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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: 806273-SUD (Substance use disorder) Investigator(s): Emily Kearns/Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) and a vulnerable adult (VA) had a sexual relationship while the VA resided at the facility and that contact between the VA and SP continued after the VA was discharged from the facility. Date of Incident(s): August - September 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 2, paragraph (c); and subdivision 17, paragraph (a): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. ‘Intimate parts’ includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 October 6, 2023; from documentation at the facility; and through ten interviews conducted with one supervisory staff person (P1), five facility staff persons (P2, P3, P4, P5, and the SP), the VA’s case manager (CM), the VA’s family member (FM), a community person (CP), and the VA’s parole officer (PO). Attempts were made via phone and e-mail to contact and interview the VA and calls were made to a former client (C), but neither responded to the requests. Facility documentation showed that the VA was diagnosed with severe stimulant use disorder, severe cannabis use disorder, anxiety disorder, depression, and post-traumatic stress disorder. The VA enjoyed writing and playing golf and other sports. According to facility documentation, the VA resided at the facility from August 4 to September 5, 2023, and the SP worked at the facility from July 24 to September 15, 2023. The facility provided substance use disorder services to clients and offered a “well-rounded balance of individual, group, and family education sessions, peer support meetings, social activities, exercise, healthy meals and alumni support.” The facility was located in a “rustic, rural setting” with a main structure, several detached dorms, and other outbuildings used for meetings or activities. Staff persons were onsite 24 hours per day and were to be awake for overnight hours. P2 provided the following information: · P2 was driving the C somewhere when the C told P2 the VA was “sleeping with” the SP. When asked to describe what that meant, P2 said, “Having sex.” P2 would take things s/he heard from clients “with a grain of salt” but felt that the C would not “stir the pot” and did not believe s/he made it up. · The C told P2 that s/he went to the bathroom during the night and heard “explicit sounds” and “the sound of sex” described as “clapping” in one of the bathrooms in a south shower area. This area was not private nor was it able to be locked, which P2 found “odd.” The C waited to see who walked out of the bathroom together and said that it was the VA and the SP. P2 thought the SP only worked one overnight shift during the time s/he was employed at the facility. · The C also told P2 that the VA was telling the C and other clients about having sex with a staff person on a “blow-up toy” which was an inflatable yard toy that attached to a water hose to provide cooling relief and was similar to an air mattress. The VA went on to tell the C and the other clients that s/he and a staff person had taken the toy to a specific detached group gathering room and “had sex” on it. The VA told the C and other clients, “This is the best treatment ever.” P2 said, “I think [the C] said [the SP’s name],” but P2 was “unsure.” · P2 did not suspect anything between the SP and the VA at “the time” but with the context, felt that they were maybe “sitting too closely” and that their contact was “a little off.” P2 did not really work much with the SP, mainly seeing him/her “in passing.” · There should be no “reaching out,” “personal friendship”, or “hanging out, even if it’s platonic” for two years after a client was discharged from the facility. The PO provided the following information: · The PO visited the VA at the facility on August 28, 2023, and the VA talked to the PO about “feelings” that the VA was having for a staff person (the VA did not name the staff person) at the facility. The VA said that s/he wished s/he “were in a better place in life” to follow-through on the feelings that the VA had. The PO emphasized to the VA that it was “inappropriate,” that it could not happen, and that there were legal consequences. Initially, the PO felt like it was “one-sided” with the VA “obsessing” about the staff person. The PO’s subsequent conversations with the VA did not involve talking about the SP. · The VA was discharged from the facility on September 5, 2023, and left for a sober living residence. After the VA left the facility, the PO did not hear from the VA, which was not the usual process, so the PO went to where the VA currently resided to see the VA. The PO went to the backyard and was met by a residence manager, the VA, and an unnamed person. The PO did not recognize the unnamed person and thought that it was odd that the unnamed person was there. The PO turned to the unnamed person and asked if s/he worked at the facility. The unnamed person responded that s/he worked at a different facility. The VA had never mentioned knowing anyone from that facility. (Investigator’s note: After the unnamed person left, the PO asked the VA if the unnamed person was the SP from the facility, and the VA confirmed that it was the SP). · The residence manager said that s/he had given the VA a two-hour pass to leave to get groceries, because the VA was unaware that s/he needed to provide groceries for him/herself at the residence. The VA asked the SP for help and the SP picked up the VA in his/her car and took him/her to get groceries, bringing the VA back several hours later. · The PO privately talked to the residence manager and while doing so, observed the VA and the SP hug and saw the SP take a drink out of the VA’s fast-food beverage cup. The PO heard the SP call the VA “honey” and state, “I will do anything to support you.” When the SP left, the PO again told the VA that it was “inappropriate” and that it was a boundary issue. The PO told the VA that s/he was the one that the VA should contact to get groceries or other needs met and that the PO had those resources available. · The next day, on September 6, 2023, the PO contacted an employee at the VA’s residence to discuss the boundary issues regarding the VA and the SP and then was directed to P1 at the facility. P1 told the PO that there had been previous “concerns” about the VA and the SP at the facility. · On Sept 8, 2023, the VA contacted the PO and was very upset because the VA was blocked from the SP’s phone and felt that the PO had “ruined [the SP’s] life and this relationship.” The VA said that s/he knew the SP “from prison” and that the SP was friends with the VA’s child’s mother. The VA told the PO that s/he “had no right to do this,” and that the SP was going to help the VA get one of his/her children back. The VA said that the SP and the VA were going to get an apartment. The PO felt like the VA “spilled the beans [about the VA’s and the SP’s relationship] in anger.” · On September 19, 2023, the VA sent a text message to the PO stating, “I fucked up,” and that s/he ate “THC [tetrahydrocannabinol] ice cream” for a toothache and was no longer able to stay at the residence. The VA told the PO that there was another place s/he could stay and provided an address that turned out to be the SP’s. The last time that the VA contacted the PO was on September 28, 2023. · On October 2, 2023, the VA was not responding to the PO’s text messages or calls and had not been in touch with the PO, so the PO and a co-worker went to the SP’s home. The VA was not there, but the PO talked to the SP who said that on September 28, 2023, the SP dropped off the VA in St. Paul near the sober living residence. The SP said s/he had not seen the VA since then. As of October 3, 2023, the PO did not know where the VA was staying, just that s/he had “not shown up for treatment,” and was “discharged.” P3 provided the following information: · The SP had “boundary issues,” specifically with the VA. Some examples provided were the amounts of time the two spent together and some of the locations they chose to sit together, such as in a dorm during a time that clients were supposed to be eating dinner together. Staff persons tended to “stick together” during shifts and work “as a team” but P3 felt like the SP would go and do his/her own thing and mainly spent time with the VA. Sometimes this would be approximately “three-quarters, if not more” of the SP’s shift that s/he and the VA spent time together. · One day when P3 was working, the SP volunteered to come back and work a second shift, an overnight shift. This was the only overnight shift that the SP worked while at the facility. The VA was very social and was typically awake during daytime hours, but on this date, the VA knew that the SP was going to be working the overnight shift. The VA missed a group meeting because s/he was taking a “rare nap,” possibly getting rest, knowing that the SP was going to be working the overnight. P3 told P4, who was also working the overnight shift with the SP to “keep an eye out” since it would only be the SP and P4 working. Overnight staff persons were to stay awake during their overnight shifts. · About a week prior to the end of the SP’s employment, P3 talked with the SP in private about the time the VA and the SP spent together, about the SP not being a “team player,” and the locations in which s/he and the VA would be. P3 cautioned the SP against this. Approximately 30-60 minutes later, the VA approached P3 and defended the SP, trying to “justify their actions,” and thought it was “unfair,” using exact phrases from the conversation that P3 had with the SP. P3 also talked to P1 about the SP’s “boundary issues” and his/her concerns about it prior to the SP quitting. · P3 was familiar with a blow-up toy and described it as a sprinkler activity for when it was hot and said it was “kind of like an air mattress . . . inflatable pool-type thing” and had no other comments on it. · A two-year separation after a client was discharged from the facility was required prior to staff persons and clients having any kind of personal relationship. That included social media or an in-person friendship, and even then, it was discouraged. P1 provided the following information: · On September 5, 2023, the VA was discharged from the facility and the SP called in sick. P3 told P1 that the SP and the VA were spending a lot of time together and that other clients had been talking about it. · On September 8, 2023, P1 spoke with the SP about concerns about the amount of time the SP and the VA spent together. The SP initially denied they spent a lot of time together, but later admitted to bringing groceries to the VA at the VA’s residence. The facility required that the SP delete the VA’s number, attend boundary training, and have no contact with the VA for two years. The SP agreed, but on September 11, 2023, put in a two-week resignation notice. · P1 purchased the blow-up toy for the facility as a means for the clients to stay cool in the summer heat. P1 had thrown the toy away and it was no longer at the facility. P4 and P5 could not attest to anything inappropriate between the SP and the VA that they had seen themselves, as they did not work shifts with the SP, but both were both aware of the allegations. Both P4 and P5 stated that a two-year time frame was required prior to any personal relationships with discharged clients. P4 provided the following additional information: · Staff persons were to be awake during overnight shifts. Clients were generally asleep during that time. · P4 was told by other staff persons who s/he did not name that the SP was having a sexual relationship with the VA. P4 worked one overnight shift with the SP. During that shift, the SP and the VA were sitting on the deck talking. At about 1 a.m., the VA went inside. Another day, the SP and the VA were sitting “a little close” next to each other during “gratitude” group. · P3 shared concerns with P4 about a lack of personal boundaries the SP seemed to be having with the VA since the SP was due to work the overnight shift with P4. P3 wanted P4 to “keep an eye on” things. Additional information provided by P5 was that the SP told P5 that s/he dropped off groceries to the VA after s/he was discharged from the facility and that the SP was taking the VA to church every weekend. The SP told P5 that s/he remained in contact with the VA and was visiting him/her but said that there was nothing sexual going on. P5 asked the SP if s/he realized that personal relationships with clients were not allowed. P5 knew that the SP was aware of this policy because they had monthly boundaries training where it was reiterated. The SP told P5 that s/he was quitting the job because s/he “found it hard to maintain professional boundaries with people,” and no longer wanted to. The FM and the VA last had communication on September 16, 2023. The FM said that the VA said that s/he “made friends” with someone at the facility, but that the FM did not recall the name of the person. The CP provided the following information: · On either August 18 or 25, 2023, (a Friday), the VA and the CP had a phone conversation. The VA said that s/he had “met someone” who worked at the facility. The CP provided the name of the SP. When the CP asked the VA if that was “illegal,” the VA said that it was not because the SP was not treating the VA “actively.” The VA told the CP that the SP and the VA were “in love with each other” and “talked on the phone for hours” after hours, and that they were “full on . . . a couple.” Sexual contact between the SP and VA was not discussed with the CP. · The VA did not tell the CP how the relationship began but that they “talked a lot.” By the time the VA told the CP about this, the CP felt that this had been going on for quite a while because the VA knew “quite a bit” about the SP’s “backstory.” The VA told the CP that s/he could make calls after 4-5 p.m. and explained to the CP that the reason why the CP and the VA had not been talking as much lately was because the VA had been talking to the SP “all the time after hours.” · The day that the VA left the facility and went to the sober living residence, the SP brought the VA to the residence, and they also went together to get groceries for the VA that the SP paid for. · The CP had not heard from the VA since October 1, 2023. The SP provided the following information: · The SP worked at the facility for about a month and “voluntarily quit.” The SP knew the VA since s/he was about “14 or 15 years old” but when s/he started working at the facility, the SP did not realize that s/he knew the VA at first. The SP said, “I didn’t do anything wrong.” · The SP and the VA “talked a lot” (described by the SP as about an hour) while the VA was at the facility, but that the SP also talked to other clients as well during that time. The SP denied spending five to six hours per shift talking to the VA. The SP felt like P3 was “harassing” the SP for “probably the entire time that I was working.” The SP said that P3 told him/her that clients knew about the VA and the SP. The SP replied, “There is no [the VA and SP’s names],” stating that they were “friends.” · The SP did not tell facility management staff persons that s/he knew the VA prior to the VA residing at the facility because the other locations that the facility operated to were “too far away” if the SP were to be reassigned as a result. The SP knew that the facility did not allow staff persons and clients to have personal relationships, but the SP said, “I didn’t think it was a big deal.” · On September 16, 2023, the SP sent a text message to P1 stating that the night before (September 15, 2023) was his/her final shift during which point, the SP was no longer speaking to the VA, “respecting [the facility’s] policies,” and did not communicate with the VA until after s/he stopped working at the facility. · The SP decided to quit working at the facility because s/he felt “harassed at work” and co-workers were continuing to ask the SP questions because of rumors going around and, “I didn’t want to deal with it.” The SP stated, “I didn’t sign up to work at a place where something like that was even going to happen…where I was going to be talked about every day I went to work.” The SP put in his/her two-weeks’ notice but then decided s/he “didn’t owe them the decency of following through with a two-weeks’ notice,” since management staff persons were talking about the SP to other coworkers. “I don’t want to work for a company that dictates who I’m friends with,” and did not like “being controlled like that.” The SP was used to working in care facilities, where hugging patients, learning about their lives, and listening to them was permitted. · After the SP no longer worked at the facility, the VA and the SP had a friendship. The SP described friendship as “being friends with someone.” This included “hanging out with each other.” The SP brought the VA to see one of the VA’s children, and took that child to a park, because that child lived close to the SP. Another time, the SP and the VA went to an art gallery to “kill time, because it’s a good, sober thing to do.” · The SP felt like it was okay to have a friendship with the VA after s/he was not working at the facility because “that’s my right as a human being.” The SP denied doing anything with the VA off-site from the facility while s/he was still working there. The SP admitted to bringing food to the VA at the VA’s residence because the SP “felt bad” that the VA did not know s/he was supposed to have brought food and had none. The SP did not think it was “something that was super huge” and felt like s/he was “just trying to do a good thing by bringing [the VA] groceries.” When asked if this was while the SP was working at the facility, the SP said that it was. The SP clarified that when previously asked if s/he and the VA had spent time together outside of the facility, and s/he stated, “No,” that the SP thought this investigator was asking if it was when the VA was still at the facility. The SP admitted to taking the VA to church a week or two before this interview. The SP thought that the last text message sent from the VA to the SP was on October 1, 2023. The next day, the SP brought the VA down to a gas station near the VA’s residence. The SP sent several more text messages after that to the VA but did not hear back. · At one point, the VA stayed at the SP’s house “for a couple of nights” on a futon downstairs after the VA got “kicked out” of his/her residence and when the SP was no longer working at the facility. The SP was going to help get the VA’s children back and said that the VA had a “good plan” for getting him/herself to “follow through.” The SP thought the plan was a good idea and was “100% on board with helping” the VA with that. The SP brought the VA places and tried to get the VA to attend his/her treatment appointments, but the VA did not want to “stick to the schedule” and was not being respectful of the time frames that the SP offered to help. As a result, the SP told the VA that s/he could not stay at his/her home that night and told the VA s/he would be bringing him/her back to “the cities” the next day. · The SP only worked one overnight at the facility and denied any sexual contact with the VA and stated that s/he “never even touched” the VA. The SP denied sexual intercourse occurring in one of the bathrooms at the facility, denied sexual intercourse on a “blow up mattress,” and denied sexual intercourse in a group therapy room. The VA never made “sexual advances” toward the SP while the two were at the facility, but one time, some of the clients, including the VA, talked about specific parts of the SP’s body. · The VA was “extremely manipulative” and unreliable, which the SP noticed after the VA left the facility. Facility documentation showed that the SP declined “New Hire Boundary Refresher” training. The Staff Personal Relationships policy stated that no direct contact, including sexual contact, was allowed outside of the facility for a period of two years following the client’s last session. Facility documentation showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3) stated that the license holder shall monitor implementation of policies and procedures by program staff persons. Conclusion: Information showed that the SP worked at the facility from July 24 until September 15, 2023, and that the VA was a client from August 4 to September 5, 2023. It was reported that the VA and the SP had a sexual relationship while the VA resided at the facility and that contact between the VA and SP continued after the VA left the facility. The VA told the C, who then told P2 that the VA and a staff person were “having sex” while the VA was at the facility. The C told P2 that the VA also told clients that s/he and a staff person “had sex” on a “blow up” toy that was purchased for the clients at the facility. P2 was not sure if the C said the SP’s name or not. Additionally, the C told P2 that s/he heard “the sound of sex” described as “clapping” in a dorm bathroom, later seeing the VA and SP exit that bathroom. The VA told the CP that s/he had “met someone” who worked at the facility, naming the SP and said that they were “in love with each other.” The VA told the CP that it was not “illegal” because the SP was not “actively” treating the VA. The VA also told the CP that after the VA was discharged from the facility, the SP drove the VA in his/her personal vehicle and took the VA to get groceries which the SP paid for. P5 stated that the SP told him/her about taking the VA to church “every weekend” and that s/he had remained in contact with the VA but that there was “nothing sexual” going on. P5 reminded the SP that personal relationships with clients were not allowed, and the SP told P5 that s/he was “quitting” the job due to finding it “hard to maintain professional boundaries with people.” P4 was told by other staff persons that the SP and the VA were having a sexual relationship. P3 stated that the SP had “boundary issues” with the VA based on the amount of time the two spent together. On August 28, 2023, the VA told the PO about “feelings” that s/he was having for the SP, but did not name the SP. The VA told the PO that s/he could not “follow through” on those feelings because of where the VA was at in his/her life. The PO emphasized to the VA that those types of relationships were “inappropriate.” When the VA was discharged from the facility on September 5, 2023, the PO did not hear from the VA and went to his/her new sober living residence and saw an individual, who turned out to be the SP there with the VA. The SP had “called in sick” for his/her shift that day at the facility. The SP and the VA had just returned from getting groceries in the SP’s vehicle. The SP was observed hugging the VA and calling the VA “honey.” The SP and the VA shared a drink out of a beverage cup. The VA admitted to the PO that the VA and the SP had known each other prior to the VA being at the facility and was upset with the PO for “ruining” this relationship and the SP’s life when the VA was blocked from the SP’s phone. The FM was told by the VA sometime on or prior to September 16, 2023, that s/he had “made friends” with someone at the facility. The SP stated that the SP and the VA knew one another prior to the VA receiving services at the facility. The two “talked a lot” but were just “friends.” The SP did not tell facility management that s/he knew the VA because s/he did not want to get reassigned to a different facility location and “didn’t think it was a big deal.” The SP decided to quit working at the facility because of “rumors” going around. The SP stated that s/he stopped talking to the VA until after his/her last day at the facility. After the SP left the facility, the VA and the SP had a “friendship” including “hanging out” with one another. The SP brought the VA to see one of his/her children and another time, the two went to an art gallery. The SP felt like it was okay to have a friendship with the VA because s/he was no longer working at the facility. The SP denied doing anything off-site from the facility with the VA while the VA was still a client at the facility. After the VA was discharged, the SP stated s/he brought food to the VA at the VA’s residence and was “just trying to do a good thing.” The SP also took the VA to church. The SP stated that sometime after the VA was discharged from the facility, the VA stayed at the SP’s house “for a couple of nights” when the VA was no longer able to stay at his/her residence. The SP stated that s/he was going to help the VA get his/her children back and brought the VA to treatment appointments. The VA and the SP never had sexual intercourse in a bathroom, in a group therapy room, or on a “blow up mattress.” The SP stated that s/he “never touched” the VA. Regarding Sexual Abuse: Although the VA told the PO that s/he had “feelings” for someone at the facility, the VA told the CP that the SP and the VA were a “couple”, the C told P2 that the VA said s/he and a staff person “had sex” on a blow-up toy, and that the C heard “sex sounds,” s/he described as “clapping” prior to the SP and the VA exiting a not private bathroom, given that the VA nor the C responded to this investigator’s attempts to interview them so further information was not provided, that the VA told the PO that s/he could not act on his/her feelings, that P2 was not sure if the C named the SP, and that the SP denied sexual contact with the VA, there was not a preponderance of the evidence that the SP had sexual contact with the VA. It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. ‘Intimate parts’ includes the primary genital area, groin, inner thigh, buttocks, and breast). Regarding Neglect: Information showed that the SP crossed professional boundaries with the VA after the VA was discharged from the facility which was not behavior expected from a caregiver providing services in a program licensed by the Department of Human Services and a violation of the facility's policy and Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3). However, given that this occurred while the VA was not a client at the facility, that the SP denied outside contact with the VA while the VA was a client at the facility, and that the VA did not respond to interview requests and did not provide further information regarding his/her interactions with the SP at the facility, there was not a preponderance of the evidence whether the SP failed to provide the VA with reasonable and necessary care and services. 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 and determined that their policies and procedures were adequate but were not followed. The facility attempted to retrain the SP on boundary training while s/he was still employed by the facility, but the SP declined the training and then no longer worked at the facility. The facility was going to hold monthly and as-needed boundary refresher courses for new staff persons. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a correction order for the violation outlined in this report because they took corrective action and the SP no longer worked at the facility. No further action was taken.
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