MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1070913-H_CRS (Home and Community-Based Services-Community Residential Setting)

1070910-HCBS (Home and Community-Based Services)

Investigator(s):

Thomas Nixon
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
thomas.c.nixon@state.mn.us

651-431-2155

Suspected Maltreatment Reported:

It was reported that a staff person (SP) gave and used marijuana with two vulnerable adults (VA1 – VA2).

Date of Incident(s): Ongoing prior to May 12, 2023 (The Department of Human Services received the report on June 19, 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 July 13, 2023; from documentation at the facility; and through eight interviews conducted with VA1, VA2, VA1’s guardian (G), VA2’s case manager (CM), two supervisory staff persons (P1-P2), and two staff persons (the SP and P3). Another staff person (P4) was contacted by phone, text, email, and letter. P4 initially agreed to an interview but then did not respond to subsequent attempts.

VA1’s diagnosis included borderline personality disorder and bipolar 1 disorder by history. VA1 liked to swim, fish, shop, listen to music, and look for rocks and agates.

VA1’s plan allowed for “independence time in the community.” The plan did not provide additional information.

VA2’s diagnoses included schizophrenia, bipolar one disorder, and stimulant use disorder- methamphetamine severe. VA2 enjoyed sports.

VA2’s Functional Assessment stated, “[VA2] does not at this time have many skills on stopping [his/her] impulse control and utilizing other skills to reduce [his/her] desire for chemicals. [VA2] does desire to stay clean and feels disappointment and self-hatred when [s/he] does abuse chemicals.” VA2’s Admit Meeting notes stated s/he was to be supervised by staff person’s “eyesight at all times when [s/he] is out of [his/her] room for the time being.” VA2 had no unsupervised time in the community.

The SP worked at the facility from June 4, 2019, through May 12, 2023.

P3 and text messages between VA1 and the SP provided the following information:

· On either June 15 or 16, 2023, P3 drove VA1 to a store and VA1 asked for P3’s personal cell number. P3 asked why VA1 needed it and VA1 said s/he was allowed to have all the staff persons’ numbers in case s/he needed them while s/he was unsupervised in the community. VA1 then told P3 that s/he talked to the SP about things and “there is more.” P3 asked what VA1 meant and VA1 initially declined to provide information but then said that s/he, VA2, and the SP smoked marijuana and THC (9-tetrahydrocannabinol) together in the facility van. VA1 said there was also a time s/he, VA2, and the SP went to the SP’s home to talk with the SP’s family members and when the SP came back outside, s/he asked if s/he “smelled like weed.” VA1 said the SP gave him/her a THC vaporizer from California. P3 knew the SP frequently went to Nevada and California.

· VA1 said s/he did not say anything about the allegations prior because s/he “did not know who to trust,” and was “scared” about how the SP might act if s/he was knew VA1 said something.

· VA1 let P3 looked through his/her cellphone text messages with the SP. VA1 and the SP texts included messages about “gummies,” vape pens, exchanges of money, “joints,” MD (which P3 said meant medical dispensary), “blunts,” and the exchange of money from VA1 to the SP P3 said the SP had a “medical card” for medicinal marijuana.

· VA1 also had text messages regarding marijuana use with his/her significant other (SO). VA1’s time with the SO was not a part of his/her unsupervised community time. VA1 was to be supervised by a staff person when s/he was with the SO because the SO was also a vulnerable adult and used marijuana. P3 asked VA1 about this and VA1 said that s/he smoked marijuana with the SO and the SP while at the SO’s home. P3 and VA1 then called the SO and the SO acknowledged that on an unknown date s/he, VA1, and the SP smoked marijuana together. P3 said the SP took VA1 to see the SO "a couple [of] times,” but was only aware there was marijuana use the one time.

· In one text message VA1 asked the SP if s/he knew how to “roll joints.” When the SP replied that s/he did not, VA1 said that P4 could help him/her. VA1 told P3 that P4 was aware s/he texted with the SP. P3 asked if P4 also smoked marijuana with VA1 and VA1 said P4 had not.

· PVA1 told P3 that “anytime” the SP took VA1 and VA2 in the van by him/herself, they smoked marijuana with the “dab pens.” P3 did not know if the SP drove high but based on what VA1 said the SP had to have done so to get back to the facility.

· VA1 told P3 that at a recent doctor appointment s/he had a blood work and was told his/her “THC levels were higher than [his/her] Delta levels.” VA1 told the doctor s/he “smoked THC and asked to keep it confidential. P3 asked if VA1 still had any items in his/her possession and VA1 said s/he had a “vape pen” at the facility. When they returned to the facility, VA1 gave P3 the vape pen. (Note: The vape pen was the brand Ghost and was labeled Gary Payton Hybrid, with a symbol of a marijuana leaf with an exclamation point CA underneath it. According to the website ghostcartsofficial.com, the pen is a Delta 9 product in compliance Prop 65 and California Health and Safety code.” P3 than called the on-call supervisory staff person and told him/her about the allegation.

VA1 provided the following information:

· On an unknown date in winter 2022, the SP drove VA1 in the community. The SP pulled out a vape pen and asked, “You want some?” VA1 asked if it was “regular delta,” and the SP said it was marijuana. The SP then gave it to VA1 and they smoked the marijuana via the vape pen.

· The SP offered VA1 the vape pen with marijuana “all the time” including in the car and at the facility by the garage door. VA2 sometimes joined them and at times hide the vape pen in his/her room. VA1 said the other staff persons did not know about this because they “did it secretively.” VA1 and VA2 each also texted with the SP and asked for the marijuana vape pen. VA1 knew the SP’s personal cellphone number because s/he was allowed to text the SP when VA1 was in the community during his/her unsupervised time. VA1 said using marijuana with the SP went on for “a couple of months” and they smoked the weed vape pen “once a day,” every shift, “as long as [the SP] had it.” The SP told VA1 s/he should not tell other people. VA1 said the SP’s “driving was good, not too bad” after the SP used the weed vape pen.

· On one occasion, the SP drove VA1 to see the SO and while at the SO’s home, the SO, the SP, and VA1 went outside and the three of them smoked marijuana together. There was also a time when the SP brought the marijuana vape pen to an overnight camp s/he and VA1 attended, and they smoked while at camp.

· On an unknown date, VA1, VA2, P4, and the SP went into the community for an activity. The SP drove them to his/her home. P4 stayed in the car while the SP, VA1, and VA2 got out to visit with the other people the SP’s home and play with the pets. VA1 and VA2 were outside by the front entry way when the SP came out from the home and said s/he “used my bong” and asked if s/he “smelled like weed.” VA1 said the SP did smell like marijuana. VA1 said P4 did not hear the SP’s question because s/he was in the car.

· VA1 said the SP gave VA1 “gummies,” that “really kicked in.” (Note: VA1 showed the bottle the gummies came in which said they were Hemp-Derived Delta 8 THC Gummies. The gummies contained ≤ 0.3% Delta 9 THC and were distributed by a company in California.”)

VA2 provided the following information:

· VA2 lived at the facility for six months. VA2’s history included chemical addiction and s/he was five months sober. VA2 got along with the staff persons at the facility and there was respect both ways and s/he hoped to be moved to a sober living in a city area.

· VA2 denied using marijuana in any form with the SP and VA1. VA2 said s/he did not use marijuana because “I get weird on weed” and s/he “can’t carry myself on that.” VA2 saw the SP and VA1 use vape pens in the company van together. VA2 was not aware if VA1 and the SP used marijuana together and denied s/he was included on any texts with the SP and VA1 about using marijuana. VA2 was shown the Ghost vape pen and said s/he had not seen it before, but others similar to it.

· One time, VA2 went to the SP’s home with the SP, VA1, and P4. VA2, VA1, and P4 visited with the others outside the home. The SP “ran in and grabbed something and then came right back out within maybe a minute.” VA2 denied hearing the SP asked if s/he smelled like marijuana.

P1 provided the following information:

· On June 16, 2023, during the morning, P1 was told that day, VA1 was driven to a local store by a staff person, s/he did not recall, and the conversation turned to VA1’s alone time. (Note: The staff person who drove VA1 was P3.) VA1 and P3 talked about how VA1 had other staff person’s phone numbers in his/her cell. P3 asked questions to VA1 why s/he knew other staff person’s phone numbers and VA1 said the SP “had given [him/her] a THC pen.” VA1 said s/he was not sure if the pen was THC or delta 8 at the time. VA1 said after a medical appointment s/he was told his/her “levels were high for delta 8” and VA1 “quit using it after [s/he] found out.”

· P3 started to ask more questions and VA1 said s/he smoked marijuana and THC with the SP on “multiple occasions” that VA1 did not recall. VA1 said s/he used with the SP and VA2 in the facility vehicle. VA1 told P3 that when the SP took him/her to see SO the three of them “smoked marijuana flower.” VA1 said the SP drove him/her and the VA2 to the SP’s home. The SP left VA1 and VA2 outside and went inside the house. When the SP returned s/he asked VA1 and VA2 if they could smell marijuana on him/her.

· P1 said there was a conversation with VA2 and P2 about the allegations and VA2 “confirmed” the stories. VA2 told P1 s/he “wasn’t coerced into smoking THC, but did not stop [him/herself].” VA2 said the opportunity was there and s/he took it.

· On June 16, 2023, P1 spoke with VA2 about the allegations. VA2 said there were “quite a few times” when s/he, VA1, and the SP rode in the company vehicle, the SP and VA1 took out their THC pens and “pass[ed] them around.” VA2 said s/he was not pressured to use the pen. P1 did not “press the issue” with VA2 about the situation with the SP and did not ask to see VA2’s cellphone for any contact or text messages.

· P1 considered VA1 to be an accurate reporter “for the most part” and believed him/her with this. While VA1 historically made up lies and stretched the truth such as how long an event was or tried to split staff persons, since s/he talked about the situation s/he showed an “increase in behaviors,” “obsessively [talked] about it,” and was “feeling guilty.”

· P1 considered VA2 an accurate reporter who was on probation and civil commitment for drug related issues. P1 said VA2 was always very polite, respectful, and apart from two attempts to leave the facility without staff person supervision, was a “dream to have.”

· P1 worked with the SP for two years, felt s/he was a “trusted person,” and was an “above average” staff person. P1 did not have any previous concerns with the SP. On an unknown date, the SP approached P1 and said VA2 was “getting too close to [him/her].” The SP said VA2 gave [him/her] an “unwanted hug” and s/he thought VA1 “tried to kiss” the SP. P1 offered to switch the SP’s facilities and the SP decided to stay on. P1 did not see any “red flags” between the VA2 and the SP. P1 did not recall the details of a follow up conversation with VA2 about the situation. P1 was not aware of the possibility VA1 knew the SP prior to when s/he was admitted to the facility.

P2 provided the following information:

· On an unknown date in the middle of June 2023, P2 was on shift and got a call from P1. P1 said s/he needed to “figure out this [the SP] thing.” P1 said VA1 reported to P3 that “[the SP] had given [him/her] a THC pen from California that while they were on outings, they would share it and pass that pen amongst the three of them.” P2 said the third person was VA2.

· That day, P2 talked with VA1 about what P1 said. VA1 was “nervous” about getting him/herself and the SP in trouble. P2 said VA1 was “open to suggestions” and “very suspectable to leading questions.” P2 “did not talk to [him/her] much about anything with it.” P2 “did not want to try to pull answers out of [VA1].

· The next day, P2 talked with VA2 about the report. P2 said there was “rumors going around about a former staff member, possibly using substance with person served.” P2 said VA2 “pretty much reverberated everything that [VA1] had reported to [P3] to me.” VA2 “admitted to using with them” and “confirmed everything” which included using in the vehicles and going to the SP’s house. VA2 described to P2 about “smoking the vape pens several times in the van several times while [the SP], [VA1], and [him/herself] were in the van.”

· P2 was told that the SP used with VA1 and VA2 “every change they got.” VA2 said “a couple times” when s/he went to a local camp with VA2 and the SP and the three of them used. P2 was told of when the SP took VA1 and VA2 to his/her home, went into the house, and then asked them if s/he smelled like marijuana.

· P2 said there was “no real training” for staff persons for VA2’s addiction. P2 said “common sense says if someone is a gambling addict, you don’t take them to the casino, if someone [had] a substance abuse problem, you don’t use with them.” P2 said the SP was aware of VA2’s addiction in the preadmission paperwork that s/he signed off.

· P2 considered VA1 to be an accurate reporter “75%” of the time. When VA1 made a report about a staff person or another vulnerable adult s/he was “typically right on.” The other 25% of the time VA1 sought out attention for medical reasons or was jealous when someone else got attention. P2 considered VA2 to be an accurate reporter unless s/he experienced a hallucination or delusion.

The G provided the following information:

· The G worked with VA1 since 2020 and VA1 did “not always make best decisions” regarding his/her health.

· The G was “not sure if [VA1’s] perspective is true and accurate. I think sometimes when [s/he] reports that is [his/her] perspective, but it is not always the true perspective.” The G said an example of this was VA1’s description of health symptoms s/he gave to get to the Emergency Room and once arrived s/he gave “totally different” symptoms to seek pain meds. The G did not recall past times where VA1 made inaccurate reports of staff persons that gave him/her items s/he was not to have.

· On an unknown date towards the middle or end of June 2023, the G was told about the allegations.

The CM provided the following information:

· VA2 was on a commitment and had chemical dependency concerns, had been homeless the last ten years, was in and out of treatment facilities, and left treatment without approval. VA2’s drug use included methamphetamine, alcohol, and marijuana. Staff persons were to “direct [VA2] away from immediate concerns.” VA2 was on probation and was not to be using drugs.

· The CM said VA2 “definitely is usually pretty truthful” and “always confessed to me whenever [s/he] [had] smoked the drugs or done something [s/he] is not supposed to.”

· On June 14, 2023, the CM met with VA2 and there was no discussion of any drug use. On June 16, 2023, the CM received an email from P1 about the allegation. VA2 told P1 that s/he, VA1, and the SP smoked marijuana in the company van “several times.” Prior to this it was the longest period where VA2 was sober.

· On June 22, 2023, the CM called VA2 and asked him/her about drug use. VA2 said, “Yup,” and that s/he “fell back into that pattern.” VA2 talked about his/her desire to get out of the facility and the CM said, “This is why we haven’t moved forward with your moving out plans, part of your thing is that you have to

remain sober.” VA2 “argued” and said, “It was just a little bit of marijuana.” The CM’s goal for VA2 was to be sober for one year prior to looking at moving from the facility.

· In subsequent conversations, VA2 “repeated the story a couple of times, as far as [him/her] smoking with [the SP] and [the SP] offering marijuana to [VA2] and to the other housemates.”

The SP provided the following information:

· The SP was told by a former supervisor at the facility, who s/he was related to, that VA1 was allowed to have staff person’s personal cell numbers as VA1 went on his/her own appointments. VA1 said s/he was not trained on boundaries with vulnerable adults by the facility and that “you should just know your boundaries.”

· The SP initially said s/he only texted with VA1 “just about [his/her appointments] when s/he worked with the facility. When confronted, the SP then acknowledged there when s/he worked at the facility there were text messages with VA1 about his/her tax information as the SP did VA1’s tax paperwork. The SP said s/he was not trained to do taxes, but was told by P2 that s/he could do them for VA1.

· The SP said when s/he no longer worked at the facility VA1 texted and asked if s/he was reason the SP no longer worked at the facility. The SP replied it was not and VA1 asked to borrow money from the SP and the SP blocked VA1. When confronted, the SP acknowledged s/he also texted VA1 about how a different vulnerable adult was instead reaching out to the facility as s/he “didn’t want to talk to anyone” from the facility. The SP said the policy was not to contact any former clients for six months after a staff person left the facility, but was told by his/her family member who used to be with the facility that it was okay.

· The SP initially denied there were any texts between him/her and VA1 about drugs or “being high.” When confronted, the SP acknowledged there were text messages from VA1 that asked the SP if s/he “was high.” The SP did not know why there were text messages between him/her and VA1 about if the other was high, but said VA1 “say that all the time, [s/he] thought it was funny.” When confronted, the SP acknowledged there were text messages from VA1 asking the SP if s/he knew how to roll joints. The SP said s/he thought the joint was for VA1 and the SO, the SP did not know how to roll a joint, and thought VA1 thought the SP knew how to roll a joint because his/her child “uses.” The SP did not know why P4 was involved in the texts message about rolling joints. When confronted, the SP acknowledged there were texts between him/herself and VA1 about “gummies.” The SP said gummies were CBD VA1’s gummies were locked in a cupboard. The SP did not recall s/he texted that VA1 needed to wait until P2 left to get them.

· The SP said s/he was not able to use THC as it “gives me seizures,” and could only use CBD. The SP said s/he tried THC in Florida and was seen at a clinic for his/her seizures. (Note: The SP agreed to provide medical records of his/her THC induced seizure, but did not.)

· The SP said s/he took VA1 to a medical dispensary for “CBD pens” as VA1 was allowed to have them, and the SP used them for “headaches.” The SP gave inconsistent answers if s/he purchased his/her own CBD pens while there with VA1.

· The SP was not trained on any policy in regards vulnerable adults being at his/her home. The SP said s/he was out with VA1, VA2, and P4 when the SP’s child called. VA1 was “insistent” s/he wanted to see the SP’s child. The group went to the home and the SP went inside the home to “grab money” for “three seconds” and came out. The SP denied s/he asked the others there is s/he smelled like marijuana and if s/he did smell like marijuana it was because his/her child uses it.

· The SP denied there was any exchange of money between VA1 and him/herself for a vape pen. The SP said the text messages that there was going to be payment was “just to say something to get [VA1] off my back. The SP denied s/he purchased any THC vape pen from California or gave any to VA1. The SP said the SO used THC and marijuana pens and “buys [VA1] stuff.” The SP said the SO gave pens and marijuana to VA1 “many times” and the SP told P2 about it. The SP denied s/he used marijuana with the SP and VA1.

· The SP used his/her CBD pen at work in his/her personal vehicle “one time” due to anxiety and a migraine as s/he had “no choice.” The SP denied there was any THC in his/her CBD pens. The SP said when s/he was at the camp with VA1, VA1 used CBD and not THC. The SP said s/he “never brought mine [vape pend]” on van rides. The SP denied at any time s/he shared his/her CBD vape pen with VA1 or used marijuana with the either VA1 or VA2 at the facility or in the community.

· The SP was aware of VA2’s chemical use from his/her preadmission paperwork, went on walks with VA2, and talked about VA2’s addiction. The SP said VA2 was “trustworthy” and “did not lie.”

· The SP said VA1 was a “manipulator,” “compulsive liar,” was a “false reporter in the past,” and “trie[d] to get people in trouble.” The SP said VA1 lied about a previous sexual assault and that a staff person touched him/her. VA1 was not to have opposite gender staff with him/her as a precaution. (Note: P3 was an opposite gender staff to VA1 and worked with him/her.) The SP said VA1 had a “medical card” and was allowed to have THC and vape pens “as long as they were locked up” in the medication cabinet.

The facility Professional Boundaries training stated staff persons should not:

Accept personal favors, gifts or money from Person Served of families.

Sell items to clients or families.

Buy or trade possessions from clients !or [sic] families.

Have romantic or sexual relationship: [sic] with clients or their family members.

The facility’s Drug and Alcohol Policy signed by the SP stated:

All employees must be free from the abuse of prescription medication or being in any manner under the influence of a chemical that impairs their ability to provide services of care.

The use, sale, manufacture, distribution, or possession of illegal drugs while providing care or to persons receiving services or on our property (owned or leased), or in our vehicles, machinery, or equipment (owned or leased), will result in corrective action up to and including termination.

According to the Star Tribune What you need to know about Minnesota’s marijuana legalization law, marijuana use became legal in Minnesota on July 1, 2023, and existing criminal penalties were lifted on August 1, 2023. However, driving under the influence of marijuana remained a crime.

Facility documentation showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s Drug and Alcohol Policy and Professional Boundaries, and on VA1’s and VA2’s plans.

Minnesota Rules and/or Statutes:

Minnesota Statutes, section 342.09, subdivision 1, states in part that an individual 21 year of age or older may use or possess cannabis. (Enacted August 1, 2023)

Conclusion:

A. Maltreatment:

The SP denied using/giving marijuana to VA1 and/or VA2 and/or driving each under the influence, and VA2 denied the allegations during his/her interview. However, VA2 told P1-P3 and the CM that s/he and VA1 smoked marijuana with the SP on multiple occasions, VA1 provided the same information to P3 and during his/her interview and also stated that the SP drove after using marijuana, and the SO corroborated the accounts. Given this, that VA2 and that the SP had each had reasons to minimize their actions for fear of repercussions, it was more likely that VA1’s, the SO’s, and VA2’s accounts to P1-P3 and the CM were more accurate.

The SP was aware of VA2’s chemical addiction history, attempts to be sober, and probation status.

While marijuana use became legal in Minnesota on August 1, 2023, and existing criminal penalties were lifted, driving under the influence of marijuana remained a crime. However, the SP’s actions occurred when marijuana was illegal and therefore, encouraged VA1 and VA2 to engage in illegal activities and encouraged VA2 to violate his/her probation condition. In addition, driving under the influence of drugs placed VA1 and VA2 at significant risk of harm. Therefore, there was a preponderance of the evidence that there was a failure to supply VA1 and VA2 with reasonable and necessary care.

It was determined that 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.)

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

Facility documentation showed that the SP was trained on the facility’s Drug and Alcohol Policy and Professional Boundaries, VA1’s and VA2’s plans, and the Reporting of Maltreatment of Vulnerable Adults Act.

The SP was responsible for maltreatment of VA1 and VA2.

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 was recurring maltreatment but was not serious maltreatment. The SP gave and/or smoked marijuana on more than one occasion with VA1 and VA2. However, neither sustained an injury that required the care of a physician.

The SP was disqualified from providing direct contact services.

Action Taken by Facility:

The facility completed an internal review, and determined that policies and procedures were adequate, but not followed. The SP no longer worked at the facility.

Action Taken by Department of Human Services, Office of Inspector General:

The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.

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