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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: 1068505-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) took seizure medications from two vulnerable adults (VA1 and VA2) for his/her own use. During the investigation, it was also reported that the SP took clothing from VA1 and one other vulnerable adult (VA3). Date of Incident(s): August 5, 2024 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 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 eight interviews conducted with two supervisory facility staff persons (P1 and P2), two facility staff persons (P3 and P4), VA1’s, VA2’s, and VA3’s guardians (G1, G2, and G3, respectively), a law enforcement officer (LEO2), and the SP. Due to their disabilities, VA1, VA2, and VA3 were not able to provide information for this investigation. VA1 was diagnosed with a profound intellectual disability, cerebral palsy, and a seizure disorder. VA1 enjoyed going bowling, attending The Miracle League baseball games, going bowling, and attending music events or other events with crowds and activity. VA2 was diagnosed with Rett syndrome (a genetic disorder), a profound intellectual disability, scoliosis, and a seizure disorder. VA2 enjoyed being outside, using the facility sunroom, going swimming, and playing with sensory items. VA3 was diagnosed with profound intellectual disability with microcephaly, spina bifida, and spastic paraplegia. VA3 enjoyed being where the “action” was and playing on his/her keyboard. VA3 was a person who was very content and liked when people joked around with him/her. According to their plans, VA1 and VA2 were both prescribed Nayzilam 5mg nasal spray to treat seizures that lasted longer than two minutes. According to www.nayzilam.com, Nayzilam nasal spray was used to treat seizure clusters in adults. The medication was a federally controlled substance because it could be abused or lead to dependence. According to VA1’s seizure protocol, for a seizure lasting longer than two minutes, staff persons were to give Nayzilam 5mg, one spray into one nostril. If seizures continued for ten minutes following the first administration, staff persons could repeat with another dose of the spray after ten minutes and would administer a bisacodyl suppository as well. No more than three doses of Nayzilam were to be given in a 24 hour period. If a fourth dose was needed, staff persons were to call 9-1-1. One of VA1’s documents labeled “Kardex” provided by the facility stated inconsistent information regarding administering seizure medications to VA1. One area of the document stated that after ten minutes, a second dose of Nayzilam could be given while further down on the document, it stated that staff persons were to wait approximately 30 minutes after the first dose before giving the second. According to VA2’s seizure protocol, generally, seizures were well-controlled with other medications. For a seizure lasting longer than two minutes, staff persons were to give Nayzilam 5mg, one spray into one nostril with a maximum dose of two sprays in a 24-hour period. P4 provided the following information: · On August 5, 2024, P4 was scheduled to work the 10 p.m. to 6 a.m. shift. P4 had not worked for approximately two weeks. P4 generally arrived for his/her shift between 9:45 and 9:50 p.m. Facility records showed that on this day s/he punched in at 9:51 p.m. When P4 arrived, the SP was finishing his/her shift. The SP told P4 that VA1 had had two seizures, and that the facility was out of VA1’s seizure medication, so if VA1 had another seizure, P4 needed to call 9-1-1. The SP told P4 that VA1’s first seizure was at 9:30 p.m. but the SP did not tell P4 what time the second seizure occurred. The SP also told P4 that VA2 had two seizures a week prior while P4 was not working. · VA1 was sleeping when P4 arrived at the facility and VA2 was in his/her bedroom, not yet asleep, but “agitating slowly” such as crying, as s/he usually did before falling asleep. · The SP was “behaving drunk,” “going up and down” while talking, repeating him/herself, walking unsteadily, and fell over at one point. P4 asked the SP if s/he was okay, and the SP affirmed that s/he was okay. The SP was looking through clients’ books, spreading them on the table, opening drawers, and P4 asked what s/he was doing. The SP replied that s/he “just wanted to make sure everything was okay.” P4 had never seen the SP “in that mood before.” · The SP was working past the end of his/her shift and went out to the facility vehicle. P4 heard the SP honking the horn of the facility vehicle. The SP was the only one inside the vehicle. The SP told P4 that s/he was looking for the “seizure protocol” inside the vehicle. P4 told the SP that the seizure protocol would not be in the vehicle. Soon after, the SP left the facility. · P4 was “scared” that VA1 would have another seizure and moved his/her chair next to VA1’s door during the overnight shift to closely monitor VA1. When P2 arrived at the facility the next morning, P4 told P2 that they were out of the seizure medication and that the SP was behaving as if s/he was “drunk” and explained how the SP was acting. P2 asked P4 to send an email to P2 documenting how the SP had acted the night before. P4 sent the email which aligned with what was discussed in this interview. · Neither VA1 nor VA2 had a seizure during P4’s shift. Both generally would sleep through the overnight shift. It “surprised” P4 to hear that VA1 had two seizures requiring medication. The SP did not show P4 any empty Nayzilam cartridges. P3 provided the following information: · On August 5, 2024, P3 was scheduled to work at the facility from 2 to 9 p.m., but due to inclement weather, and according to facility records, s/he stayed a little later, punching out at 9:30 p.m. The SP, who was also working, told P3 that s/he could leave early, but P3 did not want to leave early due to the heavy rain. VA1 went to sleep at about 8 p.m. When P3 left the facility, all clients were in bed and P3 stated VA1 and VA2 had not had any seizures during his/her shift. · The next day, P3 learned, after reading the “T-Log” from the shift the night before that the SP documented that VA1 had two seizures. The SP said s/he dropped a pan while putting dishes away, which made a loud noise prompting VA1 to have a seizure. P3 said that s/he put the dishes away that night and not the SP. · P3 did not think that VA1 “really needed” the Nayzilam, especially twice in a short period of time because P3 left at 9:30 p.m. and knew that P4 generally arrived early, at around 9:45 to 9:50 p.m. most evenings. P3 did not think that VA1 really had a seizure due to VA1’s usual seizure patterns and due to the short period of time in which VA1 would have had to have two seizures. · VA1 had “a lot” of seizures, generally when an item was dropped on the floor or something “scared” VA1, but usually they lasted “a couple of seconds,” not to the point where VA1 needed the Nayzilam. VA2 typically only had a seizure when s/he missed a medication or received a medication late. “Never in my life” had P3 seen VA1 have two seizures in a fifteen-minute span. Only once had P3 given VA1 Nayzilam, which was in May 2024, and P3 had never given VA2 Nayzilam. P3 stated there was a “sheet” that had instructions on when to give the Nayzilam and thought that the medication was to be given after the clients had a seizure lasting more than one minute and that it was administered through the nose. · The Nayzilam was kept in an unlocked box by the medication cabinet. When documenting medication administration, staff persons were to check off a “bubble sheet” showing the date, time, and initials. When the Nayzilam expired, the facility nurse would take it and replace it with a new prescription. · Before August 5, 2024, P3 saw the SP wearing two different pairs of shorts belonging to VA1 and a tank top belonging to VA3 on different days at the facility. The clients’ clothing was marked with permanent marker on the backside and P3 observed the SP wearing items with VA1’s and VA3’s initials and items that s/he had seen VA1 and VA3 wearing before. · P3 saw the SP wearing the clothing when arriving to the facility and when leaving from the facility. Other times, the SP changed into VA1’s shorts at the facility after P2 left the facility. P3 thought the SP changed into VA1’s shorts because P2 did not allow staff persons to wear shorts while working. · P3 described the tank top as a white undershirt style tank top. P3 described the shorts as one pair being green and the other pair being dark blue or black.
P2 provided information consistent with P3 and P4 and added the following information: · VA2 had recently received a refill of the Nayzilam (one box containing two cartridges each containing one dose) from the pharmacy. On August 5, 2024, when P2 was putting them away in the medication box where they were stored, P2 saw there were three doses of nasal spray for VA1 and two existing doses for VA2. The boxes came from the pharmacy with the clients’ name on them but the individual cartridges inside did not have client names. VA1’s and VA2’s prescriptions were stored separated from one another within the medication box. VA1 had one box plus one dose for a total of three doses. · On August 6, 2024, when P2 arrived at the facility at about 5:35 a.m., P4 told P2 that they were out of all five doses of the Nayzilam. The SP told P2 that they ran out the night before after the SP gave two doses to VA1 after s/he had had two seizures. P2 checked the medication box. There was at least one empty box which had previously contained two cartridges and there were three used cartridges in the box. Both VA1’s and VA2’s cartridges were either gone or used and P2 would have had no way to know which clients’ box the empty cartridges came from other than all five were gone or used. There should have been more doses in the medication box. P2 notified his/her supervisor of the missing medications and law enforcement was contacted and went to the facility. · P2 knew that P3 stayed late until about 9:30 p.m. due to the weather and when P3 left the facility, VA1 was asleep. The SP’s shift should have ended at 10 p.m. but P2 stated that the SP left closer to midnight. · After law enforcement left the facility, P3 called and said that s/he had read the T-Log from the night before and that the SP had documented that VA1 had woken up and crawled out of bed and “went into two seizures” but at 9:30 p.m., VA1 was in bed, asleep, and P3 was leaving the facility. · When VA1 or VA2 had a seizure lasting two minutes or longer, they were to receive a dose of Nayzilam 5mg spray into one nostril. VA1 generally had seizures in the morning or around suppertime and did not have them when s/he was sleeping. VA1 sometimes had seizures when “unexpected, loud noises” occurred or sometimes they “just happened.” VA2 only had seizures when other medications were missed. · The facility nurse prematurely ordered a box containing two Nayzilam cartridges for VA1 so there were doses at the facility, but they were locked up when P2 was not at the facility and no one else knew that there were doses for VA1. If VA1 had needed the doses during the middle of the night, there would not have been a way to access them. VA1’s doses were replaced from the locked office into the medication cabinet by about 10 a.m. on August 6, 2024. VA1 did not have additional seizures requiring the medication during that time. · VA2’s medications were refilled three to four days later. VA2 was without Nayzilam for about three days and staff persons would have had to call 9-1-1 for VA2 if s/he had had a seizure during that time. VA2 did not have additional seizures requiring the medication during that time. · Staff persons were not to wear “short shorts” or tank tops that “hung low.” Staff persons were not allowed to wear clients’ clothing and P2 had not seen any staff persons wearing clients’ clothing. P1 and facility documentation provided information consistent with P2, P3, and P4 and added the following: · The SP asked P4 if s/he could notify the supervisor in the morning that they were out of the Nayzilam. · Earlier in the week, on July 31, 2024, VA2 had two seizures where the SP administered two doses of Nayzilam to VA2. P1 questioned whether VA2 actually had seizures on July 31, 2024, because VA2 did not have seizures often. However, VA1 had seizures “pretty often.” · P1 was not aware of either VA1 or VA2 needing the medication and not being able to have access to it but “it could have happened.” Information from law enforcement (LE) showed: · On August 6, 2024, a law enforcement officer (LEO1) responded to the report of a theft at the facility’s address. Upon arrival, LEO1 spoke with P2 who told LEO1 that when s/he arrived at the facility on the morning of August 5, 2024, there were five doses of Nayzilam; three were prescribed to VA2 and two were prescribed to VA1. They were stored in the medicine container. LEO1 was told that those five doses of Nayzilam were “stolen” at some point on the night of August 5, 2024, because there were no doses left. There were records of two of the doses being used on VA1, but that back-to-back seizures for VA1 were “unlikely.” There was no documentation for VA2’s three doses being used. · According to P2, the SP had been “acting differently” and it appeared as though s/he had been “under the influence of something” when s/he arrived to work at about 2 p.m. · LEO1 requested that LEO2 respond with him/her to the SP’s residence to speak with the SP. LEO2 interviewed the SP who initially denied taking the medication, saying that there were not five doses in the medication box at the start of his/her shift, but then admitted to taking five doses of nasal spray and using two of them. The SP provided LEO2 with four of the used canisters. The packaging for two of the canisters showed the name of VA2. The individual canisters were not labeled with a name. The SP was then arrested. · The total value of the five doses were in the range of $1,700 to $2,000 with a two-pack costing $815.20. The SP provided the following information: · On August 5, 2024, the SP arrived to work at the facility at around 2 p.m. The SP had been feeling “stressed out” when s/he arrived at the facility and felt like s/he had mental health symptoms which were making him/her feel “drunk” and “impulsive.” Two of the clients at the facility used Nayzilam as a seizure “rescue” medication so the SP took a “few of the doses.” · VA1 had two seizures that night and the SP gave VA1 two doses of Nayzilam. The SP “messed up the documentation” of the times of the seizures, s/he realized. The SP documented that the seizures occurred at 9:30 p.m. and a little after 10 p.m., but actually, the seizures occurred at a little after 8:30 p.m. and a little after 9 p.m. · P3 was working with the SP that evening and the clients were in bed by 8 p.m. P3 was able to leave earlier that night. VA1 “crawled out of bed” and had the first seizure at about 8:34 p.m., so the SP gave VA1 the medication at about 8:36 p.m. The SP made several phone calls to the nursing on-call phone line from the facility phone but was unable to reach anyone. The SP continued to check on VA1. At about 9:06 p.m., VA1 started having another seizure. The SP was counting and at about two minutes the SP gave VA1 another dose. The SP attempted to call the nursing line again three or four times. The SP was unsure if s/he was supposed to administer a second dose but later learned that s/he was supposed to administer a second dose. The SP thought that VA1’s seizure protocol stated that if staff persons had to administer more than two doses, they were to call 9-1-1 if they could not get a hold of anyone on the nurse line. The SP was “panicking.” The SP wasn’t sure if there needed to be thirty minutes between doses but didn’t think there was. · After “all this happened,” and the SP knew that VA1 was “okay” and in bed, the SP used the other three doses for him/herself between 9:30 p.m. and 10 p.m. Things were “fuzzy” at that point. · P4 arrived at around 9:40 p.m. The SP was scheduled to work until 10 p.m. but punched out closer to 10:30 p.m. The SP stayed late because s/he had to document the seizures, get everyone settled after administering the medication, and wanted to finish cleaning. The SP thought that P3 did the dishes that night but said that maybe the SP “finished up” any extra dirty dishes. · The SP heard that P4 thought that s/he had been acting “drunk” and the SP agreed that it was a “side effect” of having mental health symptoms. · The SP thought s/he threw away the two empty cartridges given to VA1. The SP gave one empty prescription box and three empty cartridges to law enforcement when they talked to him/her and arrested him/her the next morning. · The SP felt “bad about the whole situation,” and said there was, “no excuse.” · VA1 had seizures almost every day but generally they did not last more than two minutes. The SP had seen them last “very close” to two minutes but had never witnessed one longer than two minutes. · The SP previously had administered Nayzilam to VA2, about a week prior. The SP called the nurse line because s/he thought that VA2 had not had a seizure in decades and had never seen VA2 have one. The SP heard a banging sound and went to check on VA2, who was seizing, and his/her head was hitting the bed frame. The SP gave one dose to VA2 and two doses to VA1 and those were the only three doses the SP could recall giving in the time that s/he had worked at the facility. · The SP denied taking any Nayzilam for him/herself on any other dates. The SP stated that each time that s/he documented giving a client medication, that s/he did in fact, give the client that medication. The SP felt “really bad” and did not know why s/he took the medication. · The SP had not thought about the fact that if the SP had taken the medication, it left VA1 without any additional doses and thought maybe s/he thought that VA1 could not be administered any more doses that day. · The SP denied taking any clients’ clothing home but stated that s/he wore client’s shorts while working at the facility because P2 told him/her to change his/her shorts. The SP changed back into his/her own shorts before leaving the facility. The SP might have put the clothing in his/her work locker so that they could get washed. The SP stated that no one at the facility wore tank top style shirts and denied wearing a client’s tank top. Facility T-Logs showed that the SP created two logs; one for each of VA1’s seizures at 9:47 and 10:28 p.m. They read: · [VA1] crawled out on bed at 9:25 p.m., checked for a void or [bowel movement,] none present. [VA1] was making [his/her] way to the couch. Staff was finishing dishes and dropped a heavy pan, which triggered a seizure. Seizure was at [two] minutes, classic drop seizure, and administered Nayzilam, due to seizure protocol in care plan. [VA1] was lifted back in bed, and fell sleep shortly after. Recorded in [electronic medication administration record] and paper copy. Monitoring [VA1] in bed currently at 9:41 p.m. . . . See seizure report. · [VA1] crawled out on bed, and was making [his/her] way to the couch. Was finishing dishes and dropped a heavy pan, which triggered a seizure. Seizure was at [two] minutes and administered Nayzilam. Fill and follow up. [VA1] was lifted back in bed. [Ten] minutes later went to check on [VA1] and [VA1] had fallen into another seizure, followed protocol after [ten] minutes and added another Nayzilam. If [VA1] had one more dose [s/he] will [require] medical attention. Pleas[e] Call 911 of [VA1] had anymore. G1 provided the following information: · G1 was told that VA1’s seizure medication “disappeared” during the evening shift and it was found the next morning. As far as G1 knew, VA1 did not need the medication during the time that the medication was missing. · VA1 usually had “light” seizures that typically did not last very long. They could occur as often as daily, and “for sure weekly.” Medication was not administered very often, probably about twice per year. G2 stated that VA2 was “non-verbal” and would not be able to relay any information. The facility’s records showed that on August 5, 2024, the SP was scheduled from 2 to 10 p.m., and punched out at 10:48 p.m. VA1’s MAR, which was entered by the SP, was inconsistent with the SP’s documentation. The SP documented that the SP administered one dose of Nayzilam at 9:30 p.m. and the second at 9:45 p.m. VA1’s seizure history showed that the seizures were documented to have occurred at 9:31 and at 10:02 p.m., both for several seconds over two minutes. The most recent date prior to August 5, 2024, that VA1 had a seizure lasting longer than two minutes and needed Nayzilam administered was on May 3, 2023. According to P4, s/he had not seen any staff person, including the SP wearing VA1 or VA3’s clothing but was aware that there was a marking on the clients’ clothing indicating whom it belonged to. G3 was not aware of any staff persons taking or using VA3’s clothing. All staff persons interviewed for this investigation were trained in the Reporting of Maltreatment of Vulnerable Adults Act and the clients’ plans. Conclusion: A. Maltreatment: Information showed that on August 5, 20254, the SP told LE that s/he took and used five doses of Nayzilam belonging to VA1 and VA2. On August 5, 2024, that left VA1 and VA2 without any seizure medications if they were to have a seizure and need medication. In addition, P3 stated that s/he saw the SP wear and take home VA1’s and VA3’s clothing. Regarding VA1’s and VA3’s clothes: Although P3 saw the SP wear VA1’s and VA3’s clothes to the facility, change into VA1’s and VA3’s clothing at the facility, and leave with VA1’s and VA3’s clothing on, given that the SP denied doing so, and that there was no further information regarding the SP taking and or keeping VA1’s and VA3’s clothes, there was not a preponderance of the evidence whether the SP used, withheld, or disposed of VA1’s or VA3’s property in the absence of legal authority. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Regarding VA1’s and VA2’s Nayzilam: However, given that the SP told both LE and this investigator that s/he took and used Nayzilam belonging to VA1 and VA2, there was a preponderance of the evidence that the SP willfully used VA1’s and VA2’s property without legal authority. It was determined that financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Although VA1 and VA2 did not have medication available if they needed it because the SP took the remaining doses, given that neither VA1 or VA2 had another seizure requiring Nayzilam, that VA1 and VA2 were not harmed, and that staff persons could have called 9-1-1 in the event of a seizure, there was not a preponderance of the evidence whether there was a failure to provide VA1 and VA2 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). 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. The SP was trained on the Reporting of Vulnerable Adults Act. The SP was responsible for financial exploitation 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 maltreatment for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because the SP took Nayzilam from VA1 and VA2 on the same occasion so was considered to be a single incident and VA1 and VA2 were not injured. Action Taken by Facility: Regarding the medication, the facility’s Internal Review showed that policies and procedures were adequate but not followed. There was not a need for additional staff person training and the incident was not similar to past incidents. The SP no longer worked at the facility. Regarding the clothing, the facility’s Internal Review showed that policies and procedures were adequate but were not followed. There was not a need for additional staff training and the incident was not similar to past incidents. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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