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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: 1069142-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who was supposed to be supervised when in the community, left the facility without supervision, went to another program licensed by the Minnesota Department of Human Services (DHS), and had sexual contact with two clients (C1 and C2) at that program (see DHS report number 202206962). Date of Incident(s): August 20, 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 September 14, 2022, from documentation at the facility, and through seven interviews conducted with the VA, a staff person (SP), a management staff person (P1), another facility staff person (P2), the VA’s legal representative (G), the VA’s case manager (CM), and a staff person from C1 and C2’s group home. The VA’s Support Plan, Intensive Self-Management Assessment and Individual Abuse Prevention Plan all showed that the VA needed visual supervision in the community so that s/he could maintain appropriate boundaries. The VA was described as being “pleasant, friendly, caring and motivated.” The VA’s Intensive Self-Management Assessment further showed that the VA had a “history of engaging in a sexual behavior with a [female/male] that [s/he] just met which may or may not have been consensual.” As a result, “staff will support [the VA] by verbally redirecting [the VA] and reminding [the VA] of the importance of healthy relationships and personal boundaries.” The VA’s Support Plan Addendum provided an “update” that was dated March 2, 2022, which stated, “We are testing [the VA’s] ability to make responsible decisions while in the community to assist if [s/he] is able to go out with a friend to a public place for up to 2 hours, such as a mall or store without staff being present. If [the VA] wants to socialize with a friend, [s/he] must first get approval from [his/her] [family member/guardian], then schedule the time and place staff will drop [him/her] off and pick [him/her] up.” On July 5, 2022, this was updated to include that the VA “may sign up for and attend activities outside the home, such as project S.O.A.R. and be dropped off and picked up by New Hope Living Staff, as long as there are staff present at the organization that hosts the activity.” On August 31, 2022, the plan was updated to reflect that the VA had “zero alone time” in the community (as a result of the incident described below). The facility’s General Event Report and an interview with P1 provided the following information: · At about 7:45 p.m. on August 20, 2022, the VA told staff that s/he was going for a walk in the community to see his/her [girlfriend/boyfriend] at a “nearby group home” and would return in 30 minutes and “staff agreed to this plan.”
· When the VA got to the other home, his/her friend was not home. After the VA spent about 15 minutes outside the home, the VA returned to the facility. · Later that night, P1 learned that while the VA was at the other home, C1 and C2 told a staff person at their home that the VA “touched them inappropriately and kissed one of them” outside while C1 and C2’s staff was inside the home. When P1 talked to the VA, the VA denied the allegations. The VA stated that when s/he left the facility, s/he told the SP that s/he was going to go for a walk to see his/her girl/boyfriend and the SP said, “make sure you come back” and do not “stay too long.” When the VA got to the other home, C1 and C2 were outside and “the staff” was “watching” from the inside. (Investigator’s note: the other home was a split entry styled home that had a glass door). Shortly after the VA arrived at the other home, the VA kissed C1 and C2 and then C1 asked the VA to “suck” one of his/her breasts. When that happened, the staff person came outside and told the VA to go back to the facility, which the VA did. The VA denied touching C2’s buttocks. C1 and C2 initially told staff where they lived that the VA had sexual contact with them, but both later told P3 that the VA did not have sexual contact with them. P2, who was not working at the time of the incident, stated that prior to the incident, the VA needed staff supervision when s/he accessed the community. The G provided the following information: · Before the incident, the VA was allowed to go anytime, without supervision, to the other group home because one of the G’s family members worked there. However, prior to August 2022, the VA got into a verbal argument with one of the clients there so the G told the VA, and facility staff that the VA should not go to that group home anymore. The G was not aware of a time that the VA went to a community place without staff supervision, aside from the other group home, and in those instances, the VA or staff notified the G.
· After the incident happened, the G talked to the VA and the VA told him/her that while the VA was at the other group home, the VA and the two clients kissed and that one of the clients asked the VA to “suck” his/her breast. When that happened, the staff person in C1 and C2’s home told the VA that was “inappropriate” and to leave. The G stated that s/he had not given approval for the VA to go to the other group home. The CM stated that although the VA was to have supervision at all times in the community due to issues of him/her leaving without supervision and concerns related to maintaining boundaries, the VA’s team had recently been working on allowing more alone time in the community for certain functions, but the CM did not believe the plan had been implemented yet. According to www.mapquest.com, the distance between the facility and the other home was .4 miles and would take eight minutes to walk. The SP stated that s/he was under the impression that the VA had one hour of alone time in the community. On the day of the incident, the VA told the SP that s/he was going to a “park.” When the VA returned 30 minutes later, the VA went to his/her bedroom and did not say anything to the SP about what may have happened in the community. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to August 20, 2022. Relevant Statutes: Minnesota Statutes, section 245D.07, subdivision 1a. states that the license holder is to provide services in response to a person’s identified needs, interests, preferences and desired outcomes as specified in the support plan and support plan addendum. Conclusion: On the day of the incident, August 20, 2022, the supervision plan in place for the VA, according to the VA’s Support Plan Addendum, was that the VA could be without staff supervision in the community for certain functions as long as the G was notified and staff took the VA to the activity and picked him/her up from the activity. The SP stated that the VA told him/her that s/he was going to a park, and returned 30 minutes later. The VA stated that s/he told the SP s/he was going on a walk to see his/her girl/boyfriend (who lived at another group home licensed by DHS). After the VA returned to the facility, concerns were raised that s/he had sexual contact with C1 and C2 at the other group home but that was not fully established that it happened because even though the VA acknowledged that it did, C1 and C2 later stated that it did not occur. The SP believed that the VA had an hour of alone time in the community did not notify the G that the VA was leaving, which was not consistent with the VA’s support plan. In addition, the G stated that prior to the incident in this report, the VA got into a verbal argument with a client at the other group home and was not to go there without supervision and the CM stated that the team was working with the VA to gain independence in the community, but did not believe the plan had been implemented yet. The VA’s support plan was not signed by the G or the CM, and did not reflect their understanding of the VA’s supervision plan, which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a. Although the VA had vulnerabilities in the community if left unsupervised, and there was an inconsistent understanding of the VA’s supervision both with staff persons and as written in the plan, it was clear that the facility and the VA’s team were addressing those vulnerabilities and working toward a plan for the VA to have more independent time in the community. Given this, that the SP stated the VA said s/he was going to a park and did not mention going to the other group home, that it was unclear what contact the VA had with the other clients at the group home, and that a staff person at the other group home intervened immediately when s/he saw the VA approach the clients, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary supervision to maintain his/her health. 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). Action Taken by Facility: The facility completed an internal review, changed the parameters in documentation to reflect that the VA no longer had any alone time in the community, and provided additional training to the SP and other staff on “ensuring that [the VA] is not unattended when [s/he] leaves the home to go for a walk and the importance of following the CSSP.” Action Taken by Department of Human Services, Office of Inspector General: A correction order was not issued for the violation outlined in this report because the facility took immediate corrective action regarding the violation.
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