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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1097669-HCBS (Home and Community-Based Services) Investigator(s): Kimberly Anderson/Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that a staff person (SP) purchased marijuana, a pipe, and lighters for an alleged victim (AV). Date of Incident(s): December 7, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child’s mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through five interviews conducted with facility staff persons (P1, P2, and the SP), the AV’s family member (FM), and the AV. This investigator tried to contact the AV’s case manager (CM) but those attempts were unsuccessful. According to the AV’s Coordinated Services and Supports Plan, video games were most important to the AV. It was also important to the AV to maintain a clean living space and a healthy weight. The AV hoped to one day have his/her driver’s license and move from Minnesota. The AV’s favorite holidays were Halloween and New Years. The AV received 32 hours of in-home service. According to the AV’s MnCHOICES Assessment Report, the AV liked stores, especially Best Buy, and also liked places for animals, such as shelters and pet stores. The AV stated s/he needed structure and a schedule. The AV was diagnosed with anxiety, eating disorders, major depression and post-traumatic stress disorder. The facility’s Incident Report and Internal Review stated that on December 8, 2022, the AV was suspended from school because the school found marijuana in the AV’s possession. The AV stated that the SP took the AV to purchase marijuana. The AV stated that on December 6, 2022, the AV went with the SP to meet with a “dealer” to purchase “weed.” The AV did not ask the SP to purchase the weed, nor did the AV pay for the weed. The SP provided the AV with “weed, a crack pipe, a lighter.” The AV smoked about one half of the marijuana without the SP. The FM stated on December 7, 2022, the AV was sent home from school because a marijuana pipe, marijuana and lighters were found in the AV’s backpack. Once at home, the FM asked the AV how s/he got the marijuana items and the AV said the SP provided the items. According to the FM, the SP picked the AV from school and took the AV to places the AV needed to go including parks, friend’s houses, stores, and medical appointments. The FM provided this investigator with a video recording of a telephone conversation s/he stated was between the AV and the SP. This investigator viewed the video and noted that the video faded in and out and the audio quality was poor. In the video the SP asked the AV to go to his/her room. The AV does so and then the SP asked the AV if police were called. The AV said, “I didn’t say anything,” and told the SP s/he was suspended from school for 3 days. The AV asked the SP if they could go purchase “more” “so that we can do it together. I won’t bring it to school.” The SP responded, “Can you go with me tomorrow?” and the AV said, “Why not today?” The AV again says, “Can we get more of it tomorrow?” The SP then asks about the FM and says, “[The AV] you have to be careful, this is not good.” The AV told the SP the lighters were taken too and they needed to get more. The SP responded s/he had one. Then the AV asked, “Are you going to call ’em?” and the video ends. The law enforcement Case Report stated the following information: · On December 9, 2022, the AV and the FM reported that the SP had provided the AV with marijuana, a pipe, and lighters. On December 7, 2022, the school the AV attended found and confiscated those items. On the evening of December 7, 2022, the SP took the AV and purchased more marijuana. · Law enforcement viewed the video recording and stated the audio was “poor” and it was “difficult to decipher any faces or people.” · Law enforcement closed the case.
P1 and P2, and facility’s documentation provided the following consistent information: · On December 8, 2022, the CM told P2 the AV’s school found marijuana and paraphernalia in the AV’s possession and that the AV stated that the SP provided it. · When P2 spoke to the SP about the incident, the SP denied taking the AV to purchase marijuana and/or smoking marijuana with the AV. · P1 and P2 listened to the audio recording of the telephone call and stated that when the AV asked the SP to take him/her to purchase more marijuana, the SP did not respond, and that most of the conversation was unclear as to what was said. P1 and P2 asked the SP about the video. The SP told P1 and P2 s/he had been asked by FM to call the AV because the AV had been suspended for having marijuana at school. · The SP worked with the AV since August 2022. Prior to the incident, the SP and the AV got along well. The SP picked up the AV from school each day. On Mondays, the SP drove the AV to therapy. On Tuesdays, the SP drove the AV to the library. On Wednesdays through Fridays, the SP could take the AV to places the AV wanted to go. The SP needed permission from the FM if s/he took the AV other places. · On December 8, 2022, P1 learned of the incident from the CM, who provided a copy of the video recording of the phone conversation between the SP and the AV. The SP provided the following information: · On December 7, 2022, the FM called the SP and told him/her s/he did not need to pick up the AV from school because the AV had been suspended. The FM told the SP s/he was worried that the AV would be “taken away” and the AV would not talk to the FM so the SP told the FM, “Let me talk with [the AV] in private.” · In reference to the video, the SP stated the “internet connection was bad,” s/he did not hear the AV asking questions, and the SP did not answer when asked to buy marijuana. The SP stated during the video, s/he was not “talking about marijuana” with the AV. · The SP denied purchasing and/or smoking marijuana with the AV. The facility’s Drug and Alcohol Prohibition Policy stated the facility supported a workplace free from the effects of drugs, alcohol, chemicals and abuse of prescription medications. This policy applied to all employees, subcontractors and volunteers. Facility documentation showed that P1 and the SP received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Maltreatment of Minors Act. The SP received training on the facility’s Drug and Alcohol Prohibition Policy and the AV’s plans. Conclusion: A. Maltreatment: On December 7, 2022, the AV was suspended from school when a marijuana pipe, marijuana, and lighters were found in the AV’s backpack. The AV provided consistent information to the FM, law enforcement, and the investigator that the SP took him/her to purchase marijuana while working with the AV, gave the items to the AV, and that they smoked it together. Although the SP denied providing the AV with marijuana and/or using it with the AV, the comments made by the SP on the video recording support the AV’s accounts that at some point the SP provided the AV with marijuana and a lighter and the SP had reasons to minimize his/her actions for fear of repercussions. Providing the AV, who was a minor, with marijuana and a lighter, encouraged the AV to engage in activities that were illegal. Therefore, there was a preponderance of evidence that there was a failure to provide the AV with necessary care required and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable able to do so. It was determined that neglect occurred (failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical or other care required for the child’s physical or mental health when reasonably able to do so and failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so.) B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of the incident, the SP was responsible for the care of the AV. The SP had received training on the Reporting of Maltreatment of Minors Act, the facility’s drug and alcohol prohibition policy, the AV’s plans. The SP was responsible for the maltreatment of the AV. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not require the care of a physician. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate and followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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