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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.”
Investigator(s): Samantha Wueste/Scout Peterson 651-431-6578 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA1) while VA1 was receiving services at the facility. Allegation Two: It was reported that the SP had a sexual relationship with a vulnerable adult (VA2) while VA2 was receiving services at the facility. Allegation Three: During the course of the investigation it was alleged that the facility did not provide supervision for the SP as required by his/her background study which resulted in the SP’s ability to develop and have inappropriate boundaries/relationships with VA1 and VA2. Date of Incident(s): Allegation One: January - February 2024 Allegation Two: July 2023 Allegation Three: December 27, 2023 – February 21, 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 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 January 4, 2025; from documentation at the facility and law enforcement records; and through ten interviews conducted with three facility supervisory staff persons (P1-P3), five staff persons (P4-P8), VA1, and VA1’s family member (FM1). Attempts were made via telephone, email, and certified mail to contact and interview the SP, however, the SP did not respond to the requests. Attempts were also made via phone and certified mail to contact VA2, however, VA2 did not respond to the requests and VA2’s probation officer (PO) stated that VA2’s whereabouts were unknown. The facility provided residential treatment for individuals seeking recovery from substance use disorders. VA1 and VA2 moved into the facility seeking supports and services related to their substance use disorder. The facility’s Staff Relationships policy “prohibited the development of personal or sexual relationships with clients during the period the client is receiving [services] or within the two-year period following the date of [discharge].” All staff persons interviewed for this investigation and the SP were trained on the facility’s Staff Relationships policy and the Reporting of Maltreatment of Vulnerable Adults Act. The facility did not provide documentation showing that the staff persons were trained on VA1’s or VA2’s treatment plans. Allegation One: It was reported that the SP had a sexual relationship with VA1 while VA1 was receiving services at the facility. VA1 moved to the facility on January 22, 2024, and was discharged on February 20, 2024. According to VA1’s Individual Abuse Prevention Plan, s/he was not susceptible to abuse in any area (sexual, physical, emotional, verbal, self, financial). VA1 provided the following consistent information during the interview and in a letter postmarked January 3, 2025: · The second week VA1 lived at the facility, the SP “made advances” on VA1. VA1 “had a feeling” that the SP was “trying to engage in something.” The SP asked VA1 questions like, “Are you single?” · The first time that the SP and VA1 kissed was in the laundry room. VA1 stated that s/he was behind a door when the SP came in. The SP “usually” came to VA1 in locations and times where there were not other people or cameras. While the SP and VA1 were in the laundry room, the SP “made a move” on VA1 and kissed VA1, but they did not touch each other’s intimate parts. · On another unknown date, the SP “approached” VA1 in his/her room and said s/he was going to help VA1 decorate his/her room. The SP then “grabbed,” “hugged,” and “kissed” VA1, but they did not touch each other’s intimate parts. · VA1 stated that other staff persons (not identified) told him/her that they “had a feeling” and “knew something was up.” VA1 also stated that other clients noticed the SP’s actions towards VA1. · On February 4, 2024, the SP told VA1 that s/he was going to call VA1 at the facility. Later when the SP called, the SP “came up with the idea” for VA1 to fake a family emergency in order to be granted a leave of absence (LOA). The SP then told VA1 what to say. VA1 stated, “I actually didn’t want to do it. Even after it was granted, I was like well let’s just leave it alone.” That night around 12:30 a.m. (February 5, 2024) FM2 called the facility and spoke to P1 while the SP and VA1 listened into the phone call. After P1 granted VA1’s LOA for three days, VA1 “clicked over” to talk to the SP. The SP stated that s/he was going to order VA1 an Uber/Lyft from the facility to his/her apartment, and then did so. VA1 left the facility around 1:30 a.m. in the Uber/Lyft and went to the SP’s apartment. · After VA1 arrived at the SP’s apartment, they had sexual intercourse “right away” and “a few times” that weekend. VA1 stated that while VA1 was at the SP’s apartment for the three days, the SP went to work one day. The SP smoked marijuana “everyday” in the presence of VA1, but VA1 did not smoke marijuana with the SP. · During VA1’s LOA, VA1 called another client (C1) at the facility who s/he had known for five years prior. VA1 told C1 “what [VA1 and the SP] were doing” and told C1 that s/he was at the SP’s residence. After the call, C1 told P1 and P2 that VA1 was at the house of a staff person, but VA1 did not know if C1 identified the SP by name. · On February 12, 2024, VA1 returned to the facility and the SP acted as s/he and VA1 were “together” and told VA1 that s/he loved VA1. P1 then moved the SP to work on a different unit until VA1 was discharged from the facility. VA1 stated that the SP was the only staff person who was moved to a different unit at the facility. · On February 20, 2025, VA1 was discharged and moved in with the SP. Later the same day, P4 and P5 each saw the SP and VA1 together in the community at separate times. VA1 thought that someone reported seeing VA1 and the SP together, because later that day the SP was fired. At that time, VA1 and the SP were still in a relationship. P4 provided the following information: · In February 2024, VA1 made up “a story” to get a LOA. After VA1 returned to the facility it was learned that VA1 was with the SP the whole time. P4 stated that the SP “struggled with boundaries” with clients and VA2 told P4 that s/he was in a relationship with the SP. (See Allegation Two.) · On February 20, 2024, the day that VA1 discharged from the facility, the SP called in sick. Later the same day, P4 saw the SP and VA1 together at the gas station “hand in hand.” The next day, P4 told P3 and P1 that s/he saw the SP and VA1 together. P1 provided the following information: · On an unknown date in 2024 (later determined to be February 9, 2024) VA1 requested a LOA from P2 because s/he had a sick family member in the hospital and his/her family was “gathering.” P2 then discussed the request with P1 and later that day, P1 and P2 met with VA1. P1 and P2 discussed the “expectations” for the LOA with VA1 and then P1 called VA1’s family member (FM2), “made arrangements” for the LOA, and explained that VA1 needed to be in a sober environment. The next morning, FM2 called the facility stating that a family member was “very sick.” P1 called FM2 who told P1 that the family was “really worried.” FM2 offered to come to the facility and pick up VA1. Around 1:00 a.m. (February 10, 2024) P1 granted VA1’s leave. P1 stated that VA1 and FM2 were told that VA1 was to return to the facility on February 12, 2024. · When VA1 returned to the facility, VA1 shared with other clients that s/he was with a staff member during the leave but did not know who. P1 interviewed staff persons, including the SP, but “didn’t have cause” and “there wasn’t anything that we could say we needed to do” because none of the staff persons said they were with VA1 over the weekend. · P1 spoke to VA1 and asked if s/he was with a staff person during his/her leave, and VA1 said the other clients and staff persons “were making it up.” · P1 stated “[the SP] was never named per say,” and that the clients named “several” other staff persons. P1 added that there were three staff persons who were named, including the SP, P7, and another staff person who P1 could not remember and those three staff persons were brought in to be interviewed. · P1 stated that the same day VA1 was discharged from the facility, a former staff person went to the SP’s house and VA1 answered the door. The former staff person took a picture and sent it to P1. P1 then called the SP asking the SP to come into the facility. P1 spoke to the SP and the SP handed P1 his/her keys, said, “I’m sorry,” and left the facility. P1 had no further communication with the SP or VA1. · In the fall of 2024, P1 received a letter from VA1 that stated VA1 and the SP were “no longer together,” and that VA1 “blamed” P1 for “allowing a staff member to sexually abuse [him/her].” P1 provided a copy of this letter to this investigator, which provided information that was consistent with the information provided by VA1. · P1 stated that the SP was “a superstar” staff person who “worked hard” and “had such great qualities.” P1 stated that s/he watched the SP’s body language and reflexes and listened to the tone of his/her voice and the SP “gave no inkling” about his/her relationship with VA1. P2 provided the following information in an interview with this investigator: · On an unknown date it was reported by an unknown staff person that that the SP and VA1 were in a laundry room together for an “undisclosed” period of time. The laundry room was kept locked, and there were cameras in the laundry room however there was a “blind spot” that the cameras did not see. P2 spoke to the SP about “improving on boundaries” because P2 did “not have much to go off of” other than that the SP was alone with VA1. At some point, the SP was then moved to another area of the facility and no longer worked directly with VA1. · P2 provided information regarding VA1’s LOA that was consistent with the information provided by VA1 and P1. On an unknown date prior to VA1’s discharge from the facility, P1 and P2 received a report that the SP and VA1 had an inappropriate relationship, and the SP was mentioned by name so P1 and P2 “suspended” the SP until they “figured out” what happened. (Note: No other persons stated that the SP was suspended after the relationship was reported.) · On February 20, 2024, VA1 was discharged from the facility. Later the same day, P4 reached out to P2 and P1 saying that there was an “inappropriate relationship” between the SP and VA1 and that P4 saw the SP and the VA together in the community. Later that day, the SP resigned from his/her position at the facility. · The SP had a “boundary issue” in the past and received training on boundaries at that time. [See Allegation Two.] P2 stated that after the initial boundary issues with VA2, P2 did not have additional concerns with the SP’s interactions with clients. The SP was “doing well” and was being considered for a promotion to a lead position at the facility. P6 worked at the facility but not directly with VA1. On an unknown date, P6 heard from C1 that a staff person had sex with a client while the client was on a LOA. C1 was “kind of a talker” so P6 did not believe it “at first.” However, then P6 heard it from a staff person. P6 stated that after VA1 returned from the LOA, s/he had a “hickey” on his/her neck that P6 had not seen prior to VA1 going on the LOA. P6 told P1 and P8 the information s/he heard. P6 did not work directly with the SP, however, s/he heard from P4 that the SP had a relationship with VA2 in the past. (See Allegation Two.) P7 provided the following information: · On an unknown date in February 2024 after VA1 returned from LOA, P1 and P2 spoke to P7 and asked if P7 had sexual contact with the VA. P7 denied the allegation. After the meeting P7 spoke to the SP about his/her meeting with P1 and P2 and the SP never told P7 about his/her relationship with VA1 or any other clients. · P7 stated that s/he did not know how the allegations first came up and stated that s/he was “shocked” when s/he heard them. P7 heard “bits and pieces” of information about the allegations from other staff persons. · Later the same day, C1 told P7 about a “rumored relationship” between VA1 and a staff person, but did not provide the name of the staff person. After talking to C1, P7 saw VA1 who had “a whole bunch of hickies” on his/her neck. · On February 20, 2024, the day VA1 discharged from the facility, P4 went to the SP’s house and took a photo of VA1 outside of the house. P7 also stated that the SP took “time off” around the same time VA1 was discharged. P7 “found out” from an unidentified staff person that the SP was “at it again” and that the SP’s relationship with VA1 was not the first time the SP was “interested” in a client at the facility. P5 stated that s/he heard “gossip” that while VA1 was on a LOA the SP and VA1 had an “inappropriate relationship” and that instead of being with family, VA1 was at the SP’s house. The day after VA1 was discharged, P5 saw the SP in P1’s office crying and never saw him/her again. P8 stated that “about a week before” VA1 discharged from the facility, a staff person who P8 could not remember told P8 that the SP was having an “inappropriate relationship” with VA1. P8 stated that at that time the information had come from another client and was “just speculation” and there was “no proof.” After VA1 was discharged from the facility, P3 saw the SP and VA1 together in the community. P8 did not have any additional information about the relationship but stated that s/he was “surprised” and “shocked” to hear that the allegations were true and that the SP was good at his/her job. P3 stated that there was a “suspicion” of inappropriate boundaries between the SP and VA1 while VA1 was receiving services at the facility. “Management staff” found out about the inappropriate relationship while VA1 was at the facility, and after VA1 was discharged, VA1 and the SP were seen together in the community the same day. Conclusion for Allegation One: A. Maltreatment: Information obtained showed that when VA1 went on leave from the facility s/he stayed at the SP’s. Although at the time, VA1 denied to P1 that s/he was with a staff person during his/her leave, and said the other clients and staff persons “were making it up,” at that time, VA1 was in a relationship with the SP and had reason to deny the relationship. After the relationship ended, VA1 provided consistent information to this investigator and in separate letters to this investigator and P1, that during his/her LOA from the facility (February 10-12, 2024), VA1 stayed at the SP’s house and they had sexual intercourse. Additional information provided by VA1 was corroborated by P2 that showed that on an unknown date, VA1 and the SP were alone together in the facility’s laundry room for an undisclosed period of time, and VA1 stated that the SP kissed him/her while in the laundry room and another time in his/her bedroom. Although the SP did not respond to interview requests to provide information for this report, given the consistent information provided by VA1 that s/he had sexual contact with the SP, that after VA1’s discharge from the facility VA1 was seen at the SP’s house and in the community with VA1, there was a preponderance of the evidence that the SP had sexual contact with VA1. It was determined that 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. 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 a staff person employed at the facility where VA1 was a resident and client receiving services. The SP was trained on the facility’s Staff Relationships policy and the Reporting of Maltreatment of Vulnerable Adults. The SP was responsible for maltreatment of VA1. 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 sexual abuse for which the SP was responsible was “serious” and “recurring” because the SP had sexual contact with VA1 more than one time. Allegation Two: It was reported that the SP had a sexual relationship with VA2 while VA2 was receiving services at the facility. VA2 moved to the facility on July 6, 2023, and was discharged on July 31, 2023. According to VA2’s Individual Abuse Prevention Plan, s/he was not susceptible to abuse in any area (sexual, physical, emotional, verbal, self, financial). P4 provided the following information: · On Friday, July 28, 2023, VA2 told P4 that s/he was “building a relationship” with the SP. P4 stated that because she had previously told P3 about interpersonal conflicts between him/herself and the SP as well as inappropriate interactions between the SP and VA2, she was going to “monitor the situation over the weekend” while the SP worked before telling P3 what VA2 said. However, P4 told another staff person, who P4 could not recall. P4 told the other staff person that s/he worked that weekend and would “keep [his/her] eyes on it.” · Over the weekend (July 29-30, 2023), VA2 told P4 “there was a quick kiss” between the SP and VA2 which was the first time VA2 said there was a relationship between VA2 and the SP. On Monday, July 31, 2023, P4 was not scheduled to work but went to the facility to talk to P3 about what VA2 said. · On July 31, 2023, P1 talked to P4 who said that VA2 was in a relationship with the SP. At that time, VA2 was no longer receiving services at the facility, so P1 was not able to talk to VA2 about the allegations. An email dated July 31, 2023, at 3:37 p.m. from P4 to P1, P2 and P3 stated that P4 had information about two “situations” that occurred on July 28 and 29, 2023. VA2 told P4 that s/he was “fraternizing” with a staff person and believed s/he “really had a chance” with the staff person and identified the SP. VA2 also told P4 that the SP and VA2 had plans to spend weekends together after VA2 was discharged from the facility and that the SP told VA2 that if VA2 remained sober for a year, they could be in a relationship. VA2 and the SP exchanged phone numbers and social media usernames. VA2 told P4 that s/he was hoping to have a “real relationship” with the SP and that the SP made VA2 feel “like a giddy school child.” P4 asked VA2 if there had been any physical contact between him/herself and the SP and VA2 denied any physical contact “with a large smile on [his/her] face.” P3 provided the following information: · On an unknown date between July 10 and 28, 2023, P4 told P3 that s/he had concerns about the SP’s “inappropriate boundaries” with VA2. The SP and VA2 wrote letters of unknown content between one another, sat together on the same bench, and VA2 knew “personal information” about the SP. At that time, P3 shared the information about “inappropriate boundaries” with P1 and P2. · On July 31, 2023, P4 told P3 that on July 28, 2023, VA2 told P4 that s/he was in a relationship with the SP and that on an unknown date VA2 and the SP kissed. P3 then immediately told P1 what P4 said. P3 did not know what P1 did with the information P3 told him/her about VA2 and the SP. According to the facility’s Internal Review, on July 28, 2023, VA2 told P4 that s/he was in a “relationship” with the SP and that the SP kissed VA2 on the lips in VA2’s bedroom. VA2 also told P4 that s/he and the SP had “personal conversations” that included talking about their “personal lives” and past relationships. P2 could not recall details of the incident between VA2 and the SP but remembered that there were “boundary issues” between the two. At that time, the SP was retrained on boundaries and P2 “made sure” the SP “knew expectations” regarding boundaries. After receiving training and working longer at the facility, P1 thought the SP was “doing well” and was considering promoting him/her to a higher-level position. P6 stated that s/he could not remember exactly what happened but recalled that the SP “had a relationship” with VA2. P6 also remembered that VA2 reported that s/he was in a relationship with the SP while s/he was a client at the facility, and told his/her counselor, P4 about it. P5, P7, and P8 had no information regarding the SP and VA2. Conclusion for Allegation Two: Information was consistent that on July 28, 2023, VA2 told P4 s/he and the SP kissed and were developing a relationship. On Monday, July 31, 2023, VA2 was discharged from the facility and was not able to be located for an interview. Although it was most likely that the SP had inappropriate boundaries and interactions with VA2, given that P4 was the sole person VA2 told about the allegation, that VA2 could not be located for an interview, and that the SP did not respond to interview request, there was not a preponderance of the evidence whether the SP had sexual contact with VA2. 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). Allegation Three: During the course of the investigation it was alleged that the facility failed to provide supervision for the SP as required by his/her background study which resulted in the SP’s ability to develop and have inappropriate boundaries/relationships with VA1 and VA2. VA2 moved to the facility on July 6, 2023, and was discharged on July 31, 2023. VA1 moved to the facility on January 22, 2024, and was discharged on February 20, 2024. The SP worked at the facility from July 10, 2023, to February 20, 2024. Information maintained by the Department of Human Services showed the following: · On July 10, 2023, the facility initiated a background study request for the SP to the Minnesota Department of Human Services, Office of Inspector General, Background Study Division (BGS). On July 13, 2023, BGS sent a letter to the SP and the facility stating that BGS needed more time to complete the SP’s background study and the license holder was not required to provide continuous direct supervision. · On December 27, 2023, BGS sent a letter to the facility’s sensitive information person (SIP) stating that the SP was disqualified from providing direct contact services. The letter also stated that the facility may choose whether or not to allow the SP to provide direct contact services pending reconsideration, however, if the facility chose to let the SP continue to work, it was required to “ensure that the individual is under continuous, direct supervision when providing direct contact services with persons receiving services from your program, pending reconsideration of the disqualification.” · On January 26, 2024, BGS received the SP’s request for reconsideration. · On February 26, 2024, a letter from BGS to the SIP stated that the SP “has not been set aside” and the SP was ordered to “remove the above-named individual from any position allowing direct contact with, or access to, persons receiving services from your program.” P1 stated that s/he did not know who provided supervision while the SP worked, stated that P2 “set that all up.” P2 was the SP’s supervisor. On an unknown date (later determined to be December 27, 2023), P2 was notified that the SP was disqualified from providing direct contact services. The SP remained working but was supervised and there was “always someone in the area” within “ear or eye shot.” Relevant Rules and/or Statutes: Minnesota Statutes, chapter 245C.02, subdivision 8, states that "Continuous, direct supervision" means an individual is within sight or hearing of the program's supervising individual to the extent that the program's supervising individual is capable at all times of intervening to protect the health and safety of the persons served by the program. Conclusion Allegation Three: A. Maltreatment: Regarding VA2: Information was consistent that on July 28, 2023, VA2 told P4 s/he and the SP kissed and were developing a relationship. Although it was not determined whether the SP and VA2 had sexual contact, it was most likely that the SP had inappropriate boundaries and interactions with VA2. From July 6 to 31, 2023, VA2 lived at and received services from the facility. Although the SP’s background study had not been completed, it had been submitted as required and the SP did not require continuous direct supervision during that time. Regarding VA1: From January 22 to February 20, 2024, VA1 lived at and received services from the facility. On December 27, 2023, the SIP was notified that the SP was disqualified and that if the SP was allowed to provide direct contact services, the SP required “continuous, direct supervision.” Despite this, information provided by VA1 and corroborated by P2 showed that on an unknown date, VA1 and the SP were alone together in the facility’s laundry room for an undisclosed period of time, and VA1 stated that the SP kissed him/her while in the laundry room and another time in his/her bedroom. VA1 also stated the SP “usually” came to VA1 in locations and times where there were not other people or cameras. Although P2 stated there was “always someone in the area” within “ear or eye shot,” information from VA1 and P2 showed that the SP had unsupervised contact with VA1, and facility staff persons were not aware and did not intervene. Therefore, there was a preponderance of the evidence that there was a failure or omission by a caregiver to supply VA1 with care or services, which was reasonable and necessary to maintain the physical and mental health and safety of the vulnerable adult. 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: (2) 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; (3) 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 (4) whether the facility or individual followed professional standards in exercising professional judgment. On December 27, 2023, the SIP was notified that the SP was disqualified and that if the SP was allowed to provide direct contact services, the SP required “continuous, direct supervision.” This remained in place through February 21, 2024, when the SP no longer worked at the facility. The facility was responsible for continuous direct supervision of the SP when s/he was providing direct contact services to clients and failed to do so, which allowed the SP and VA1 to be alone together in the laundry room and bathroom. Therefore, the facility was responsible for maltreatment of VA1. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 facility was responsible did not meet statutory criteria to be determined as serious because the facility’s failure to supervise the SP as required demonstrated a pattern of neglect which constitutes a single incident of maltreatment. Information showed that although the SP and VA1 kissed while at the facility, there was no information provided that criminal sexual conduct occurred at the facility. Action Taken by Facility: The facility completed Internal Reviews for Allegations One and Two and determined for both that policies and procedures were adequate but not followed. All staff received additional training on making MAARC reports on March 13, 2025.
Action Taken by Department of Human Services, Office of Inspector General: On July 23, 2025, the SP was notified that s/he was responsible for serious and 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. On July 23, 2025, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that four individuals failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failures to report the suspected maltreatment and potential consequences for future such failures. In addition, it was determined that facility mandated reporters had knowledge of two alleged incidents and did not report the incidents as required. The license holder was ordered to forfeit a fine of $400 ($200 per incident) for failing to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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