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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: 1005657-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA) and they married while the VA was receiving services. Date of Incident(s): Unknown prior to February 24, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c); and subdivision 17, paragraph (a): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 April 14, 2025; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisory staff person (P1), and three staff persons (P2, P3, and P4). Attempts were made to contact and interview the SP. This investigator spoke to the SP who at that time declined to provide information and wanted to obtain legal counsel. The SP did not respond to subsequent requests for an interview. The license holder provided a broad spectrum of treatment and recovery programs that assisted persons to gain freedom from chemical addiction that included outpatient, residential, and long-term recovery. The Department of Human Services (DHS) has jurisdiction for maltreatment investigations in the residential program and in outpatient programs only when a person was deemed a vulnerable adult. The VA’s diagnoses included cocaine, alcohol, and cannabis dependence. The VA received residential services between September 27 and November 26, 2024, when s/he then began receiving outpatient services. The Vulnerable Adult Determination stated that as of November 26, 2024, the VA was not determined to be a vulnerable adult. On February 24, 2025, the VA discharged “against staff advice.” The DHS therefore only had jurisdiction for incidents that occurred when the VA was receiving residential services between September 27 and November 26, 2024. The VA’s Individual Abuse Prevention Plan said that the VA had a history of emotional, verbal, sexual, and physical abuse. There were “no specific measures” to minimize the risk but the VA said that s/he had received therapy for the “abuse.” The VA’s CD Discharge Summary dated November 26, 2024, said that the VA had “reported” prior relapses due to “getting into a relationship and losing focus.” The Program Abuse Prevention Plan said that the facility had multiple cameras. However, there were areas not monitored including a chapel, cafeteria, offices, group rooms, and client bedrooms. P1 and text messages and photos from the SP to P1 provided the following information: · On February 26, 2025, (two days after the VA discharged) the SP stopped working at the facility. On April 4, 2025, the SP sent P1 a text message of a photo of him/herself wearing a wedding ring and said that s/he needed to tell P1 something “off the record” that s/he was “married” but not to “tell anyone.” P1 then called the SP who told P1 that s/he was married to the VA. The SP then sent a photo of him/herself with the VA and the SP’s family. P1 was in “shock” and asked the SP when s/he and the VA began dating and the SP said, “after we got married,” which P1 found “odd” and said, “Normally, you date first and then get married.” The SP also told P1 that s/he “did not want to live in sin anymore” but did not provide additional information regarding that. · The SP worked in both the residential and outpatient programs. Based on documentation, the SP worked with the VA seven times while the VA was in the in-patient program and two times while in the outpatient program. P1 and the SP shared an office so P1 saw the SP interacting with clients including the VA. P1 had no concerns with the SP’s interactions with any clients, including the VA. · Staff persons were trained not to be in a “relationship” with a client for two years after the client left the facility. The VA denied that s/he was in a relationship and then declined to provide any additional information stating that s/he “did not want to be a part of no gossip.” P2, P3, and P4 provided the following information: · P2, P3, and P4 did not have any concerns with staff persons interactions with the VA, including the SP. However, P3 said that after s/he became aware of the incident, P3 looked at documentation and saw that the SP met with the VA a total of nine times which was “excessive.” P3 was in the same role as the SP and said that the most s/he met with a client was five times. · P2 said that the VA “mentioned” having a significant other but P2 did not know the person’s name, including if it was a staff person. P4 said that the VA told him/her that s/he “struggled finding [him/her] self” at the facility because s/he was not getting any “physical or emotional connections” from others due to being in a “program with 70 other [persons of the VA’s same gender].” The VA told P4 that s/he “enjoyed” relationships and often “found [him/herself] getting into new ones if one had ended.” P4 said that the VA was interested in the facility “sexual sobriety group” which focused on using “sex or intimate relationships” in a “healthy way” instead of “masking” any trauma. · P3 said that the VA and the SP did not know one another prior to the facility. · P2, P3, and P4 each said that staff persons were trained not to have a sexual relationship with a client. The VA’s and the SP’s marriage license was public information online and showed that the SP and the VA were married on February 14, 2025. The Staff/Client Relationship Policy said that all staff persons must maintain professional boundaries with clients. This included that staff persons must not develop close personal relationships with current clients. Relationships with clients must be maintained at the level of a “role model and guide.” Staff persons were not permitted to have personal conversations with clients unless it was required in the performance of their job. Sexual, flirtatious, or romantic interactions or relationships were never permitted with any current client. Facility documentation showed that the SP, P1, P2, P3, and P4 were trained on the Staff/Client Relationship Policy and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information obtained showed that that the SP and the VA married while the VA was a client receiving outpatient services at the facility and the SP worked at the facility with the VA which was inconsistent with the standards of a professional caregiver in facility licensed by the Department of Human Services. However, given that the Vulnerable Adult Determination stated that as of November 26, 2024, the VA was not determined to be a vulnerable adult, the Department of Human Services only had jurisdiction when the VA received in-patient residential services between September 27 and November 26, 2024. Although it was most likely that during the time the VA was receiving inpatient services, the VA and the SP began developing a non-therapeutic relationship, no staff persons observed any concerns with the SP’s interactions with the VA. In addition, the SP and the VA each declined to provide information for this report. Therefore, without additional information regarding how and when the relationship started, there was not a preponderance of the evidence whether the SP had sexual contact with the VA or whether there was a failure to provide reasonable and necessary care and services to the VA while the VA was receiving inpatient services. It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast). It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed, including because the facility was not made aware of the concerns until after the incident and then took appropriate actions, including reporting. The SP no longer worked at the facility. The incident was not similar to prior incidents. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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