosive behavior, schizoaffective disorder, depression, borderline personality disorder, bipolar type psychotic features, and “binge eating/drinking.” The VA was supervised 24 hours a day with staff persons on site including an overnight sleep staff person. The VA’s bedroom was located downstairs and there was a “doorbell” at the bottom of the stairs that the VA was supposed to ring prior to coming upstairs. The G, P2, P3, P5, and SP2 each provided information that the doorbell was installed to alert staff persons that the VA wanted to come upstairs as there were safety concerns that resulted between the VA and a housemate that occurred at the top of the stairs. The door at the top of the stairs was not locked. Overnight staff persons slept in an upstairs office located across the hall from the door leading downstairs or in the living room. A Daily Routine for the VA stated that s/he woke up at “7:15 a.m. every day during the week.” After waking up the VA took some of his/her medications, showered, straightened his/her room and bathroom, and then took the rest of his/her medications with breakfast. A Rights Restriction dated December 29, 2020, stated that s/he was restricted regarding “fluid intake and allowing access to food at all times” because the VA was not able to control him/herself when it came to eating and drinking. The VA had seizures as an infant and also experienced some “seizure like activity” from polydipsia (excessive or abnormal thirst leading to the consumption of large quantities of water). The VA had a history of “sneaking” fluids/food and in May 2020, the VA needed cardiopulmonary resuscitation (CPR) after eating taco shells out of the garbage. The VA’s fluids were measured daily, his/her weight was monitored weekly, and the cupboards and refrigerator were locked. The VA’s Behavior Outcome stated that s/he was not always in eyesight of staff persons when s/he was in his/her room or downstairs. Staff persons were supposed to check on the VA “every 30-45 minutes during the day and once at night.” Staff persons were to be “within auditory distance” of the VA. A Serious Injury Report dated April 6, 2022, stated that the VA choked on a “large amount of food.” A Death Report showed that on April 6, 2022, a medical emergency resulted in an ambulance transporting the VA to an emergency room. The VA was admitted to the hospital and died on April 16, 2022. This investigator contacted the medical examiner’s office regarding an autopsy report and a response was received that the VA died at the hospital and no autopsy was completed. The VA’s Certificate of Death stated that the immediate cause of death was “probably complications of asphyxia” with an underlying cause of “aspiration of food bolus.” Other contributing factors included “seizure disorder.” Regarding the VA’s access to food: The G provided the following information: · The VA was “constantly seeking food” so the kitchen cupboards and the refrigerator were supposed to be locked, and no food was supposed to be placed in the garbage. Staff persons were supposed to check the facility at 10 p.m. to ensure locks were used and food was not available. However, the G heard that in January 2022, after P5 left the facility and P1 began supervising, the cupboards and refrigerator were not consistently locked.
· Regarding the incident on April 6, 2022, the G heard that the VA obtained noodles from “off the counter” that the G “assumed” came from the garbage that was not locked. The G said that it did not matter where the VA found the noodles, the concern was that SP1 was not in the kitchen supervising at the time of the incident. SP2 provided the following information: · The VA was supposed to ring a doorbell prior to coming upstairs due to safety concerns at the top of the stairs regarding interactions between the VA and a housemate. Additional precautions taken for the VA’s safety included locks on cabinets, the refrigerator, and the freezer to limit the VA’s access to food. When the overnight staff person arrived, they were responsible to “go around the house and make sure everything is picked up, cleaned up, cupboards locked, and check on the [clients] in their bedrooms.” · The overnight staff person was allowed to sleep between 11:30 p.m. and 5:30 a.m., and either slept in the office with the door open or on a couch in the living room. Upon awakening, they were supposed to make coffee and “get the house ready” for the clients to wake up. The VA liked to come upstairs in his/her pajamas and have coffee.
· SP2 worked on the evening of April 5, 2022, and brought “noodles, like Ramen noodles” from a Mongolian restaurant for his/her dinner. When the VA went downstairs to go to bed around 9 p.m., SP2 ate some of the noodles and left the closed container (described as a Chinese food box that closed on the top and had a wire handle) inside of a plastic grocery bag “next to the sink in the kitchen.” SP2 believed a half cup of noodles remained in the container. SP2 said that it was “an honest mistake” and “I am 100% at fault for leaving my own food out, that was my fault, I should not have left food out.” · SP2 left the facility at 10 p.m. and was scheduled to return to the facility at 7 a.m. on April 6, 2022. P4 worked with SP2 on the evening of April 5, 2022. P4 left the facility at 8 p.m. SP2 was scheduled to work until 10 p.m. and SP1 worked the overnight shift. P4 was trained to have all food locked up and leftover food was supposed to be disposed of in the garbage disposal. Overnight staff persons were trained to make sure everything (food) was locked up and the trash was placed in the garbage outside. Staff persons could either sleep in the office or the living room. P4 generally slept in the office with the door shut and said that s/he was not told that the office door was supposed to remain open. P5, a former supervisory staff person, stated the following: · The refrigerator and cupboards were supposed to be locked to prevent the VA from obtaining food. Staff persons were not supposed to leave any food in the kitchen trash and the garbage disposal was supposed to be run if any food was placed inside. · P5 heard about the incident on April 6, 2022, from P3, who called P5 shortly after 6 a.m. and told P5 that the VA was on his/her way to the hospital. P5 went to the hospital and an unidentified health care professional stated they found “noodles” in the VA’s throat. P5 heard that the noodles belonged to SP2 who “forgot them the night before” and set the noodles “on the side of the sink.” Overnight staff persons were supposed to “go through and do a room check and make sure the cupboards are locked.” P5 believed that if SP1 checked the kitchen s/he “should have found the noodles.” · The overnight staff person was allowed to sleep from 10:30 p.m. to 5:30 a.m. (This investigator found no documentation indicating specific sleep and awake hours.) P3 was not present on April 6, 2022, and initially heard about the incident from the G. P3 then sent a text to SP2 around 6:30 a.m. and SP2 said s/he was on his/her way to the facility. SP2 was crying because s/he “already figured out it was [SP2’s] noodles that [s/he] forgot on the counter.” P3 said that overnight staff persons either slept in the bed in the upstairs office or in the living room. When P3 worked an overnight shift s/he slept in the office with the door open. The VA told P3 that SP1 slept in the office with the “door closed.” P2 said that s/he heard about the incident from SP1 and SP2. SP2 told P2 that on April 5, 2022, s/he left his/her food on the counter by the sink. SP1 told P2 that on April 6, 2022, s/he found the VA “right at 6 a.m.” upstairs on the floor. P2 said that overnight staff persons usually slept upstairs in the office and that the office door was “supposed to stay open.” SP1 provided the following information: · SP1 worked the overnight shifts and was usually awake until midnight or 1 a.m. SP1 described him/herself as a “very light sleeper” because there was a client who woke up in the night and needed assistance with the bathroom. SP1 slept in the office and usually kept the office door open. · In an attempt to keep the VA downstairs until 6 a.m., the VA was supposed to ring the doorbell at the bottom of the stairs; and wait for a staff person to open the door at the top; however, the VA “never used to really do that” and came upstairs anyway. Sometimes the VA woke up at 5 a.m. and SP1 had to tell the VA to go back downstairs because it was too early to be up. There were other times when SP1 did not hear the VA come upstairs and s/he was already upstairs walking around when SP1 awoke. The VA liked to come upstairs to drink coffee. · SP1’s duties in the morning included assisting clients with bathing and breakfast. To prevent the VA’s access to food, the cupboards and refrigerator were locked. SP1 described the VA as “sneaky” and said s/he waited for staff persons to help other clients and then looked for food to eat, even from the trash. · On the evening of April 5, 2022, SP1 arrived at the facility shortly before 10 p.m. SP1 checked on and saw that all the residents, including the VA, were sleeping. SP1 checked to make sure the cupboards and refrigerator were locked and s/he looked around the kitchen and “did not see anything.” · On the morning of April 6, 2022, SP1 had his/her alarm set for 6 a.m. and a minute or two before it was supposed to go off, SP1 heard the VA upstairs. The VA did not ring the doorbell before coming upstairs. As SP1 was about to get out of bed, s/he heard a “loud bang.” SP1 went to the kitchen and saw the VA on the floor with food in his/her mouth. SP1 immediately called 9-1-1 and minutes later called 9-1-1 a second time “just to make sure” because emergency medical services (EMS) had not arrived yet. SP1 said that s/he was never advised to give CPR. · SP1 said s/he was “scared,” his/her “mind was so blank,” and s/he “didn’t know what to do” while s/he waited for EMS to arrive. SP1 did not to do CPR because s/he did not know if the VA was choking, had a head injury from falling, or had a seizure. The VA’s eyes were open and s/he was “kind of shaking.” · SP1 did not observe any food on the VA’s clothing or any eating utensils; however, s/he saw food in the VA’s mouth and saw an opened food container on the counter with “a little bit of food” left in the container. SP1 said that s/he took “some [of the food] out” of the VA’s mouth but it “didn’t do anything.” SP1 also saw broken glass from a coffee mug on the floor surrounding the VA. · SP1 called 9-1-1, and also telephoned P1 to tell him/her that s/he called 9-1-1. EMS arrived and left prior to P1’s arrival at the facility. The food that SP1 swept out of the VA’s mouth was on the floor when P1 arrived. · After the incident, SP1 said that s/he “didn’t think that somebody would have left their food there” because staff persons were aware that the VA choked when s/he obtained food in the past. Regarding the 9-1-1 call: · The G heard that SP1 asked the 9-1-1 dispatch if s/he should do CPR and SP1 was told “no.” However, the G obtained the 9-1-1 transcript and said that SP1 “lied” because the record showed SP1 never asked, “Should I do CPR?” · P1 said that on the morning of April 6, 2022, s/he received a call from SP1 who said that the VA was on the floor. SP1 already called the paramedics and asked P1 to come to the facility. As P1 arrived at the facility, emergency responders were driving away. P1 walked into the kitchen and observed “glass all over the floor” from a broken coffee carafe. SP1 was in the kitchen and his/her hands were shaking. There was no written protocol regarding the use of the doorbell and SP1 told P1 that “a couple minutes before 6 a.m.” SP1 heard the VA and thought s/he should ask the VA to go back downstairs. However, SP1 then heard glass shatter and a “big thunk” and SP1 ran to the kitchen and observed the VA on the floor. SP1 immediately called 9-1-1, and called 9-1-1 a second time a few minutes later because “they were taking so long.” SP1 said that s/he asked if s/he should start CPR and s/he was told “no.” Transcripts from the 9-1-1 calls made on April 6, 2022, showed the following: · An initial call was made at 6:00:56 by SP1. SP1 told the dispatch person (DP) that the VA “just fell I don’t know what [s/he] ate” and “I can see food in [his/her] mouth.” Twice the DP asked SP1 if the VA was conscious and each time SP1 replied, “yea.” When asked if the VA was “breathing normally” SP1 replied, “Yes [s/he’s] breathing.” The DP said that s/he was going to transfer the call over to the ambulance service. When the call was transferred, SP1 again stated there was “food in [the VA’s] mouth and then [she] is kind of opening [his/her] mouth].” The DP ended the call at 6:02:49. (After the DP ended the call, the conversation was only between SP1 and the ambulance service. Several requests were made by this investigator for a transcript of the conversation between the ambulance service and SP1; however, no transcripts were available.) · A second call to 9-1-1 was made by SP1 at 6:08:19 stating s/he called a few minutes ago and was “still waiting for help.” The DP asked if the VA was “still conscious and okay” and SP1 said, “Yes, [s/he] is, [s/he] is just opening [his/her] mouth in and out it’s just really (inaudible).” SP1 was reassured a fire truck and ambulance were on the way and the call ended at 6:08:52. An ambulance report dated April 6, 2022, stated that a call was received at 6:02:31 a.m. and the EMS crew arrived at the facility at 6:11:53 a.m. The VA was “lying supine on the kitchen floor with glass all around [him/her].” A staff person (determined to be SP1) stated that s/he “heard” the VA fall and thought the VA “was having a seizure.” The VA’s airway was “partially obstructed-emesis,” and his/her pulse and breathing were “absent.” The VA had “food in [his/her] mouth and required suctioning prior to intubation.” The “estimated” time of arrest was 10-15 minutes. Documentation showed that CPR was not provided prior to EMS arrival. EMS moved the VA out of the kitchen (due to the glass on the floor) and CPR was initiated at 6:15:00 and was maintained for 20 consecutive minutes. CPR was discontinued when the VA returned to spontaneous circulation (pulse or blood pressure noted). The VA was then transported to a hospital. The VA’s hospital records stated that on April 6, 2022, the VA had an “unwitnessed fall” in the kitchen and “likely respiratory leading to cardiac arrest.” When EMS arrived the VA did “not have a pulse.” The VA was resuscitated following a “down time of 10-20 minutes, 10 minutes of CPR, and 1 dose of epinephrine.” “Seizure-like activity” was noted in the emergency department. Further documentation showed that during the VA’s hospitalization severe anoxic brain injury was determined and s/he remained unresponsive to verbal and tactile stimuli. On April 10, 2022, the VA was transferred to hospice care and died on April 16, 2022. Additional information: The G said that prior to the incident on April 6, 2022, P3, P5, and SP2 each told the G that they brought concerns about SP1 to P1. Examples included SP1 sleeping in the office with the “door closed” while the clients were awake “bouncing around the house in their pajamas unfed at 8 a.m.,” that SP1 drank alcohol at the facility out of a water bottle that smelled like “booze,” and arrived for his/her overnight shift after s/he “had been drinking.” P5 said that prior to the incident in April 2022, a staff person (P7) found two “water bottles” and P7 thought they “smelled like booze.” P5 smelled one of the bottles and said that it “smelled like it could have been” alcohol but it was also possible that it was something else. On one occasion there was a water bottle that left a “sticky” substance on a desk and paperwork. P3 said that s/he “never witnessed” SP1 in “a supposedly inebriated state.” However, on “three to four” occasions, P3 arrived on a weekend at 8 a.m. and SP1 was “sound asleep,” the “house would be a mess” and once there was something “red and sticky” on the counter and in the office. P3 said there was no harm or injury that resulted from those observations. P2 said that sometimes when s/he arrived at 6 a.m. SP1 was sleeping and the office door was shut. P2 said that “last summer” (2021) s/he heard from another staff person (P6) about SP1 possibly drinking alcohol at the facility because a water bottle was found in the garbage that smelled like alcohol; however, P2 did not observe the bottle or SP1 drinking alcohol. Attempts by this investigator to contact the VA’s case manager (CM) were not successful. However, a “coverage worker” reviewed the CM’s records and said the VA did not require an awake overnight staff person so staff were allowed to sleep for eight hours. Facility information showed that in May 2020, the VA obtained food out of the garbage, choked, and CPR was performed prior to the VA’s transport to a hospital. A review of SP1’s and SP2’s job descriptions showed there were no specific times indicating when staff persons were allowed to sleep or required to be awake. An employment evaluation completed by P5 in October 2021 stated that SP1 “does an excellent job on overnight. [SP1] is a very reliable and consistent staff.” In addition, SP1 “is always willing to help out with picking up shifts, staying late just to help out or see the clients get what they need.” The facility’s policy regarding Responding to and Reporting Incidents stated that staff persons were to “first call 9-1-1” and to then “give first aid and/or CPR to the extent they are qualified, when it is indicated by their best judgment or the 9-1-1 operator, unless the person served had an advance directive.” Facility information showed that staff persons were trained regarding the VA’s program plans, the Reporting of Maltreatment of Vulnerable Adults Act, and First Aid/CPR prior to the incident. A review of the American Red Cross Organization website showed a training poster (ConsciousChokingPoster_EN.pdf (redcross.org) that stated after checking the scene for safety, call 9-1-1, give five black blows, give five abdominal thrusts, and repeat back blows and abdominal thrusts until the object is forced out, the person can cough forcefully or breathe, or the person becomes unconscious. In addition, “continue providing care until the object comes out or the person begins to breathe or cough. If the person becomes unresponsive, call EMS/9-1-1 and begin CPR, starting with chest compressions.” Conclusion: A. Maltreatment: The VA’s diagnoses included mild developmental disability and “binge eating/drinking.” A Rights Restriction plan showed that the VA was restricted regarding “fluid intake and allowing access to food at all times” because the VA was not able to control him/herself when it came to drinking and eating. On April 5, 2022, SP2 brought takeout food to the facility, ate some of it after the VA went to bed, and left the remainder of the food in the container inside a plastic grocery bag in the kitchen. SP1 stated that around 10 p.m. on April 5, 2022, s/he observed that each of the residents, including the VA were sleeping. SP1 also checked to make sure the cupboards and refrigerator were locked and s/he looked around the kitchen and “did not see anything” prior to going to sleep that night. On the morning of April 6, 2022, the VA obtained food that was left on the kitchen counter the previous night. At approximately 6 a.m., SP1 was within auditory distance of the VA when the SP heard a loud noise and observed the VA on the kitchen floor. SP1 saw food in the VA’s mouth and glass on the floor around the VA. SP1 immediately called 9-1-1 and took some of the food out of the VA’s mouth. When EMS arrived, CPR was initiated and the VA returned to “spontaneous circulation” and was transported to a hospital. The VA remained hospitalized for 10 days and severe anoxic brain injury was determined. The VA died on April 16, 2022. Although SP1 immediately called 9-1-1, the conversation between the paramedics and SP1 was not available, and there was no information that s/he was advised to start CPR. However, the facility’s policy stated that staff persons were to “first call 9-1-1” and to then “give first aid and/or CPR to the extent they are qualified, when it is indicated by their best judgment or the 9-1-1 operator . . . .” Although it was not possible to determine whether the outcome would have been different if SP1 had started CPR, it was reasonable to expect that a staff person trained in CPR would have responded by attempting to dislodge the visible food and initiate care as trained. In addition, a thorough check in the kitchen would have likely shown food inside a bag left on the kitchen counter. Given the aforementioned, and the fact that food was left out/available for the VA to obtain, there was a preponderance of the evidence that there was a failure to provide the VA with the care or services that were both reasonable and necessary, to maintain his/her physical health. 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: (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. Regarding SP1: SP1 said that s/he made sure the locks were in place to prevent the VA from obtaining food; however, s/he “did not see anything” when s/he checked the kitchen. A thorough check in the kitchen would have likely shown food inside a bag left on the kitchen counter as consistently described by SP2. In addition, SP1 was responsible for the VA’s care at the time of the incident and after seeing the VA on the floor with food in his/her mouth, SP1 called 9-1-1, but did not initiate further care as trained while s/he waited for EMS to arrive. Facility documentation showed the SP1 received training specific to the VA, CPR, and on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. SP1 was responsible for maltreatment of the VA. Regarding SP2: On April 5, 2022, SP2 brought takeout food into the facility and ate some of the food after the VA went to bed and then left the container inside a grocery bag next to the kitchen sink which allowed the VA to later obtain the food. SP2 received training specific to the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. SP2 was responsible for maltreatment of the VA. 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 maltreatment for which SP1 and SP2 were each responsible did not meet the statutory criteria to be determined as recurring, as it was a single incident for each of them. In addition, it was not determined whether the failure to perform CPR directly contributed to the VA’s death. However, given that part of SP1’s job responsibility was to ensure no food was accessible to the VA and s/he did not observe the food left on the counter which allowed the VA to access the food on which s/he later choked and died, it was determined that SP1 was responsible for serious maltreatment. Additionally, the maltreatment for which SP2 was responsible was also determined to be serious because SP2 failed to ensure no food was accessible to the VA and the VA obtained the food on which s/he later choked and died. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed when staff persons left food out on the counter. The incident was similar to an event that occurred in May 2020 when the VA obtained food out of the garbage, choked, and CPR was performed prior to the VA’s transport to the hospital. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were 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 SP2 were responsible for maltreatment and the disqualification of SP1 and SP2 are each subject to appeal.
|
