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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: 1070672-H_DSF (245D-Home and Community-Based Service-Day Services Facility) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) had a romantic relationship with a vulnerable adult (VA) at the facility. Date of Incident(s): Prior to July 11, 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through interviews conducted with facility staff persons (P1 and P2). This investigator requested an interview with the VA, but s/he did not respond to the request. However, the VA provided information to a law enforcement officer (LEO) and to P1, which was included below. Two letters, one certified, were sent to the SP requesting an interview with this investigator but s/he did not respond to the letters, or to this investigator’s email and phone call. Facility documentation showed that the VA was diagnosed with a developmental disability, might have poor boundaries, and had a history of substance misuse. The VA received employment services at the facility and worked with the SP a few days a week but resided at another facility where s/he received additional services. The VA previously worked at jobs in the community, but when this report was received, s/he was seeking employment. The VA had a history of seeking “sexual encounters” online and in person and was likely to seek or cooperate in possibly abusive situations if s/he was attracted to other persons in the encounter and might give money or personal items to those to whom s/he was attracted. The VA was permitted to use telephones but was not permitted to own a cell phone or use social media sites or apps because of his/her vulnerabilities, and staff persons were to limit their use of cell phones when the VA was present. Staff persons were to observe the VA at the facility to ensure that s/he did not engage in potentially unsafe actions with others. The VA was good at repairing items and hoped to live independently in an apartment in the future. Facility documentation and interviews with this investigator provided the following: P1 and P2, who were supervisory and administrative staff persons, provided consistent information that in early July of 2023, the SP abruptly and immediately resigned after working a shift with the VA. On July 8, 2023, the SP’s family member (FM) told facility administrators about a note written by the SP which the FM found, that showed that there was relationship between the SP and the VA and that the SP and VA were communicating using cellular phones. P1 and P2 were aware that the VA was not supposed to have a cell phone and thought that it was possible that the SP gave a phone to the VA. When the VA’s team talked with the VA about concerns that s/he had a relationship with the SP and communicated with him/her using a cell phone, the VA said that s/he was in love with the SP, and they had a “plan” for what to do if they were “caught.” Prior to learning of the note written by the SP, staff persons did not observe anything inappropriate between the SP and the VA and had no information that there was a relationship between them. When the facility became aware of the concerns regarding a relationship between the SP and the VA, it immediately began an investigation. The SP did not complete an interview with this investigator or law enforcement officers, but in the Internal Review, s/he told P1 that s/he was leaving employment at the facility on July 7, 2023, and sent P1 a text the next date, confirming his/her resignation. Records from the law enforcement agency showed that the LEO was unable to locate the SP, and his/her family members described the SP as “missing.” According to the records, the VA and SP exchanged sexual messages, photos, and videos using cellular phones, but the LEO thought that it was unlikely that the VA and SP had a physical relationship based on the information s/he gathered. The agency investigated the allegations in this report but took no further action. The facility’s Boundaries Policy stated that staff persons were not to share information about themselves or other employees with clients but might share their lived experiences when it was therapeutic and/or beneficial to clients. In addition, staff persons were not to engage in relationships with clients outside the facility. The facility’s Conduct Between Staff and Individuals Receiving Supports Policy showed that staff persons were not to give individuals items or money. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care prior to July of 2023. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, states that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of this chapter. Conclusion: Facility documentation showed that the VA received employment services at the facility and the SP worked with him/her there. The VA might seek sexual encounters, might have poor boundaries, or misuse cell phones/social media. Because of his/her vulnerabilities, the VA was not permitted to own a cell phone or use social media, and staff persons were to limit their use of cell phones when working with the VA. Information was consistent from P1 and P2, that the facility had a note written by the SP showing that there might have been an interpersonal relationship between the SP and the VA and that the SP and VA communicated with each other using cell phones. It was unknown how the VA obtained a cell phone, but it was possible that the SP gave the VA the phone. The VA and the SP did not provide information to this investigator, but the VA told his/her team that s/he was in love with the SP, and they had a “plan” for what to do if they were “caught.” No information showed that staff persons were aware of a possible relationship between the SP and the VA, until the facility obtained the SP’s note. Records from a law enforcement agency showed that LEOs were unable to locate the SP, but the VA and SP exchanged sexual messages, photos, and videos using cell phones. However, it was unlikely that the SP and VA had a physical relationship, and the agency took no further action. Having a relationship with the VA outside the facility was not consistent with the standards of a professional caregiver in a DHS licensed program and was a violation of the facility’s policies and procedures and Minnesota Statutes, section 245D.07, subdivision 1a. Although there was a relationship between the SP and the VA outside the facility, given that the extent of the SP’s relationship could not be determined, that a law enforcement agency investigated the allegations in this report but took no action, that it was unknown how the VA obtained a cell phone, and that no information showed whether the services provided to the VA were affected by the SP’s actions, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health or safety. 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 which determined that its policies and procedures were adequate but were not followed. The SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined in this report.
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