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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: 1067675-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Danielle Morrison 651-431-2155 Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) was able to access a facility van key through an unlocked door, took the van, and was arrested for joyriding. Allegation Two: It was reported that the VA’s social security benefits lapsed due the facility failure to follow up on paperwork. Allegation Three: It was reported that the VA did not receive access to services and/or supports from the facility. Date of Incident(s): Ongoing prior to February 13, 2023 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 March 13, 2023; from documentation at the facility; and through seven interviews conducted with three facility supervisors (P1 – P3), a staff person (P4), the VA’s family member (FM), the VA’s case manager (CM), and the VA’s guardian (G). During the site visit the VA declined to talk with investigators. Attempts were made via phone and mail to contact and interview a staff person (P5), but P5 did not respond to the requests. The VA was diagnosed with attention deficit hyperactivity disorder, conduct disorder, and adjustment disorder. The VA enjoyed being outside, playing basketball, using his/her cellphone, and listening to music. Facility documentation showed that P1-P5 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that the VA was able to access a facility van key through an unlocked door, took the van, and was arrested for joyriding. The program Admission Form and Face Sheet stated the VA had up to four hours unsupervised time at the facility and if the VA was gone from the home longer 24 hours staff persons were to call 9-1-1. (Note: the VA does not have a driver’s license.) P1 to P4 provided the following information: · P3 and P4 were staff persons at the facility for many years prior to the VA being admitted to the program. P4 said there was no sign in/out system for staff persons to use the van. The staff person who used the van was responsible to return the keys to the office. · The VA regularly struggled to follow staff direction and P2 said the VA “does what [s/he] wants to do.” The VA would not tell staff persons when s/he was leaving and would be gone for days at a time. P2 said the VA stole “to support [his/her] marijuana habit” and previously law enforcement searched the VA’s room due to the VA possibly having a firearm. The VA also snuck friends into the facility who spent the night in another unused room. · The program van was out of commission for several months, and the van key was unaccounted for. Since the van did not work staff persons were not concerned that key was gone, it was believed a staff person misplaced it, and a replacement key was obtained from the corporate office. The replacement key was placed in the locked staff office and hung on the wall. P4 said, “Periodically [the VA] would ask when the van would get fixed.” · When P2 began working at the program the van did not work. P2 tried to have it repaired several times, but it continued to have issues and was not used. On October 28, 2022, after being repaired, the facility’s van was returned to the facility and parked in the driveway. P2 was not aware or informed the van key locked in the staff office was a replacement key. · On October 29, 2022, around 1 p.m., P4 was going to drive the VA and other facility residents to a Halloween Party off-site, but the VA declined to attend the party. The VA had four hours unsupervised time in the home. P4 then used his/her own vehicle and drove the other facility residents to the party while the VA remained at the facility. P4 informed P3 the VA declined to attend the party. P2 also attended the Halloween Party. P4 believed another staff person drove the VA to the Halloween Party in the facility van “probably for a minute” and the VA left with that staff person, but P4 did not remember “exactly.” (Note: The facility schedule did not show any additional staff persons worked that morning and there is no record that the VA attended the party.) · Around 3:30 to 4 p.m., P3 arrived at the facility and the VA was not there. P3 saw the van was gone and called P4 to find out if s/he used it. P4 told P3 s/he drove the residents in his/her personal vehicle to the party. P3 phoned office staff to confirm the van was not towed anywhere and then called the police to report it stolen. P3 talked with P2 on the phone and s/he was instructed to file a police report about the stolen van. P3 contacted the police. · At the facility, P2 saw that the van key was still in the locked office that only staff persons had access to. P2 questioned if s/he locked the van when it was dropped off the previous day. P2 suspected that the van was hotwired and stolen, possibly by a friend of the VA. P2 believed that the VA did not return to the facility that evening, which was not unusual for him/her. · On October 30, 2022, the VA returned to the facility while the van was still gone. The staff persons present did not suspect the VA took the van and s/he was not asked about it. (Note: Program Notes showed that on October 30, 2022, the VA was at the facility that evening and on October 31, 2022, the VA left the facility during the day.) When P3 next saw the VA, s/he did not ask if the VA took the van but P3 heard another staff person ask the VA if s/he took the van and the VA denied it. · On November 1, 2022, around 4 a.m., law enforcement stopped the facility van for speeding. A community person the VA knew from the neighborhood was driving and the VA and another community were passengers in the van. The police located the key to the van in the vehicle. There were no injuries or accidents while the van was missing from the program. The VA was arrested and charged with theft of the vehicle. · P2 was not aware there was a second van key. P3 and P4 suspected that “a long time” prior the key was left out unattended by a staff person and the VA took the key. P2 did not suspect staff persons would have left a van key out unattended because the van did not work and there would be no reason for the key to be out of the office. P2 did not know when the VA took the van key. P2 saw there were damaged marks on the office door frame near the deadbolt. P2 believed the VA broke into the office at some point and took the key. P2 had the door locks replaced. · The VA was only allowed into the office under the supervision of staff persons while medications were passed. Staff persons typically would not allow the VA to enter the office past the door area. · P3 was told by P5, a new staff person, that s/he did not always closely monitor the VA while in the office and might have his/her back to the VA at times. P5 allowed the VA to walk around the office, go into the office closet, and to grab snack items without permission. P3 said s/he believed the VA was not closely monitored by P5 while in the office which allowed the VA to take the key. P5 did not respond to interview requests by phone and mail. The FM was aware the VA accessed the facility van key that should have been locked and took the van. The VA then gave the key to a friend who did not have the VA’s best interest in mind, “went joyriding,” and went to court as a result. The FM believed that staff persons did not “take the time to get to know” the VA or built a relationship with the VA which resulted in the VA taking the keys. The CM was aware the VA stole the van and ended up in jail. The CM was not certain if the VA was able to access the key or if s/he hotwired the van. The CM did not have any significant concerns about the facility program and staff persons. The G was aware the VA stole a key for the facility van. The G said, “When they found the van [the VA] and one of [his/her] friends, people [the VA’s] been hanging out with that are not the best group of people, were found in the van.” The G was not sure how long the VA was gone with the van as the VA returned to the house in-between when the van went missing and when the VA was arrested. Conclusion for Allegation One: The facility van did not work for several months and was serviced for repairs multiple times. The van key was missing prior to June of 2022, and replacement key was obtained and hung on the wall in the office. P2 was not aware this was a replacement key and believed it to be the only one. The VA inquired several times to staff persons when the van would be fixed. On October 28, 2022, the van was returned to the facility from being repaired and the key was secured in the office. On October 29, 2022, the VA declined to attend a Halloween Party and the VA was home alone. That afternoon P3 arrived at the facility and saw the van and the VA were not present. P3 talked on the phone with office staff, P2, and P4 to confirm no one had the van or knew of its whereabouts. P3 phoned the police and reported the van missing. The VA was at the facility on and off the next several days as the van remained missing. On November 1, 2022, the VA was in the van with two other individuals when it was pulled over for. The VA was arrested and the missing van key was with the VA. Although P3 was told by P5 that s/he did not closely monitor the VA when s/he was in the office, given that it was unknown when the key went missing, how the VA obtained the key, and/or if the VA took the key from the office or if a staff person left the key accessible to the VA, there was not a preponderance of whether there was a failure to supply the VA with reasonable and necessary care. 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 Two: It was reported that the VA’s social security lapsed due the facility failure to follow up on paperwork. The VA moved into the program on February 24, 2021, and did not receive social security benefits prior to admission and the process was started. The FM had concerns regarding the facility’s failure to ensure that the VA complete the social security paperwork, so s/he did not receive the benefits. The FM was told that the VA had an appointment at social security, but the VA refused to attend. The FM believed the staff persons did not adequately prepare or process with the VA the importance of the appointment and how it would benefit the VA to attend. P1 provided the following information: · When the VA moved into the program s/he did not have social security benefits. The program started the appeal process for the VA to collect social security income. · The program appealed on March 1 and 9, 2022, and the social security income stopped in June of 2022. Additional appeals were made on October 5, 2022, and February 1 and 22, 2023. · In March 2023, the VA again started to receive social security benefits. P2 provided the following information: · The VA moved into the facility shortly after his/her 18th birthday and at that time, the VA did not receive social security benefits. Appointments for the VA were made with social security but the VA refused to attend multiple appointments which then caused him/her to exceed his/her chances for an appointment. · Staff persons discussed several times with the VA why the appointments were important and the financial benefit of going. The VA was told about each appointment the night before and a note was placed on the VA’s door as a reminder. Then in the morning the VA declined to attend. · The facility made efforts to get the benefits application reinstated and were involved in the appeals process to have the application reopened. The CM was not aware of any issues with the VA’s social security benefits. The G stated that s/he and staff persons made several appointments for the VA regarding his/her social security benefits application and, “Every time [the VA] refused to go.” The VA’s social security lapsed and was in the appeal process, but there was concern that the VA would again refuse to attend and it would be denied. The G had no concerns about the facility and said the staff persons were “really good.” P3 and P4 were not involved with the VA’s social security benefits. The VA’s Minnesota Disability Determination Services of an Appointment Notice dated January 24, 2022, showed that there was a Mental Status Exam set up for the VA on February 7, 2022, at 1 p.m. The facility noted that the VA declined to attend this appointment. The facility provided documentation from Social Security Administration of a Request for Reconsideration – Disability Cessation Right to Appear of the facility’s request to appeal the cessation notice the VA received on March 6, 2022. Conclusion for Allegation Two: On February 24, 2021, when the VA moved into the facility, the VA was not receiving social security benefits, and the application process was begun. Although the FM had concerns regarding the steps staff persons took to get the VA social security benefits for the VA, information from P1, P2, and the G was consistent that the VA refused to attend appointments and as a result lost his/her ability for additional appointments and the application process was closed. Given that the VA had the right to refuse to attend appointments, that staff persons discussed the importance of the appointments with the VA, and that staff persons started the appeals process to get the application reinstated, there was a preponderance of evidence there was not a failure to supply the VA with reasonable and necessary care or 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 Three: It was reported that the VA did not receive access to services and/or supports from the facility. P1 was not involved in facilitating day to day support services for the VA. The VA’s Coordinated Services and Supports Plan showed the VA’s goals included finding employment, “learning to respond to upsetting situations in a more productive way,” and attending a transition school program. The VA’s Support Plan Addendum state that the VA’s outcomes included completing his/her daily personal cares, completing daily household chores with direct verbal cues, and displaying target free behaviors. The FM provided the following information: · The VA was on the DD waiver program for three years and did not receive the needed assistance including: increasing the VA’s independence and increasing the VA’s skills in chores, employment, or education. The VA moved into the program on February 24, 2021, and did not have any goals to accomplish. Though the staff persons cannot force the VA to do items, they did not take responsibility for the VA’s actions while at the facility. · The FM believed that the facility did not support the VA in a manner that worked best for him/her to make positive choices and avoid “triggers.” The VA needed to be approached in the correct manner and have questions phrased a certain way to support good decisions. The VA did not have a positive connection with staff persons which led to the VA’s poor decisions. The staff persons did not offer the VA activities to foster relationships and the VA did not trust with the staff persons. The CM provided the following information: · The CM talked with the G and staff persons about the facility’s role and how to encourage and get the VA registered for school, involved in community activities, and how to assist the VA with transportation. · The CM was not aware of the VA or the G declining any offered waiver services. The CM said that while it was important for the VA to gain more independence and that s/he could do his/her own daily cares, the VA needed cues for cooking and home management items that included financial management. · When asked if s/he had concerns, the CM said, “For the most part they are doing okay” with the services at the program for the VA. The CM said, “We just got to do a few tweaks by maybe having a bit more meetings.” The G provided the following information: · The G and the CM talked with the VA about education options and initially the VA said s/he did not want to go to school, but recently changed his/her mind and was assisted to re-enroll. · The VA regularly left the facility without telling staff persons about his/her plans or where s/he was going. The VA would not change this because s/he did not want staff persons involved “[his/her] business.” The G was in communication with the facility about the relationship with the VA and staff persons. · The G had no concerns about the facility programming for the VA and said staff persons were “really good.” P2 provided the following information: · Staff persons regularly interacted with the VA and attempted to process with him/her about his/her choices and possible outcomes. The VA often agreed to what was discussed until the time arrived to act and then refused. Other times when staff persons discussed with the VA about what was occurring the VA denied events happened or any involvement. · The staff persons attempted to support the VA’s passion for basketball and use build a relationship with the VA. As the VA was not regularly around staff persons were limited in how to build a relationship with the VA. P3 said that the VA was very outgoing and in the last year began being involved with “a bunch of trouble things” that had others “worried.” P3 attempted to process with the VA about items and s/he would lie to P3. P4 usually worked the overnight shifts and occasionally worked daytime hours. P4 said that the VA would decline directions provided from staff persons. Conclusion for Allegation Three: The FM had concerns that the VA did not have goals and that staff persons did not assist the VA to increase his/her independence or skills related to chores, employment, or education. However, information from P2, the G, and the CM, and the VA’s plans was consistent that the VA had goals and outcomes that staff persons encouraged the VA to work towards and meet. Given this, and that the CM and the G each had no concerns regarding the facility or staff persons provision of services to the VA, there was a preponderance of evidence that there was not a failure to supply the VA with reasonable and necessary care or 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). Action Taken by Facility: The facility completed an internal review for each allegation and determined that their policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken.
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