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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: 1121259-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Scott Brandt/Jamie Randall Suspected Maltreatment Reported: It was reported that a staff person (SP) engaged in a sexual relationship with a vulnerable adult (VA) while the VA received services at the facility and that the relationship continued after the VA left services. Date of Incident(s): Prior to February 28, 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 March 7, 2025, from documentation at the facility and through ten interviews conducted with the VA, the SP, the VA’s case manager (CM), the VA’s family member (FM), two facility management staff persons (P1 and P2), two facility staff persons (P3 and P4), a community person (CP), and a law enforcement officer (LEO). Although attempts were made to contact another facility staff person (P5), P5 did not respond to requests to be interviewed. The CP, who previously worked at the facility, and the SP resided together. The VA was not subject to guardianship. The facility provided intensive residential treatment and crisis stabilization services to adults who were diagnosed with a serious mental illness. Length of stay in the crisis stabilization program ranged from one to ten days and in the intensive residential treatment program up to 90 days with reauthorization for clients requiring longer lengths of stay. Each of the client bedrooms were single occupancy. The facility was in a rural area in a farm like setting, with several outbuildings, including a barn, and animals on the property. The barn was two levels and on the top level, there were several bales of hay. The VA’s Functional Assessment stated that some of the VA’s diagnoses included post-traumatic stress disorder (PTSD), bipolar disorder, and attention deficit hyperactivity disorder (ADHD). The assessment showed that the VA had a history of substance use and “suicidal ideations/attempts.” P1 stated that the VA was admitted to the program on August 19, 2024, and that the VA was “creative, resourceful,” and “often took a mentorship role with [his/her] peers.” The VA’s Discharge Summary showed that the VA was discharged from the facility on November 15, 2024, and his/her discharge was “successful.” The VA’s Individual Abuse Prevention Plan showed that the VA was not susceptible to sexual abuse. The CM provided the following information: · On February 24, 2025, the CM learned from the FM that the VA had been hospitalized for a “suicide attempt.” The FM told the CM that s/he had information that while the VA received services from the facility, the VA and the SP engaged in some type of relationship that continued after the VA was discharged from the facility. When the SP tried to end the relationship in February 2025, the VA’s mental health declined, which led to a suicide attempt and hospitalization. · On February 27, 2025, the CM talked to the VA (while the VA was hospitalized) on the phone. During the discussion, the VA stated that s/he and the SP began a “sexual relationship” in September 2024 and “had sex on a daily basis.” The VA named two rooms at the facility, the “hayloft” and the “donation closet” where the SP and the VA engaged in sexual activities. The VA also told the CM that the VA had messages that showed that s/he had contact with the SP and that the sexual contact and communication continued after the VA was discharged from the facility, but the VA did not provide details. · The CM stated that the VA was “not always truthful” and could be “manipulative,” but that the VA might not be “truthful” related to “treatment,” but “not so much” the case in terms of his/her “relationships.” The VA provided the following information to this investigator: · Although the VA did not know the date, s/he, the SP, and other staff and clients went to a Halloween activity in October 2024. During the activity, the SP “pressed down” on both of the VA’s shoulders in an attempt to “calm down” the VA. Then the SP asked the VA “if I liked” him/her. The VA said, “Yes.” When the VA asked the SP if the SP liked the VA, the SP “never responded,” but had a “smile” on his/her face. · One week later, the SP and the VA were alone together in the laundry room. When the VA asked the SP for a “hug,” the SP agreed to that and while they hugged, the SP “kissed me.” · On various other unknown dates, the SP and the VA went to one of four locations, the “hay loft,” “donation closet,” “laundry room,” and the “med[ication]room.” While in those rooms, the SP touched the VA’s “genitals” over the VA’s clothing. (Investigator’s note: the VA’s description of the hay loft was consistent with what the investigator saw during the site visit on March 7, 2025). The VA stated that it was typical for staff to bring clients, including the VA, to the hay loft to assist with feeding the animals in the barn. · The VA did not remember the date, but on the last night that the VA received services from the facility, the SP and the VA were in the VA’s bedroom at the facility for about 45 minutes and were “fooling around” and “making out.” The SP put his/her hands “down” the VA’s pants. The VA then undressed, and the SP remained dressed. After that, the VA used a sexual stimulation device while the SP “watched.” At some point, P5, who did not respond to requests from this investigator to be interviewed, knocked on the VA’s bedroom door, which was closed, because P5 heard “moaning” coming from the VA’s bedroom. When P5 asked the VA if s/he and the SP were in a relationship, the VA said, “No,” but that the SP “likes me.” · At various times, the SP and the VA used “sex toys” and “went down on each other.” · The VA did not remember the date, but at some point, while the VA received services from the facility, the VA and the SP communicated on WhatsApp. (The website www.whatsapp.com described the WhatsApp application as a “simple, reliable, private messaging and calling for free available all over the world”). The SP set up an account, but used the CP’s name, which meant that the CP’s name showed up as messages to the VA from the SP. · At some point while the VA received services, a staff person came up with a “code word,” which was “peanut butter.” When staff used that word, it meant that the VA and the SP “spent too much time together.” · On February 8, 2025, the SP told the VA that they should “limit our interactions.” After that date, the SP did not respond to the VA. As a result of that, the SP “destroyed my mental health” and “put me on an emotional roller coaster,” which led to the VA trying to “kill myself.” The following were messages shared between the SP and the VA, according to the VA. The messages, from the VA’s phone, showed the CP’s name: · On October 27, 2024, the SP said, “[The CP] got me this we can use,” and “is it working?” The VA responded, “Yeah,” and “Got it.” The VA also told the SP, “When you get here, try and sneak into my room for a kiss, door will be unlocked.” The SP responded, “I’d love to.” The SP also said, “Earlier today I was thinking I want you to sit on my face until you cum all over it,” and “I want to sit on yours…pretty sure I could cum with contracting and relaxing my pelvic muscles because I’m so fucking aroused its almost becoming painful.” · On October 28, 2024, the VA sent intimate pictures of him/herself to the SP and the SP said, “OMG I wanna fuck the shit out of you right now.” The VA responded, “Come in.” The SP said, “I will soon…did you squirt? Or are you that wet.” The VA said, “I’m that wet,” and “The door is unlocked when you can.” · On an unknown date, a message from the VA to the SP said, “What were you thinking?” The SP replied, “Just about how much I loved cumming sort of together and I love how you sound.” · On an unknown date, the SP told the VA, “Let’s limit communication.” After that, the VA communicated with the SP, but the SP did not respond. The facility’s payroll records showed that the SP worked from 3 until 11 p.m. on October 27, 2024. The VA shared text messages between the VA and the SP which included some photos. According to the VA, the name from incoming messages was the SP’s middle name (which was verified during the SP’s interview) and there was a picture of the SP at the top. The messages provided the following information: · On November 19, 2024 (after the VA discharged from the facility), the SP said, “I miss you so much,” and “I love you too.” When the VA asked the SP about how “work” was going, the SP responded, “It’s good.” · On November 21, 2024, the SP said, “I can’t wait to kiss you and have you here.” · Some of the photos which did not have dates showed the SP and the VA with their faces touching one another and one with their lips less than an inch apart appearing to be almost kissing. The FM provided the following information: · Around Halloween 2024, the VA told the FM that the SP was “cute.” The FM told the VA that the SP was a “worker” and that the VA “can’t get involved with that.” · The VA told the FM that s/he and the SP were in the VA’s bedroom, but the VA did not provide the date, and the VA did not say what happened in the bedroom. The VA said that P5 asked the VA what s/he and the SP were doing in the VA’s bedroom because P5 heard “moaning,” but the VA did not provide the date. The VA also told the FM that s/he and the SP went to the “barn” and that they “made out,” but the VA did not provide dates. · The VA also told the FM about the code word “peanut butter,” that was used when the VA and the SP spent too much time together. P3 was the person that implemented the use of the word. · The VA told the FM that the SP and the VA communicated on the WhatsApp application while the VA was at the facility and after the VA was discharged and that they used the CP’s name because the VA “didn’t want to get [the SP] in trouble.” · The FM did not know the date that the VA was discharged from the facility, but thought that in January 2025, the VA told the FM that the sexual relationship continued. The FM told the VA it was “not appropriate,” and that the FM was going to “turn [the SP] in.” When the FM said that to the VA, the VA “begged” the FM to not do that. · The VA told the FM that the last communication the VA had with the SP was in February 2025. P1 provided the following information to this investigator and the LEO: · The facility had a policy about staff/client relationships that stated they were “strictly prohibited.” · Shortly after the VA began receiving services from the facility in August 2024, the VA became “fixated” on the SP, which meant that the VA spent a lot of time seeking out the SP and that the SP had difficulty setting boundaries with the VA. As a result, P1, P2, the SP and the VA met to discuss the concerns and P1 told the SP it was okay to tell the VA, “You’re in my space,” or “You’re making me uncomfortable,” but P1 did not remember when the meeting occurred. After the meeting, the VA “wasn’t super into the idea,” but P1 saw some improvement from the SP even though the SP “really struggled” with boundaries and told P1 that s/he could not be “direct” when the SP talked to the VA. · P1 did not know the date, but P2 set up the code word “peanut butter,” but P1 did not know how often staff had to use that word. The word was to be used if staff noticed any boundary concerns between any staff or client. · P1 said that the SP was more “guarded” when working with the VA, toward the end of the VA’s stay at the facility and was “hesitant” to work with the VA because the VA continued to struggle with boundaries. · P1 did not have any information that the SP and the VA engaged in sexual activity while the VA received services from the facility and no staff person brought concerns forward related to that. P2-P5 provided information to this investigator and the LEO that was consistent with the information provided by P1. There was no information provided by P1-P5 that they saw any sexual activity between the SP and the VA. The facility had a “Mission, Culture, and Boundaries Training” that stated that staff persons were expected to “understand what professional boundaries are and how to maintain positive relationships.” The facility provided “Boundaries in the Treatment Relationship” training. Some of the information included statements, such as, “overstepping the therapeutic boundary can pose a serious risk, as it can also harm the individuals you aim to help” and “it is crucial that behavioral health professionals are aware of the potential risks and danger signs of these harmful boundary violations.” The SP’s Job Description, signed the SP on July 29, 2024, stated that some of the SP’s “essential functions” were to “provide services that are rehabilitative and enable the recipient to develop and enhance psychiatric stability, social competencies, personal and emotional adjustment and independent living and community skills,” and “maintain professional manner at all times, serving as a positive role model for the individuals and respecting professional boundaries in the workplace.” The SP provided the following information to this investigator and the LEO: · About four to six weeks after the VA began receiving services from the facility, the VA became “fixated” on the SP, which meant that the VA “was following me around every shift.” As that progressed, the SP asked other staff to assist the VA with his/her needs. The SP described the interactions with the VA as not being “healthy.” As a result, the SP talked to P1 and P2 to “brainstorm” ideas how to best redirect the VA, such as having others work with the VA. The VA told the SP that the SP reminded the VA of a family member and that brought “comfort” to the VA. Other staff offered to assist the VA as needed “instead of me doing it.” · The SP knew that the use of the word “peanut butter” was implemented when the VA was “clinging” to the SP. Although the VA “agreed that [s/he] would try to rectify that by giving space or backing up,” use of the word did not work all the time. · After the VA discharged from the facility, the VA called the facility several times because the VA was “struggling.” The SP only communicated with the VA one time, via phone. · The SP went to the VA’s bedroom in an effort to help the VA pack when the VA was preparing to leave the facility and when that occurred, the bedroom door was open. The SP denied going to the VA’s bedroom at the facility for any other reason and denied any type of sexual contact. · When the SP was asked to provide information about concerns that s/he and the VA communicated through the WhatsApp application or text messages, the SP denied that and said, “No,” that s/he did not have the application on his/her phone and that s/he did not have text communication with the VA while the VA received services from the facility or after the VA discharged. · When the LEO asked the SP to show his/her personal phone to the LEO, the SP was hesitant to do so and said that s/he was “really uncomfortable” with having the LEO view the SP’s personal phone. After much discussion between the LEO and the SP, the SP agreed to allow the LEO to view the SP’s personal phone, and the SP was told that s/he could “revoke” the consent to search the SP’s personal phone. The SP signed the LEO’s form, but prior to signing the form and agreeing to the search, the LEO told the SP, “Right now you’re manipulating your phone.” · When the LEO viewed the SP’s phone, the LEO saw that the WhatsApp application was downloaded on the SP’s phone, but the SP said that s/he had not used the application and that it was a “common download.” Through the LEO’s review of the SP’s phone, the LEO determined that the SP created an account for WhatsApp and a password on October 27, 2024, and as of November 18, 2024, the SP used WhatsApp application. The SP thought that s/he was “testing the app,” but did not “remember talking to anybody specifically.” When the LEO asked the SP about that, the SP said, “I guess maybe” that the SP used the application. After that, the LEO told the SP that s/he was going to review messages on the WhatsApp application from October 2024 and the SP said, “Let’s just stop it it’s making me uncomfortable.” The SP revoked his/her consent for the LEO to search the SP’s phone, so the LEO stopped the search. The SP denied that s/he and the CP set up the WhatsApp account so the SP and the VA could communicate with one another. When the SP left the interview room with this investigator and the LEO, the LEO immediately called the CP and asked questions while this investigator listened to the conversation. The CP told the LEO that although s/he did not remember the date, the SP and the VA talked on the SP’s phone because the SP, left the room and handed the SP’s phone to the CP who then talked to the VA, who talked about his/her medications that the VA was discontinuing. The CP thought that the VA got the SP’s phone number while the VA received services at the facility and that the VA called the SP, but the CP was not certain of that. The CP stated that although s/he was familiar with the WhatsApp application, the VA and the SP did not ask the CP to create an account from the CP’s information so that the VA and the SP could communicate with one another and that the CP did not use WhatsApp. P1 and P2 each said that after the SP left his/her interview with this investigator and the LEO on Friday March 7, 2025, the SP did not say anything about the interview and that the SP sent text messages stating that s/he would be unable to work his/her scheduled shifts that weekend. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to March 7, 2025. In addition, training records showed that the SP received training on “Boundaries in the Treatment Relationship” on August 8, 2024, and “Boundaries in the Treatment Relationship” on August 14, 2024. Conclusion: A. Maltreatment: The VA received services from the facility between August 19 and November 15, 2024. On February 27, 2025, the VA told the CM that the VA and the SP had a “sexual relationship” in September 2024 and “had sex on a daily basis” while the VA was at the facility. The VA named two rooms at the facility where this occurred, and that the VA and the SP communicated with one another after the VA was discharged from the facility. The FM said that around Halloween 2024, the VA told the FM that the SP was “cute,” and that the FM told the VA that s/he should not “get involved with that.” The VA also told the FM that s/he and the SP went to the “barn” and that they “made out,” but the VA did not provide dates. The VA told the FM that the SP and the VA communicated on the WhatsApp application while the VA was at the facility and after the VA was discharged and that they used the CP’s name because the VA “didn’t want to get [the SP] in trouble.” The VA told the FM that the last communication the VA had with the SP was in February 2025. The VA said that about a week after a Halloween activity in October 2024, the SP and the VA were alone together in the laundry room and that they kissed. The VA also said that while the VA received services from the facility, the VA and the SP had sexual contact and that they communicated on WhatsApp, but that the SP set up the account and used the CP’s name, which meant that the CP’s name showed up as messages from the SP, instead of the SP. The SP denied this occurred. The CP stated s/he was not asked to use his/her name on WhatsApp. The VA also said that on February 8, 2025, the SP told the VA that they should “limit our interactions.” After that date, the SP did not respond to the VA. As a result of that, the SP “destroyed my mental health” and “put me on an emotional roller coaster,” according to the VA, which led to the VA trying to “kill myself.” Messages the VA had showed messages between the SP and the VA that talked about sexual acts together, were sexual in nature, and conversation about the SP going to the VA’s room at the facility when the SP was working. In addition, the VA showed photos of the SP and the VA together with one photo of the two nearly kissing. Although P1-P5 discussed some concerns that the VA had boundary issues, there was no information from staff that they saw the SP and the VA engaged in sexual contact while the VA received services from the facility and information from the investigation showed that P1, P2 and other staff persons tried to minimize the time that the VA spent seeking out the SP. The SP told this investigator that s/he did not use the WhatsApp application, did not communicate with the VA via WhatsApp or text messages, and did not have sexual contact with the VA. However, when the SP was interviewed by the LEO, with the investigator present, the LEO determined that the WhatsApp application, on the SP’s personal phone, was downloaded on October 27, 2024, and used by the SP at least one time, but the LEO was not able to search more because the SP requested that the LEO stop searching the SP’s phone. The SP provided conflicting information saying that s/he did not communicate with the VA more than one time via phone. However, the VA had messages from the SP which used the SP’s middle name with the SP’s photo and the VA had photos of the SP and the VA together and the SP stated s/he did not use the WhatsApp application, but the LEO found an account created on October 27, 2024, and used at least once. Therefore, although the VA might not be truthful about his/her treatment, the VA’s information was consistent, so the VA’s information was considered more credible than the SP’s information. Given the VA’s history of substance use and mental health diagnosis, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA, both now and in the future. Therefore, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health. In addition, given that the VA provided consistent information that the SP and the VA had sexual contact and that the VA’s information was considered more credible than the SP’s who also had reason to minimize his/her actions for fear of consequences, there was a preponderance of the evidence that the SP had sexual contact with the VA. It was determined that sexual abuse and neglect 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 or 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 prior to March 7, 2025, and trained on maintaining professional boundaries on at least two occasions, August 8 and 14, 2024. The SP was responsible for neglect and sexual abuse 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. The substantiated neglect for which the SP was responsible for was not serious maltreatment because it did not meet the definition and was not recurring maltreatment because the SP’s behavior was a pattern that was considered a single incident. However, the substantiated sexual abuse for the which the SP was responsible for was serious maltreatment because it met the statutory definition of serious maltreatment and was recurring maltreatment because the SP had sexual contact with the VA on more than one occasion. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that it was “uncertain” whether its policies and procedures were adequate or followed “due to a lack of information regarding the report.” The facility provided additional training to all staff that “orientation training will be revised to include clear expectations regarding therapeutic boundaries, professional working relationships and best practice methods that promote clients to build natural relationships and prohibit staff from interacting with them outside of their role and scope during receipt of services.” The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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