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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: 1070007-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: Allegation One: It was reported that there were concerns regarding a staff person’s (SP’s) treatment of two vulnerable adults (VA1 and VA2) including restricting outings, seclusion, removing personal items, and yelling; making disparaging remarks about weight; and withholding/locking up food. Allegation Two: It was reported that the SP made purchases for VA1, but VA1 did not receive the items for the total amount of money spent and that the SP took $200 from VA2 stating VA2 owed that money to the facility for long-distance phone calls. Allegation Three: It was reported that VA2 had a toothache for two months and the SP did not make an appointment for him/her. Date of Incident(s): Ongoing, prior to December 27, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b); and Minnesota Statutes, section 626.5572, subdivision 15; subdivision 2, paragraph (b), clauses (2-4); subdivision 9, paragraph (b), clause (1); 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. · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and
· Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. 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 during a site visit conducted on March 22, 2024: from documentation at the facility and law enforcement records; and through 12 interviews conducted with a supervisory staff person (P1), five staff persons (P2-P6), one administrative staff person (P7), VA1’s and VA2’s case managers (CM1 and CM2 respectively), VA1’s guardian (G), and the SP. Attempts were made via phone and email to interview an additional staff person (P8), but P8 did not respond to the requests. VA1 was unable to provide information due to his/her diagnoses. This investigator met VA2 at his/her new residence. VA2 provided minimal information due to his/her diagnoses and requested to end the interview before it was completed. In early January 2024, the facility temporarily closed its services due to inadequate staffing. Subsequently, VA1 and VA2 moved to different residences operated by the same license holder. The facility reopened in July 2024 but VA1 and VA2 did not move in. VA1 was diagnosed with profound intellectual disabilities, autism, and epilepsy. VA1’s Coordinated Service and Support Plan Addendum Summary, stated VA1 received 24-hour residential services that supported him/her with activities of daily living, household management, community integration, quality of life, and supportive safety needs. VA1 received 1:1 staffing up to 30 hours a week. VA1 enjoyed when staff persons gave him/her choices for the day and preferred a “quiet home.” VA1 liked to be “active and on the move” and it was important for VA1 to be involved in the activities around his/her home, including caring for it—especially things that needed to be done outside. VA2 was diagnosed with mild intellectual disabilities and anxiety disorder and was not subject to guardianship. VA2 loved to draw, scrapbook, go out for ice cream, shopping, and van rides. The facility’s personnel files showed that P1, P5, P6, and the SP were trained on VA1’s and VA2’s plans. P2 was trained on VA1’s plans. P1-P7, and the SP were trained Reporting of Maltreatment of Vulnerable Adults Act. The facility did not have records to show P2, P3, and P4 were trained on VA2’s plans or that P3 and P4 were trained on VA1’s plans which was a violation of Minnesota Statutes, section 245D.095, subdivision 5 which states in part that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, and training that includes orientation to individual service recipient needs. P7’s position at the facility did not require him/her to be trained on VA1’s or VA2’s plans. Information obtained showed that there was interpersonal conflict between the SP and P2-P4. Allegation One: It was reported that there were concerns regarding a staff person’s (SP’s) treatment of two vulnerable adults (VA1 and VA2) including restricting outings, seclusion, removing personal items, and yelling; making disparaging remarks about weight; and withholding/locking up food. VA1’s plans stated that VA1 picked activities to do/be involved in in his/her community such as shopping, out to eat, movies, walks, picnics in the park, church, etc. The desired outcome for that was at least once a week. VA1 liked staff persons to plan outings and explain where s/he was going if s/he was leaving his/her residence. Regarding the SP restricting outings, seclusion, removing personal items, and yelling: P2 and an email P2 sent to P7 provided the following information: · On December 15, 2023, P2 emailed P7 about concerns s/he had with the SP’s interactions with VA1 and VA2. VA1 and VA2 “couldn’t go places” but additional details were not provided. The SP “often” sent VA1 and VA2 to his/her bedrooms “like little kids.” · The SP used VA2’s iPad as a “punishment/reward thing” such as if VA2 did not do something the SP wanted him/her to do, the SP took the iPad or iPad charger away from VA2. Additionally, on an unknown date, the SP took away VA2’s fan in his/her bedroom because VA2 had broken a different fan. · On an unknown date, the SP yelled at VA1, “What are you doing? You don’t need to do that,” as VA1 opened a cupboard. This resulted in VA1 being “timid” around the SP. On another unknown date, the SP yelled at VA1 to stop adjusting staff’s shirts. · P2 heard the SP yell at VA2 about “two to three times a week.” On an unknown date, VA2 called the SP an “idiot,” and the SP “yelled” at VA2 that s/he needed to go to his/her room if s/he was going to “talk like that.” On another unknown date, the SP yelled at VA2 to shower and to “get away” from VA1 because s/he was sitting too close to him/her. VA2 appeared “scared” and apologized “profusely” and said s/he wanted to move out of the facility. P4 provided the following information: · The SP was “mean” and “treated” VA1 and VA2 “really bad.” · On an unknown date in December 2023, VA2 asked if s/he could “go for a ride in town” and P4 wanted to take him/her to see Christmas lights. However, the SP told P4 that they could not go because VA2 “already went out” to his/her doctor appointment earlier that day. P4 did not consider that an “outing.” · The SP “constantly” took away VA2’s iPad because s/he “wanted to be in control” of charging it. When P4 worked, s/he gave it to VA2. P4 talked to P1 about the concern and after that, the iPad was not taken away. However, the SP then took the charger and locked it in the medication drawer. · On an unknown date, either at the end of November 2023 or beginning of December 2023, the SP “snapped” at VA2 and asked VA2 when that last time s/he took a shower was and made a comment about his/her hair looking “greasy” and told VA2 to “go wash [his/her] hair.” On an unknown date in December 2023, VA2 started to touch the SP’s hand, and the SP said to VA2, “Don’t you touch me,” and “Wash your hands.” P4 stated the SP had not said that to VA2 prior to that incident or again afterwards. · P4 talked to P1 about his/her concerns with the SP and also sent an email regarding them to P7. P3 said s/he was concerned with how the SP treated VA1 and VA2 and that the SP “bullied” them by telling them to “sit down” or “stay” on the couch. When P3 brought up her concerns to the SP, the SP said that was how s/he treated his/her own children. Additionally, the SP took VA2’s iPad or iPad cord as “punishment.” P3 could not remember specific dates or times the instances occurred. P6 said s/he had no concerns with the SP but heard from other staff persons that the SP was “very up front” with staff persons; however, the SP was not that way with VA1 or VA2. P6 had no concerns with how the SP treated VA1 or VA2 and said that the SP “always made sure” that if they wanted something, they had it. There were a “couple [of] times” the SP said, “No,” but that was only when VA1 or VA2 wanted to do something they had already done such as go for a drive or a walk and would ask again within a short timeframe. VA2 liked to listen to staff conversations during shift overlaps regarding VA1, so often time staff suggested VA2 go to his/her room to watch TV or color during that time. P6 had no concerns of VA2 being secluded to his/her room, but said VA2 spent a lot of time in his/her room by his/her “own choice.” P6 stated s/he did not see/hear of VA2’s iPad being taken away from him/her. P6 heard of a time when VA2’s fan in his/her room broke, so it was taken out of his/her room for safety reasons. When the SP talked to VA1 or VA2 s/he “was very nice” and “respectful” and always gave them “choices.” P6 had no concerns with staff persons, including the SP, yelling at VA1 or VA2. However, sometimes staff persons yelled from the laundry room asking if there was any dirty laundry. P5 said VA2 had an iPad and the charger for it was kept on the staff desk, but VA2 kept the iPad in his/her room. The SP was sometimes “short” with VA2 in the way s/he communicated to him/her, but P5 never saw/heard any staff persons tell VA1 or VA2 to go to their rooms. P1 said that s/he was aware of P2’s, P3’s and P4’s concerns regarding the SP’s interactions and P7 was going to address the concerns. The facility had been short staffed requiring shift changes, which P2-P4 were “not happy” about. P1 saw the SP at the facility at least one to two times a week and did not have any concerns with the SP. P1 never saw/heard the SP yell at VA1 or VA2 and said that both clients were “always happy” and wanted to talk to the SP. P7 and the Internal Review written and conducted by P7 provided the following information: · Facility documentation showed VA1 and VA2 had the ability to choose where they wanted to go during the day and had options presented to them. The only time outings were limited was when the facility vehicle was getting repaired which P7 thought it was in November 2023). The facility did not require staff persons to use their personal vehicles to transport clients. The license holder also had other houses in the area where a vehicle could be borrowed if needed. Facility documentation showed that VA1 and VA2 were taken on outings such as driving around a lake, going out to eat, or attending community events. · Concerns of the SP taking away VA2’s personal items such as his/her iPad/cord and fan as well as “punishing” VA2 to his/her room were addressed with the SP and the SP said when VA2 demonstrated maladaptive behaviors including yelling, throwing items, self-harm, pounding his/her fists, or property destruction, VA2 was encouraged to be in his/her room to calm so s/he was not risk for harming other individuals. Additionally, when VA2 exhibited behaviors, items were removed from his/her path to avoid being thrown or broken. VA2 chose to keep his/her iPad and cord in the cabinet in the kitchen and enjoyed having it on the counter when s/he watched his/her shows or listened to music. One time a fan was removed from VA2’s bedroom when VA2 attempted to throw it; however, it was replaced when VA2 asked for it back as s/he used it for sleeping. · VA2 told P7 that s/he “did not think” that any personal items including his/her iPad were taken away and stated that s/he “loved” the SP and “got along with [the SP] well.” VA2 also told P7 that the SP did not yell at him/her or put him/her in a “timeout.” · When P7 visited the facility, s/he did not see/hear any concerns and did not have any concerns with the SP. The SP was a “very black and white” type of person and “very factual.” P7 thought there was interpersonal conflict between the SP and some of the staff persons at the facility because of that. The SP provided the following information in combination with a law enforcement officer (LEO): · The facility tried to do outings for VA1 and VA2, but at times was hard due to a staff shortage. However, VA1 and VA2 went on a lot of vehicles “rides.” One staff person came to the facility once a week to take VA1 and VA2 out, but in October or November 2023, that person no longer worked at the facility. The SP was concerned about the lack of outings and “wished” VA1 and VA2 got out more. · P2- P4 thought that the SP was “targeting” him/her because P2-P4 were not “doing their job,” “got in trouble” for med errors, and had “no call, no shows” which the SP told P1 about. According to the SP, they had an SP “hate club going on.” · VA2 liked to spend time in his/her room but was not told s/he had to go there, and the SP denied ever telling VA2 s/he had to go to his/her room. · VA2 had an iPad and kept the charging cord for it in a cupboard outside of his/her bedroom. The cupboard was not locked and VA2 wanted to keep it int there to “keep it safe” so s/he would not lose it. The SP did not know of any times the iPad was taken away from VA2. VA2 had a fan in his/her room that belonged to the facility and on an unknown date, VA2 threw it, so the SP removed the fan from VA2’s bedroom. · The SP stated s/he had a “tone” sometimes but that it was “just me” with a “[parent] voice.” The SP denied yelling at VA1 or VA2 and stated VA2 needed communication to be “direct” and “stern.” VA2 tried to find “the weakest link” in staff persons and knew s/he could not do that with the SP. Summary: Although P2-P4 had concerns regarding the SP’s treatment and care towards VA1 and VA2 including restricting outings, seclusion, removing personal items, and yelling, given that P1, P7, P5, and P6, had no concerns regarding the allegations listed above; that the SP denied the allegations; and that there was interpersonal conflict between the SP and P2-P4, there was not a preponderance of the evidence whether the SP engaged in adverse treatment or care of VA1 and/or VA2. Regarding the SP making disparaging remarks about weight: P2 said that the SP talked “openly” in front of VA1 and VA2 about VA2’s weight and how VA2 gained weight since moving to the facility. On December 15, 2023, P2 emailed P7 about the SP “body shaming” VA2. P2 stated the SP “belittled” VA2 regarding his/her weight and told VA2 that s/he could not have certain items like chips because VA2 needed to “watch [his/her] weight.” When those comments were made, VA2 said nothing, but gave “blank looks.” VA2 looked “sad” and “constantly” asked P2 if s/he looked “fat.” P3 said that sometime between late October and December 2023, multiple times per week the SP talked about VA2’s weight and said that VA2 should not have candy because s/he was “fat.” The SP made the remarks to P3 in the common area of the facility, but not directly to VA2. Additionally, the SP refused to let VA1 or VA2 have seconds with their meals because they did not “need” it. P4 did not provide information regarding the SP making remarks about VA2’s weight, but said s/he thought VA2’s doctor said s/he was overweight and said for VA2 to “watch [his/her] weight.” P5 said s/he never heard any staff person comment about VA2’s weight such as being fat; however, VA2 said that about him/herself. On an unknown date, P5 heard an unnamed staff person (not the SP) tell VA2 s/he needed to go for a walk if s/he did not want to be “fat.” P7 and the Internal Review written and conducted by P7 provided the following information: · Unnamed staff persons told facility management that the SP “body shamed” VA2 on “almost a daily basis” and told VA2 that s/he was “fat” and did not need “anything extra” to eat. The “body-shaming” became “so severe” that VA2 started asking staff persons if s/he was “fat.” · P7 said that VA2 gained some weight when s/he moved into the facility so staff persons were to encourage VA2 to choose healthy food options. VA2 ate and then an hour later want to eat another meal. There was a “fear” VA2 would get sick and at times P7 overheard staff persons suggest something small to eat or tell VA2 maybe s/he was not really hungry. · VA2 told P7 that his/her doctor talked about his/her weight and that VA2 needed to eat “healthier meals,” but that the SP did not “shame” VA2 for his/her body. VA2 said s/he “loved” the SP and “got along with [him/her] well.” The SP provided the following information during his/her interview, to law enforcement, and in facility documentation: · On December 28, 2023, the SP wrote in an electronic log that VA2 came out of his/her room and asked the SP if s/he thought VA2 was “fat.” The SP asked VA2, “Where that came from?” and VA2 said his/her family member “called [him/her] fat all the time” and that it “hurts [VA2’s] feelings.” The SP told VA2 that “even if [VA2] was [fat], we are working on [that],” and that it was “not nice to say” and the family member should not have said that. VA2 then gave the SP a hug and said, “Thank you.” · The SP said that weight was a “big thing” to VA2, because s/he had recently gained weight. The SP denied telling VA2 s/he was overweight or calling VA2 fat. Summary: P2 and P3 each had concerns with the SP “body shaming” VA2 about his/her weight. However, given that P2 and P3 each stated that although the SP said comments in front of VA2, it was not said to VA2; that VA2 told P7 that the SP did not “shame” him/her for his/her body, that s/he “loved” and “got along” with the SP; that there was interpersonal conflict between the SP and P2-P3; and that the SP denied telling VA2 s/he was overweight or calling him/her “fat,” there was not a preponderance of the evidence whether the SP spoke about VA2’s weight in a disparaging way to VA2. Regarding the SP withholding/locking up food: VA2 said that staff persons at the facility made the meals and that the meals were “good.” Snacks were kept at the facility but locked up by the SP in the pantry. However, if VA2 wanted a snack, s/he asked a staff person, and they would give it to him/her. VA2 did not know if there was ever a time when s/he wanted a snack that staff persons told him/her that s/he could not have one. VA2 said that the SP was a “cool” staff person and did not provide additional information or concerns regarding the SP. P2 and an email P2 sent to P7 provided consistent information that VA1 and VA2 were on a “strict eating schedule” and staff persons could only cook what the SP told them to. During December 2023, VA1 and VA2 “never had snacks” and were not “allowed” seconds for meals. The SP also “locked up” bread inside a kitchen drawer and put cereal “out of reach.” The SP told staff persons that VA2 could not have bread unless it was with a meal but VA2 typically did not ask for bread “out of the blue.” The key to unlock the drawer was kept nearby in the kitchen. P3 said that the SP locked bread and chips inside a drawer at the facility because VA2 “stole” it. “Almost daily,” VA2 asked for bread or chips, but P3 was trained to tell VA2, “No,” because s/he was “heavy.” The clients “were supposed” to get snacks, but when P3 worked at the facility, they got three meals a day and one serving at each. P3 also stated that s/he made cookies and would offer clients a “bedtime” snack. P1 said that there was a drawer/cupboard at the facility where the snacks were kept and sometimes VA2 ate half a loaf of bread before dinner. Because of this, at some point snacks were locked up, but VA2 had access to and was able to get the key and get snacks whenever s/he wanted. The purpose of locking the snacks was “just a step” to “slow [VA2] down” because s/he would “have four sandwiches down in a minute and a half.” P1 asked the SP about the allegation of withholding food and the SP told P1 about the drawer of snacks and denied withholding food from the clients and did not know of a time when it would have happened. They key was kept “right on the counter.” P4 said there was popcorn “hidden” on the top shelf in the kitchen labeled for movie nights. On unknown date in December 2023, P4 suggested that they do a movie night with popcorn. Even though VA2 had no dietary restrictions to popcorn, the SP said they could not have it because VA1 was unable to due to his/her dental problems. P4 suggested other snacks for the SP to purchase that VA1 was able to eat, but the SP “refused” to buy them. Additionally, P4 said that the SP put cheese in the freezer, locked up bread, and said VA1 and VA2 “weren’t allowed to have seconds” after meals. The bread was locked up in a drawer in the kitchen, but there was a key nearby. P4 thought VA2 could probably use the key and open the drawer, but P4 never saw VA2 do so and instead P4 unlocked the drawer for VA2 if s/he wanted something. P5 said food was “comfort” for VA2 and sometimes when VA2 was “bored” s/he wanted to eat even after s/he had a full meal. P5 encouraged activities for VA2 such as a walk outside, coloring, or workout videos. The SP locked up bread and “snacky foods” in a desk drawer so VA2 “didn’t just grab them.” There was a key to unlock the drawer that staff had access to, and the key was usually just sitting on the desk. The SP wanted staff persons to “limit” the number of snacks VA2 consumed and said s/he could have one snack after lunch and one snack after supper. VA2 could have access to the key, but P5 did not think s/he knew how to unlock the drawer. P5 was not concerned that VA1 or VA2 were not getting adequate nutrition and P5 gave “decent” portion sizes when s/he worked and gave seconds “within reason.” P6 said that fruit was put on top of the refrigerator because VA2 would eat it all and then there would not be any for VA1; however, there was also other fruit available/not on top of the fridge for VA1 and VA2 to eat. VA2 told P6 that s/he felt like there was a “big hole” in his/her stomach and s/he “always” felt hungry. VA2 had a tendency to eat a lot of chips in one sitting so those kinds of snacks and bread were locked in a drawer in the staff desk. The key for the drawer was next to a staff computer and VA2 saw staff persons use the key “multiple times.” P7 and the Internal Review written and conducted by P7 provided the following information: · P7 was not aware of any food restrictions for VA2, or food being locked up. When VA2 moved into the facility, s/he gained weight because after VA2 ate a meal, an hour later s/he wanted another one. staff persons encouraged VA2 to eat “proper portion sizes” along with making healthy snack choices. VA2’s food of choice was “never withheld.” · VA2 told P7 that his/her doctor talked about his/her weight and that s/he needed to eat “healthier meals.” VA2 told P7 and P1 that staff persons did not restrict his/her food and VA2 would be able to say something if s/he was. The SP provided the following information during his/her interview and to law enforcement: · P5 made the menus and asked VA1 and VA2 what they liked, but they seemed to “like everything.” VA2 had no restrictions on what s/he could or could not eat. Bread was “locked up” because at times, VA2 tried to eat an entire loaf at once, so having it locked up “slowed” him/her down. The key was kept in an open space which VA2 knew where and how to use it and at no point did VA2 not have access to the key. · The SP tried to “limit” seconds to meals because VA2 after VA2’s family member told VA2 that s/he was fat, the SP asked VA2 if s/he wanted to lose weight, and VA2 said that s/he did. However, food was not restricted and staff persons did not say that VA2 could not have them, it would just be a “smaller portion” if there were extra portions available after a meal. Summary: Although there were concerns that the SP withheld and locked up food from VA2, information showed that VA2 wanted to excessively eat even after s/he had a meal and the key was kept in an open space nearby for which VA2 had access to it and either VA2 was able to use the key to get the food or staff persons gave it to him/her. Therefore, there was not a preponderance of the evidence that food was withheld from VA2. Conclusion Allegation One: Although P2-P4 had concerns regarding how the SP treated and cared for VA1 and VA2 at the facility, as stated above in the summaries, there was not a preponderance of the evidence that the SP engaged in adverse treatment or care of VA1 and/or VA2, whether the SP spoke about VA2’s weight in a disparaging way to VA2, or whether food was withheld from VA2. It was not determined whether emotional abuse, adverse deprivation, or neglect 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; Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and/or Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. 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). Allegation Two: It was reported that the SP made purchases for VA1, but VA1 did not receive the items for the total amount of money spent and that the SP took $200 from VA2 stating VA2 owed that money to the facility for long distance phone calls. Regarding the SP making purchases for VA1, but VA1 did not receive the items for the total amount of money spent: VA1’s Coordinated Service and Support Plan Addendum Summary, stated VA1 received services that supported him/her with money management and budgeting. VA1’s Individual Abuse Prevention Plan stated that VA1 was susceptible to financial exploitation and had an “inability to handle financial matters.” VA1 did not “recognize” the value of money and could easily be subject to financial exploitation. Staff persons helped VA1 with all financial transactions and kept records of all the transactions according to the facility’s policy. Staff persons were trained on “financials” upon hire and annually thereafter. P2 said that in December 2023, the SP purchased “all this stuff” for VA1 but was concerned that it was not documented in VA1’s books. CM1 said that sometime in October 2023, CM1 told the SP that VA1 needed to spenddown money in his/her account and the SP and P1 were responsible for the spenddown. On December 18, 2023, CM1 visited the facility and talked to P1 and the SP and approved purchasing an iPad for VA1, which CM1 later received a statement for showing the iPad was purchased on December 20, 2023, for $690.37. CM1 had no concerns of where/how VA1’s money was spent. P1 said VA1 had to spenddown his/her money and purchased clothes from Kohls and items for use outside. P1 had no concerns of how VA1’s money was spent and the facility had receipts for the items purchased and everything was accounted for. P6 was aware of the spenddown from the SP. P6 stated that around December 20, 2023, the SP purchased an iPad for VA1, and staff persons also went shopping for other “necessities” such as new bedding, pillows, sheets, and a foot bath. Fidget toys and magnetic building blocks were also purchased and VA1 had a “full day” going out and doing things such as getting a haircut. P6 had no concerns with how VA1’s money/spend down was spent/managed and no concerns with the SP’s accounting of purchases or items for VA1. P3 said that sometime between late October and December 2023, P3 saw a few big purchases made for VA1 which included a new bedding (comforter and sheets), towels, clothing, and a Wii. P4 stated VA1 purchased a tablet. P5 did not have information on specifics items purchased but said that s/he had no concerns with how the SP managed VA1’s finances/purchases.
The G did not have concerns regarding VA1’s financial matters. P7 and the Internal Review written and conducted by P7 stated that that VA1was “over assets” and was required to spenddown his/her money. P1 and the SP oversaw VA1’s personal money and receipts were kept for purchases. After financial audits, assessing VA1’s personal belongings, and reviewing receipts, the items purchased for VA1’s spenddown were all accounted for and P7 had no concerns about how VA1’s finances were handled at the facility. The SP told this investigator and law enforcement that around October or November 2023, VA1 had close to $4,000 in his/her account but could not have over $3,000 in order to keep his/her insurance. At that time, CM1 told the facility that VA1’s funds should be under $2,500. With input from staff persons, the SP purchased items for VA1 such as new bedding, pillows, clothes, towels, a foot massager, a Wii, things to use outside, and an iPad, all of which were documented and receipts were kept. The SP stated, “Everything was accounted for.” The law enforcement report stated there was no account of VA1 missing any money or inappropriate spending by the SP; however, “it was clear some of the business policy had not been provided as some of the receipts for the spend down were missing from the online account.” The case was closed. Regarding the SP taking $200 from VA2 stating VA2 owed that money to the facility for long-distance phone calls: VA2’s Individual Abuse Prevention Plan stated that VA2 was susceptible to financial exploitation and had an “inability to handle financial matters.” VA2 had a representative payee who helped him/her with financial tracking and the facility staff persons assisted VA2 while withdrawing personal cash. P2 said that VA2 owed the facility $200 or $300 for long-distance phone calls and P2 was confused as to why because s/he had never seen VA2 use the phone to call anyone. VA2’s family members always called VA2 first. P1 said VA2 had his/her own landline at the facility and VA2 was encouraged to have his/her family members call him/her instead of VA2 calling them. P4 did not have information regarding the long-distance phone calls, but said s/he heard VA2 called a family member but did not know when or for how long. P7 and the Internal Review written and conducted by P7 stated that typically clients covered the cost of their own phone calls but would also ask whoever they were calling to call them back to avoid the costs. P7 did not know how many times VA2 made calls, but VA2 called his/her family members who lived within the state but in different cities. The Internal Review stated that the VA was never required to pay $200 for long-distance phone calls and that the facility paid the phone bill. However, the cost of long-distance phone calls was discussed with VA2, and it was encouraged for him/her to call the person s/he wanted to talk to and then have that person call him/her back to help lower costs. The SP told this investigator and law enforcement that VA2 “charged up” over $200 in long-distance phone calls calling family members and was supposed to pay the license holder for the calls, but “never had the money.” After that incident, VA2 made the calls, but would have whoever s/he called, call him/her back as to avoid the charges. Conclusion Allegation Two: Although there was concern that the SP made purchases for VA1 and that VA1 did not receive the items that were purchased, given that information showed the items purchased for VA1 were accounted for via receipts and in VA1’s possession, there was a preponderance of the evidence that the SP did not willfully use, withhold, or disposes of funds or property of VA1. Although P2 said that VA2 owed the facility money for long-distance phone calls, given that the Internal Review stated the facility paid the phone bill and that if had VA2 had a phone bill it was reasonable that s/he paid it, there was a preponderance of the evidence that the SP did not willfully use, withhold, or dispose of funds of VA2. It was determined financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult.) Allegation Three: It was reported that VA2 had a toothache for two months and the SP did not make an appointment for him/her. VA2’s Coordinated Service and Support Plan Addendum Summary stated that VA2 required assistance with scheduling doctor’s appointments, and transportation to appointments. VA2’s Intensive Support Self-Management Assessment stated that VA2 did not track and/or schedule any appointments or transportation for medical, dental, or other health appointments, and required support in those areas. VA2 told staff persons if s/he needed to see a doctor or dentist due to not feeling well or an injury and told them if s/he needed to go to an emergency room. P2 said that sometime around the end of November beginning of December 2023, VA2 complained of tooth pain. P2 told the SP about it and the SP said, “Oh, [VA2] was just doing that for attention” and “brushed [it] off.” The SP also said “something” about VA2 not being subject to guardianship and that the dentist thought VA2 did not understand some information. P1 said staff persons accompanied VA2 to medical appointments but that VA2 “refused” to go the dentist. On April 4, 2023, VA2 had a consultation for general anesthesia for dental work, but because the dentist and staff person at the appointment felt that VA2 did not understand the information because VA2 was unable to repeat the information back to them, both the dentist and staff were unsure VA2 would be able to sign the consent form. On December 18, 2023, it was discussed at VA2’s annual team meeting that the county/CM2 was going to get a medical advocate for VA2. P3 did not have any information regarding VA2’s tooth pain but said VA2 had “poor dental hygiene.” The SP told P3 that VA2 “refused” to have dental work done. P4 stated that s/he did not have information regarding VA2’s tooth pain. P5 said that sometime during the end of 2022 beginning of 2023, VA2 had a “chunk” of his/her tooth “came out.” VA2 went to the dentist, but “refused” treatment and would not sign the necessary paperwork to remove his/her tooth. After that incident, VA2 complained of tooth pain from “time to time” but P5 did not know what came of it. VA previously refused dental treatment and did not want to be put under anesthesia. When VA2 complained of tooth pain, s/he was given Tylenol or ibuprofen. P6 said that in February 2023 VA2 had a “toothache” and the supervisor at the time said s/he would look into it. “After a while,” VA2 did not complain of the tooth pain anymore. When the SP took over as a supervisory staff person, P6 did not have a conversation about VA2’s dental appointments and VA2 was not complaining about the tooth pain anymore. CM2 said that the SP either made VA2’s appointments or helped VA2 make them. While VA2 lived at the facility (VA2 moved in on April 29, 2022), VA2 had an “abscess” or a “bad tooth” that bothered VA2 “off and on” and caused “some pain.” VA2 was not subject to guardianship and staff persons did not think VA2 understood the process of what needed to be done regarding dental work. On December 18, 2023, during the VA’s team meeting, there was talk of getting VA2 a “supportive decision maker.” However, at that time, VA2 was not having any “difficultly” with his/her teeth. VA2 would be able to communicate if s/he was in pain or if his/her mouth was hurting and was usually pretty “up front” with things that bothered him/her. However, CM2 also stated that VA2 might say his/her mouth/teeth hurt when they did not and that VA2 was “a bit of an attention seeker.” P7 and the Internal Review written and conducted by P7 provided the following information: · P1 and/or the SP were responsible for making VA2’s medical appointments including dental appointments. At VA2’s last dental consultation, in April 2023, the dentist said that VA2 needed general anesthesia to complete dental work/extractions. At that time, the facility had “quite a bit of turnover” in staff persons so P7 thought it might have “fallen off the radar” for getting a dental referral. · There was no documentation in VA2’s logs that VA2 complained about tooth pain. · In December 2023 at VA2’s annual meeting, VA2’s oral health was discussed. The dentist would not do “anything” since VA2 was not subject to guardianship and they did not think VA2 understood the processes. In May 2023, VA2 was referred for treatment under general anesthesia with an oral surgeon. CM2 discussed getting VA2 a guardian/advocate for medical decisions, but that did not happen prior to VA2 moving out of the facility. VA2 could make his/her own choice whether to follow through with medical advice and/or his/her dental care. Facility log notes stated that on April 3, 2023, a supervisory staff person (prior to the SP’s employment), wrote an entry stating VA2 had a dental consultation for treatment under general anesthesia. VA2 was referred to general anesthesia due to his/her “behaviors” and medical diagnoses. During the consultation, the staff person and the dentist had a “long discussion” with VA2 regarding his/her medical history and the proposed procedure along with the “risks” and “complications.” The dentist staff stated that VA2 had a difficult time gibing his/her medical history and “was really unsure” if VA2 ever had surgery and/or anesthesia before so the dentist staff discussed it with VA2. According to the dentist staff, VA2 “really didn’t understand” the discussion or grasp the concept of what was being presented. VA2 was not able to repeat back to the dentist staff what was being presented or any of the risks associated with the procedure. The dentist staff was unsure that VA2 would be able to sign the consent form for anesthesia and the procedure itself. It was agreed upon that the facility staff person would reach out to CM2, regarding obtaining a guardian for VA2 to assist him/her in making these decisions and signing consent forms. The dentist discussed referrals for oral surgeons for extractions and could come back to the dentist facility after the extractions were completed and VA2’s guardianship status was updated. The SP told this investigator and law enforcement that s/he oversaw VA2’s medical appointments. However, VA2’s dental appointments were in a “stand still” because CM2 was trying to get a guardian/advocate for VA2. VA2 needed all of his/her teeth removed but when that was explained to VA2, a previous supervisory staff person did not think VA2 understood what that meant and the dentist would not do it. On occasion, staff persons told the SP that VA2 complained of tooth pain but VA2 never complained to the SP. Because VA2 was not subject to guardianship s/he was his/her own decision maker and could refuse treatment so there was not much staff person could do except administer Tylenol and/or ibuprofen. However, sometimes when VA2 said s/he had tooth pain, it was not always accurate because sometimes s/he just wanted attention. Conclusion Allegation Three: Although there was concern regarding VA2 complaining of tooth pain and the SP not addressing it with a dentist, information was consistent that VA2 was not subject to guardianship so was able to decline dental care/treatment. In addition, at the time, CM2 was working on getting a decision maker/guardian/medical advocate for VA2 because it was unclear if VA2 understood the dental forms and necessary work s/he needed. It was also unclear whether VA2 accurately reported when s/he was in pain and when VA2 did complain staff persons gave VA2 over the counter pain medicine. Therefore, there was a preponderance of the evidence that there was not a failure to supply VA2 with necessary dental care. It was determined that neglect did not occur (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 UI not the result of an accident or therapeutic conduct.) Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate and followed. Upon re-opening the facility, the facility would ensure that every staff person was fully trained on Therap (electronic documentation system), and that daily documentation would be completed. Additionally, thorough training for all staff persons would be done. Action Taken by Department of Human Services, Office of Inspector General: On June 13, 2025, the facility was issued a correction order for the violation outlined in this report.
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