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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: 1096289-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person’s (SP’s) conduct toward vulnerable adults (VA1, VA2, and VA3), included “speaking unprofessional,” calling names, and yelling. It was also reported that the SP did not provide adequate supervision for VA1, VA2, and VA3. Date of Incident(s): Ongoing
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 (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 June 10, 2024; from documentation at the facility; and through interviews conducted with VA1, VA1’s family member (FM), VA1’s case manager (CM1), VA1’s and VA2’s guardian (G1), VA2, VA2’s case manager (CM2), VA3, VA3’s guardian (G2) who was also VA3’s family member, VA3’s case manager (CM3), VA3’s social worker (SW), facility staff persons (the SP and P1), and supervisory staff persons (P2 and P3). This investigator attempted to interview a facility housemate (H); however, s/he was difficult to understand and did not respond in an intelligible manner. The H did not have an alternative communication device. A supervisor told this investigator that the H’s communication was “very limited;” “[The H] struggles to get things out;” and “We can only communicate on certain things.” The H did not provide information for this investigation. VA1, VA2, VA3, and the H lived together at the facility, which was a single-family home. The facility provided at least one staff person 24 hours a day for care and supervision. VA1’s support plans included the following: · In February 2020, VA1 moved into the facility seeking supports and services relating to his/her diagnoses, which included bipolar disorder, persistent mood disorder, borderline personality disorder, and reactive attachment disorder. · VA1 liked fashion and art. VA1 wanted to live on his/her own someday. · VA1 could be unsupervised at home for up to three hours and in the community for one hour. · VA1 sometimes struggled with “acting confrontational towards others,” which might provoke a reaction from others. “[VA1] has a history of creating drama with others in an attempt to get attention from others. [VA1] has a history of learning personal facts about others, then using those facts in an attempt to ‘hurt’ the other person which can be very provoking … [VA1] has a history of false reporting or reporting distorted situations when [s/he] is unhappy with a staff or having behaviors.” VA1 would not be able to protect him/her if others became aggressive towards him/her. Staff observed VA1’s interactions and modeled positive social interactions. Staff intervened in potentially abusive situations and reported suspected or known abuse on VA1’s behalf. VA2’s support plans included the following: · In September 2022, VA2 moved into the facility seeking supports and services relating to his/her diagnoses, which included generalized anxiety disorder and attention deficit hyperactivity disorder. · VA2 liked to be outside, listen to music, and garden. “[VA2’s] ultimate goal is to live independently.” · VA2 could be unsupervised in the community for one hour. · VA2 did not have a history of being susceptible to abuse from others. · VA2 sometimes struggled with “taking responsibility for [his/her] actions.” VA2 did this “by creating issues with a peer or reporting a false issue, in order to take the focus off of [him/herself].” Staff encouraged VA2 to talk through his/her concerns. “Staff will be direct with [VA2] in order to allow less room for [VA2] to manipulate … Staff will listen and be aware of what [VA2] is saying and attempt to redirect [VA2] when [s/he] is targeting [his/her] peers.” VA3’s support plans included the following: · In March 2024, VA3 moved into the facility seeking supports and services relating to his/her diagnoses, which included traumatic brain injury, impulsive disorder, bipolar disorder, and schizoaffective disorder. · VA3 liked to play cards and games and go for walks. · VA3 could not be unsupervised at home or in the community. A staff always remained with him/her. · At times, VA3 struggled with managing his/her physical and/or verbal aggression, which might provoke a reaction from others. Staff always modeled positive interactions and intervened in potentially abusive situations. The facility’s Internal Review stated, “On 5/9/24, [VA2] called [P3] to ask who was bringing [him/her] to work. [VA2] also stated that [the SP] was being ‘mean’ to [him/her]. [P3] called [the SP] … [The SP] began to raise their voice [and said that VA2] shouldn't be calling [P3] or anyone else for rides. [The SP] said, ‘That is why they do not listen to me because they know they can call you or other staff … 5 minutes later, [P3 and P2] received videos from [VA1] of [the SP] yelling and degrading [VA2].” VA2 provided the following information: · On May 9, 2024, the SP was the sole staff person at the facility with VA1, VA2, and VA3; the H was not home. · VA2 called P3 asking about transportation to his/her job that day. VA2 worked in the community and always needed a ride to and from work. VA2 typically called P3, who would then find a staff person to drive him/her. VA2 believed the SP was aware of this arrangement. · However, when the SP found out that VA2 made a call, the SP “went off on me for no reason … all hell broke loose.” The SP said, “You know I’m staff and I’m going to do it.” VA2 told the SP, “Stop talking like this. Lower your voice down.” VA1 was present for the start of this interaction but left to another room and recorded the interaction using his/her cellphone. · VA2 said that whenever the SP worked, there was “tension in the air.” · The SP treated VA1, VA2, and VA3 like “kids” and said things like, “If you were adults, you wouldn’t be in this place. You guys are just kids.” These statements made VA2 feel “bad.” VA2 did not hear the SP call the housemates any other names or swear at the housemates. · The SP cooked meals for VA1, VA2, and VA3, but only when they had “good behavior.” Otherwise, the SP declined to cook for them. · The SP gave VA1, VA2, and VA3 rides to places, but “every time” stopped along the way to run his/her own errands. One time, the SP brought them to the county jail where s/he went inside to visit someone for about 30 minutes leaving VA2, and possibly VA1 and/or VA3, waiting in the van. Another time, the SP went into the bank while VA2, and possibly VA1 and/or VA3, waited in the van for 20 to 40 minutes. The SP sometimes bought the housemates a soda or something else if they remained “quiet” (did not tell a supervisor) about the SP stopping for his/her own errands. · The SP’s driving was “bad” and “outrageous.” The SP drove “fast” and turned the music volume loud so that s/he could not hear the housemates talking. The SP was “rude about it.” · VA2, and possibly VA1 and/or VA3, told P2 and P3 about their concerns with the SP’s conduct, but nothing was done. Instead, P2 and P3 said they needed “concrete proof” before they acted, which prompted VA1’s recording of the SP and VA2 on May 9, 2024. Three recordings of an interaction between the SP and VA2, included the following:
VA1 provided the following information: · The SP’s statements, as heard on the recordings, happened “many times,” not just May 9, 2024. One time, while in the living room, VA1 told the SP to stop talking to him/her and the SP “got up in my face,” with his/her hands raised. VA1 backed away and left the area. The SP did not touch VA1 during this instance but was “really rude.” · The SP called VA1, “bitch,” “whore,” and “fat,” and said the same things to VA2 and VA3. The SP said these things “over and over again, every single day.” The SP made VA1 feel “not really good.” · The SP gave VA1, VA2, VA3, and the H rides to outings and appointments, but only when a supervisor was present at the house. When the SP was the sole staff, s/he refused to drive them to outings and appointments. One time when the SP took them out in the van, s/he brought them to the county jail to visit the SP’s significant other. VA1, and possibly VA2 and/or VA3, sat in the van for around one hour while the SP was inside the jail. · VA1 did not want to live at the facility because “everyone was mean to each other.” VA3 provided the following information: · The SP was “really rude” and “mean.” The SP “yelled” at VA3 and called him/her “bitch” and “baby.” This happened “every day.” The SP once called G2, “bitch.” If VA3 asked for something, like a soda, the SP “wouldn’t do it” but if VA3 pressed the matter, the SP would say, “Stop being a baby. I’m getting it. Damn it.” This made VA3 “mad” and like s/he wanted to punch the SP. · VA3 heard the SP act “mean” to VA2 and say things like, “I’m not here to be friends with you. I’m here to work and I don’t care if you get a ride.” · One time, VA3 saw the SP yell at VA1 in the living room. The SP “got closer” to VA1 and flipped an ottoman “on purpose” striking VA1’s ankle. · The SP talked on his/her cellphone while driving and drove “too fast.” The SP almost got into an auto accident with VA3 and possibly VA2 present. The SP swerved in time to avoid striking another vehicle and almost ran over a curb. This happened twice when VA3 was in the van. The FM heard the recordings captured by VA1. The FM said that if the SP spoke to him/her like what was heard on the recordings, “I would cry.” VA1 did not like the facility and wanted to move closer to the FM. G2 provided the following information: · VA3 told G2 that the SP told VA3, “You’re nothing but a bitch and [G2] is too … If you think you’re going to get me fired, they (supervisory staff persons) don’t believe what you say.” · G2 believed that if VA1 had not recorded the SP’s statements (on May 9, 2024), the facility might have “swept it under the carpet.” G2 was concerned that it took recording a staff person in order for the facility to act. · VA3 told G2 that the SP used his/her cellphone while driving, which made VA3 “nervous” and “really anxious.” CM3 said that VA3 “complained” about the SP in the past, including that the SP declined to make lunch and did not give choices for community outings. An unknown staff person told CM3 that VA1 and VA2 convinced VA3 not to like the SP and, “[VA3] wasn’t giving [the SP] a fair chance.” CM3 was new to VA3’s interdisciplinary team and was not familiar with VA3’s ability to provide accurate information about situations or the SP’s conduct. “[VA3] does have negative interactions with staff, not just [the SP].” G1 said that VA1 and VA2 each had “complaints about the staff.” However, G1 added, “I don’t always get accurate information from the clients.” The facility was not always responsive and did not routinely provide incident reports. G1 wanted to be better informed by the facility of the goings on. CM1 heard the recordings captured by VA1. “It was not okay what [the SP] was saying to [VA1]. It wasn’t the worst thing I’ve seen, I guess, too.” VA1 had a history of not always liking staff and having “complaints” about staff. “This isn’t the first time … [VA1] is kind of someone who cries wolf a lot but now [s/he’s] been better about recording things.” The facility was “usually” responsive to concerns. CM1 did not have concerns with the facility’s overall care and supervision. CM2 said that VA2 was “very honest,” but had a history of “blaming others” and not always taking responsibility for his/her own actions. The facility was “very responsive” to concerns. CM2 did not have concerns with the facility’s overall care and supervision. The SW said that on May 8, 2024, VA3 called on speakerphone with VA1 also present. “[VA1] would say something that happened and [VA3] would remember it after [VA1] had said it.” During this conversation, VA1 and VA3 said that the SP swore at them, called them “bitch,” and said, “bad things” about G2; and told VA3, “You can’t get a [boy/girlfriend] because you have no hands.” The SW was not aware of VA3 having a history of making such statements about staff conduct. VA1 and VA3 also told the SW that P1 was present when the SP said these things and was “laughing,” but not intervening. P2 and P3 provided the following information: · In March 2024, the SP began working at the facility. Around that time, VA1 told P2 that the SP “talked meanly” to the housemates and did not take the housemates out or give them rides. At that time, P2 met with the SP. The SP told P2 that s/he “gets mad” if the housemates called other staff for rides. P2 reminded the SP of his/her job duties. The SP “took the feedback.” P2 was not aware, or informed, of other concerns regarding the SP’s conduct until VA1’s recordings on May 9, 2024. · VA2 once told P3 that the SP “yelled” and was “mean.” “[VA3 also] has said something along the lines that [the SP] does yell.” P3 added, “[The SP] does have a louder voice and has a stern voice and is very, kind of, to the point.” · On May 9, 2024, the SP called P3. The SP was “upset” because VA2 called a staff, from a different house, to bring him/her to work. The SP said, “I’m the staff.” The SP believed that VA2 should ask the SP for a ride before reaching out to someone else. The SP said, “That is why they do not listen to me because they know they can call you or [P2].” P3 reminded the SP that the housemates could call anyone they wanted. The SP seemed to “calm down” and the call ended. However, about five minutes later, VA1 sent P2 the recordings. · P2 and P3 listened to the recordings and identified those speaking as the SP and VA2. P2 said, “[The SP] was upset with [VA2]. [The SP] was raising [his/her] voice at [VA2] and belittling [VA2].” P3 was “distraught” by what s/he heard on the recordings. · P2 and P3 went to the facility and met with the SP in the staff office. P2 asked the SP, “When you were talking to [VA2] about the ride, were you talking to [him/her] like I am talking to you right now?” [Note: P2 demonstrated to this investigator by speaking in an even tone at conversational volume.] The SP responded to P2’s question, “Yes.” P2 then said, “Would it surprise you if there were recordings of you belittling and raising your voice?” The SP did not respond to the question, but instead, stood up, verbally ended his/her own employment, and left the facility. · P2 and P3 each said that they were not aware, or informed, of any times when the SP called the housemates names, like, “bitch,” or any times the SP made comments about VA3’s hands. · P2 and P3 each said that VA1, VA2, and VA3 had a history of providing inaccurate information “usually” about staff. P2 could not recall examples. P3 said, “There is a very extensive history with [VA1], and with [VA3]. When [VA3] came to us, [G2] said that there is a history of falsifying with [VA3]. We have noticed some.” VA1’s and VA3’s “falsified information” included that about themselves and about staff. P1 provided the following information: · P1 said that s/he was “absolutely not” present at any time when the SP swore at VA1, VA2, and/or VA3. P1 “never” heard the SP call them “bitch,” and/or tell VA3, “You can’t get a [boy/girlfriend] because you have no hands.” · The SP was “very straight forward.” If a housemate stole something from another housemate, the SP called it out and was “head on about it.” “You stole this and need to return it.” · P1 “never” heard the SP swear at VA1, VA2, and/or VA3. One time, VA1 told P1 that the SP called him/her “bitch.” When P1 asked the SP about this, the SP denied calling VA1 “bitch.” Instead, the SP said that VA1 said, “Bitch,” and the SP responded that it was not okay to say “bitch,” “I didn’t call [VA1] bitch, but I said it to [him/her].” · P1 said, “[VA1, VA2, and VA3] will band together if they want something. Lie on staff. Spreading rumors.” VA1, VA2, and VA3 only seemed to like each other when they had a mutual goal; otherwise, they did not typically get along. “That house became a high school.” · VA1 was “very manipulative.” “[VA1] is good at getting [VA2 and VA3] onboard with [him/her]. [VA1] will make stuff up” about staff. · VA2 and VA3 each had a history of not always providing accurate information. Staff had to “communicate purposefully” with one another to prevent staff-splitting.
The SP provided the following information: · The SP listened to the recordings captured by VA1. In response, the SP said, “Volume-wise, that was not appropriate at all to be using that tone of voice. I can definitely take accountability there.” “It was my intention to get [VA2] to work on time and let [him/her] know that I want to take responsibility for that … I don’t want [VA2] to stress about it.” · The SP was not scheduled to work at the facility on the day of the recordings, May 9, 2024. The SP had already submitted his/her “two-week notice” to end his/her employment, which was pending. However, P3 asked the SP to work, and the SP agreed to “help out.” · At the time of the recording, the H was not yet home from work. The H typically was dropped off by bus after work at 2 p.m. and needed a staff person to meet him/her outside due to his/her risk of falling. VA2 needed a ride to work about ten minutes prior to 3 p.m. However, VA2 had a history of becoming stressed about transportation and trying to go to work early, which his/her job had previously told the facility was not allowed. At the time of the recordings, VA2 was trying to go to work early and had called other houses/staff requesting a ride. These other houses/staff did not know VA2’s history and were calling the SP asking what was going on and why the SP could not drive VA2. The SP planned to drive VA2; however, the SP was the sole staff person and needed to be there for the H when s/he arrived and also needed to not leave VA3 home alone. VA3 did not have unsupervised time at the facility. The SP was trying to figure out these logistics during the timeframe of the recordings. · The SP repeatedly text messaged and called P3 asking if a second staff was coming in that day but P3 was not responding. However, P3 was responding to VA2’s text messages. The SP felt “frustrated” and “really, really overwhelmed.” “Nobody is communicating with me.” · The SP typically was the sole staff person during his/her shifts, despite being told there should be a second staff. Prior to May 9, 2024, the SP expressed concerns to P2 and P3 about needing a second staff person at the house. This was not only to help with the housemates, but also to protect the SP from being accused of wrongdoing by VA1. “I just started noticing little things [VA1] would do or [VA1] would tell [VA2] to do, and there’s no cameras. There’s no witness … [The housemates] pick up on that. You know, I’m new and I’m alone, and I probably don’t know what to do and they’re calling other people, and it was just a lot.” “There was no way for me to protect myself or prove anything.” The SP wrote daily notes on the housemates’ activities and behaviors, but there were no other staff to witness the interactions or the SP’s conduct. · “[VA1, VA2, and/or VA3] would definitely do things to get a reaction out of you.” One time, one of the housemates called “management” and said the SP declined to give them lunch but, the SP was sitting right there, and they just had lunch. “You literally just ate, and then you’re calling management right in front of me to tell them I didn’t feed you. So, every day, I had to write in my notes what I made them for lunch.” P2 and/or P3 never called the SP or asked for the SP’s account. “You just believe anything [VA1, VA2, and/or VA3] says.” · VA1, VA2, and VA3 were “a gang.” They “made reports on staff” and “created storylines to see what power they could get.” VA2 and VA3 “were followers of” VA1. “[VA1] would influence them. Especially when [VA1] wanted something done. [S/he] would have them help.” VA1, VA2, and VA3 “targeted” the SP. The SP looked like a former staff, who the housemates did not like. · The SP did not call the housemates names. “I don’t use profanity. It’s a professional environment.” The SP went into work with a “positive attitude” and hoped that his/her attitude influenced the housemates’ attitudes. “I went in with the attitude I wanted to receive back from them.” · The SP never made a statement about VA3 not being able to get a boy/girlfriend because s/he did not have hands. This was not true. While the SP worked at the house, VA2 “already had” a boy/girlfriend. · The SP “never” ran his/her own errands with VA1, VA2, and/or VA3 present. “They have never been with me while I ran personal errands.” The SP did not visit anyone at the county jail with the housemates in the car. VA1 was talking to someone who was in jail and the SP told VA1, “Be careful.” · The SP said s/he was “not trained” and s/he did not shadow other staff on the job to learn about the job. The SP saw P3 signing off on his/her training checklists, but this was for training the SP did not receive. “I wasn’t trained on the floor with [the housemates]. I was barely introduced to them.” Facility documentation stated that the SP, P1, and P2 received training on VA1’s, VA2’s, and VA3’s support plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), states, in relevant part, that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion: Regarding alleged emotional abuse: VA1 said that the SP called him/her, “bitch,” “whore,” and “fat” “over and over again, every single day.” VA3 said that the SP called him/her, “bitch” and “baby” “every day;” and told G2 the same. VA2 said that the SP called them “kids,” but did not hear the SP call any person names or swear at them. On May 9, 2024, VA1 recorded an interaction between the SP and VA2. The recordings were provided for this investigation. The SP’s voice was raised and continued to increase as s/he talked to VA2. At one point, VA2 told the SP to lower his/her “fucking voice,” and the SP responded, “No the fuck I won’t.” The SP also said, “I don’t give a damn.” The SP did not say things, like “bitch, whore, baby,” etc. P2 described the SP, on the recording, as raising his/her voice and “belittling” VA2. P3 was “distraught” by the recordings. The SP’s interaction with VA2 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). The SW said that when VA3 called him/her about concerns with the SP, VA1 was also present on the call. VA1 and VA3 said that the SP swore at them and called them “bitch,” and that P1 was present for these statements. However, P1 denied being present and did not hear the SP swear or name-call. Instead, P1 told this investigator that VA1-VA3 had a history of “banding together” and “making stuff up” or “lies on staff.” CM1 heard the recordings and said, “It was not okay what [the SP] was saying to [VA1]. It wasn’t the worst thing I’ve seen, I guess, too.” VA1 had a history of not always liking staff and having “complaints” about staff. “This isn’t the first time … [VA1] is kind of someone who cries wolf a lot but now [s/he’s] been better about recording things.” G1 said, “I don’t always get accurate information from [VA1 and/or VA3].” CM3 was new to working with VA3 and was not familiar with VA3’s ability to provide accurate information. CM2 said that VA2 was “very honest,” but had a history of “blaming others” and not always taking responsibility for his/her own actions. P2 and P3 each said that VA1, VA2, and VA3 had a history of providing inaccurate information “usually” about staff. VA1’s support plans stated, “[VA1] has a history of false reporting or reporting distorted situations when [s/he] is unhappy with a staff or having behaviors.” VA2’s support plans stated that s/he had a history of “reporting a false issue.” The SP denied name-calling and swearing at the housemates and said that VA1-VA3 were “a gang.” VA2 and VA3 followed VA1, who was “manipulative” and “targeted” the SP. Regarding the recordings on May 9, 2024, the SP said, “Volume-wise, that was not appropriate at all to be using that tone of voice. I can definitely take accountability there.” Although VA1, VA2, and VA3 provided consistent information regarding the SP’s verbal interactions, they each had some history of providing inaccurate information in the past. VA1 said that the SP called him/her, “bitch,” “whore,” and “fat,” and said the same things to VA2 and VA3. VA3 said that the SP called him/her, “bitch” and “baby.” VA2 did not hear the SP call anyone names, other than “kids.” The recording of the SP’s interaction with VA2 showed the SP in a heightened state but yet did not show the SP name-calling, despite VA1 and VA3 saying the name-calling happened, “every day” or “over and over again, every single day.” However, given the concerns regarding VA1’s-VA3’s credibility and without additional witnesses to support their accounts, there was not a preponderance of the evidence whether the SP’s conduct was repeated and produced or could reasonably be expected to produce emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Regarding alleged neglect: VA1 and VA2 each said that the SP ran his/her own errands while on outings with the housemates including stopping at a county jail and a bank while the SP went inside and left them in the vehicle. VA2 and VA3 each said that the SP drove “fast” and/or used his/her cellphone while driving. VA3 said that twice the SP almost got into an auto accident with VA3 in the van. Although VA1 and VA2 each said that the SP brought them on his/her own errands while in the community and left them in the car, VA1 and VA2 were allowed to be unsupervised in the community and there was no information of any harm because of this conduct. The SP also denied the allegations and there were no other witnesses to support either account. There was also no information that VA3, who was not allowed to be unsupervised in the community, was left in the van unsupervised. In addition, although concerns were raised regarding the SP’s driving, there was no information of any harm or any auto collision as a result. Therefore, there was not a preponderance of the evidence whether the SP’s conduct included a failure to supply VA1, VA2, and/or VA3 with care or services, which were reasonable and necessary to maintain their physical or mental 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 and determined that policies and procedures were adequate but not followed. The SP’s statements in the recordings were not consistent with the facility’s expectations for staff conduct. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 11, 2024, the facility was issued a correction order for the violation outlined in this report.
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