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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: 1072313-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) provided a vulnerable adult (VA) with a marijuana vape pen, and snorted a medication with the VA. Date of Incident(s): On-going since August 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 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 17, 2024; from documentation at the facility and through eight interviews conducted with the VA, two facility supervisors (P1-P2), two residential facility supervisors (P3-P4), the VA’s case manager (CM), the VA’s guardian (G), and the SP. Facility documentation showed the VA valued his/her family, friends, and cultural background. The VA enjoyed playing video games, hunting, fishing, and working out. The VA worked in the community with job coaching services provided by the facility. The VA was diagnosed with adjustment disorder with mixed anxiety and depressive mood, impulse disorder, generalized anxiety disorder, alcohol induced psychotic disorder with delusions, fetal alcohol syndrome, and borderline personality disorder. The VA’s Support Plan Addendum Outcomes and Supports showed job coaches would provide the VA with cues and support per his/her job coaching form and preferred positive supports. Job coaches would not assist the VA with his job duties, but they would provide quality assurance, encouragement, and cues/reminders as needed. The VA was transported to and from work by a facility staff person. The VA’s Intensive Support Self-Management Assessment showed the VA was aware of the importance of his/her sobriety, and substance use worsened his/her mental health symptoms. The VA’s Individual Abuse Prevention Plan (IAPP) showed s/he was suspectable to all forms of abuse. The VA also had a history of substance use, and his/her actions while under the influence had placed him/her at risk. The VA’s “Client & Job Placement Information” showed the following: · The VA was working on recovery from substance use, and recently struggled with relapsing due to co-workers smoking or vaping indoors. · The VA actively tried to avoid situations with substances, and staff persons should support the VA. The VA was triggered by the smell associated with drugs or work areas that contained paraphernalia. · Staff persons were instructed to document and report events in which the VA attempted to “covertly use marijuana or THC.” The VA’s Support Plan provided the following information: · The VA had a goal to maintain sobriety, and refrain from using drugs so that s/he could work toward community independence and manage his/her mental health appropriately. · The VA’s marijuana use may put him/her at risk for losing his/her housing, job, independence in the community, or cause a decline in his/her mental health. The VA was aware of the risks and consequences of using substances and not maintaining his/her sobriety. The facility completed an Incident Report on January 3, 2025, after the VA communicated concerns the SP provided the VA with marijuana. The VA was hospitalized due to self-injurious behaviors by the time the facility was aware of the concerns. Prior to the hospitalization the VA provided his/her residential facility a vape pen which the VA said the SP had given him/her. The SP denied the accusation that s/he provided the VA with marijuana and the vape pen. P1 and P2 provided the following information which was consistent: · The SP started working with the VA in the spring of 2024, and there were no concerns with the VA and the SP’s work relationship prior to January 1, 2025. Additionally, the SP worked with other vulnerable adults, and there were no concerns with the SP and those persons served. · The SP did not communicate any concerns related to the VA using any substances while the SP provided care and services. · P1 received a text message from the VA on or around January 1, 2025, and the VA stated the SP had providing him/her with “substances” for the past five months. The VA stated s/he went “home high every Friday,” after the SP worked with the VA. · P1 discussed the concern with P4, and found out the VA said the SP gave him/her vape pen and a small bag of marijuana. The VA provided those to the residential facility, and the VA also shared information that a medication (Adderall) was also potentially used while the SP worked with the VA. P3 and P4 provided the following information: · P3 said the VA provided him/her with marijuana and a vape pen, and the VA said the SP provided those items to the VA. The VA also told P3, the SP grew his/her own marijuana, and the SP and VA got “high” every Friday. Furthermore, the VA said s/he met the SP in the community to get additional marijuana. · The VA also said the SP took crushed medication while working with the VA, and the SP had a history of smoking methamphetamine. (It was unclear whether or not the methamphetamine use was during a time the SP was working with the VA.) · P3 and P4 did not observe any change in the VA’s behavior upon returning home from work, and there were minimal behaviors indicators the VA had been using any substances prior to an incident on January 1, 2025. P3 and P4 said the VA’s mental health symptoms were affected by his/her substance use. · P3 and P4 said the VA had his/her own cell phone, and unsupervised time in the community. · P4 said the color/design of the vape pen was not consistent with other items the VA would buy. · P4 said the VA had previously obtained substances while working, but there was no information that was from the SP. · P3 and P4 spoke with the VA separately, and the VA provided consistent information related to alleged incident. P5 said although the SP initially denied the allegations, the SP reached out to P5 on January 16, 2025, and provided additional information regarding the VA using marijuana. P5 requested the SP complete a written statement as the SP indicated s/he was aware of the VA’s substance use, and there were other boundary issues between the SP and the VA, but the SP maintained s/he had not provided the VA with any substances. The SP did not provide P5 a written statement prior to the SP’s employment ending. The VA provided the following information: · The VA said over the past six months the SP had provided him/her marijuana, and recently gave him/her a vape pen. The VA said s/he smoked marijuana with the SP every Friday after work while the SP transported him/her back to the residential facility. The VA added that on at least one occasion the VA and the SP were “high” while working. The VA estimated s/he had smoked marijuana with the SP more than ten times, and the SP had provided the VA with small containers of marijuana. Additionally, the VA said the SP took mediations, and offered them to the VA, but the VA declined to take the medication. The VA said the SP knew the VA’s history with substance use. · The VA described other boundary issues with the SP, including exchanging text messages, and meeting the SP outside of work hours. The VA added that the SP sent the VA a video of an apartment that had a marijuana grow. The VA deleted the video and was unable to provide it to this investigator. · On or around January 1, 2025, the VA told the SP that s/he was going to tell P1 about the substance use with the SP. The SP responded that s/he would deny it “to the day I die.” The VA added that s/he was struggling with his/her mental health around January 1, 2025, and had also called the SP some names. The SP provided the following information: · The SP said s/he was aware of the VA’s history with substance use as it was included in the VA’s client specific documents, and the VA and the SP discussed the VA’s substance use. · The SP denied providing the VA with marijuana, medications, and drug paraphernalia, but said the VA saw the SP take his/her prescribed medications. The SP also denied the VA smoking in the SP’s vehicle, but said s/he was aware the VA used marijuana while at the job site. However, later in the interview the SP stated s/he was unsure if s/he shared a vape pen with the VA while transporting the VA. Before stating s/he was unsure, the SP said s/he was “nervous,” and felt “like I'm not thinking straight,” and continued on to say that s/he had “barely slept, I haven't eaten. I'm just stressed out.” · The SP said there were professional boundaries that s/he had crossed with the VA including discussing the SP’s marijuana use, sending the VA a picture of marijuana plants at a neighbor’s house, meeting the VA at a gas station outside of work hours, and other conversations in which the SP acted like a friend to the VA. The SP said those conversations were in-person, text messages, and social media. Additionally, the SP said the VA sent two pictures of his/her genitals to the SP, and the SP did not inform the facility. The SP was not sure why s/he had shared the picture of the marijuana plants with the VA. The SP said s/he met the VA at the gas station as the VA wanted to return the SP’s “food container or plastic container.” · The SP said the VA went to Arizona to visit family, and purchased marijuana and edibles, but the SP did not inform the facility. · The SP said s/he erased all the text messages from the VA after the VA called the SP names. The SP said s/he was embarrassed, and that was why s/he did not provide the information to the facility. The facility’s Drug and Alcohol Policy stated: · The workplace was free from the effects of drugs, alcohol, chemicals, and abuse of prescription medications. The policy applies to all of our employees, subcontractors, and volunteers (employees). · The consumption of alcohol or cannabis is prohibited while directly responsible for persons receiving services. · The use, sale, manufacture, distribution, or possession of illegal drugs while providing care or to persons receiving services would result in corrective action. P1, P2, and SP completed training on the VA’s client specific information, the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s policies and procedures. Conclusion: A. Maltreatment: The VA’s client specific programming showed s/he had history of substance use, and the VA was transported to and from his/her job by staff persons, including the SP. The VA had an increase of mental health symptoms around January 1, 2025, and was hospitalized due to SIB. The VA said over the past six months the SP had provided him/her marijuana, and they smoked marijuana every Friday when the SP transported the VA to his/her residential facility. The VA added that the SP provided the VA with a container of marijuana and a vape pen. The VA provided the vape pen and marijuana to P3. Additionally, the VA said on at least one occasion the VA and the SP were “high” while working. The VA described other professional boundaries that the SP crossed, including, but not limited to communicating outside of work hours, and sending the VA a video of marijuana plants. There were no other persons interviewed that observed the VA and SP smoke marijuana together, or observed the VA have any significant behavioral changes on Fridays. However, the VA informed P3-P4 of the alleged marijuana use, and the information P3-P4 provided was consistent with the information the VA provided this investigator. The SP said s/he was aware of the VA substance use, and initially denied any wrongdoing. However, later the SP disclosed that s/he crossed professional boundaries with the VA, and described multiple concerning interactions with the VA. The SP did not inform the facility about the concerning interactions, including the VA smoking marijuana while at work, or the VA sending pictures of his/her genitals to the SP. During the SP’s interview, the SP admitted to deleting all of the text messages exchanged with the VA, that s/he was was aware of the VA’s marijuana use and did not inform the facility. The SP also said s/he unsure if s/he shared a vape pen with the VA while transporting the VA. Although the SP denied giving the VA marijuana, given that the VA provided consistent information to several people that the SP gave the VA marijuana and a vape, that the SP at first denied the allegations but then said s/he had boundary issues with the VA and was not sure if s/he shared his/her vape with the VA, that the VA had a history of substance use and was working toward recovery, and that staff persons were to support the VA with recovery, there was a preponderance of evidence that the SP failed to provide the VA with reasonable and necessary care and services. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s client specific programming, and the facility’s Drug and Alcohol Policy. The SP was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not serious maltreatment because it did not meet the definition but was “recurring” maltreatment because the VA stated the SP supplied the VA with marijuana on multiple occasions. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility took corrective action to ensure the safety of the individuals that received services. The report was not similar to past events, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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