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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: 1123292-H_CRS (Home and Community-Based Services-Community Residential Setting) - Facility A 1123291-H_CRS (Home and Community-Based Services-Community Residential Setting) - Facility B Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding the supervision and care of vulnerable adults (VAs) at the facilities. VA1, VA2, VA3, and VA4 resided at Facility A, and VA5 and VA6 resided at Facility B at the time the incidents occurred according to an administrative/supervisory staff person (P1). VA5 previously resided at Facility A, but there were no individuals or staff persons whose names matched two other persons idenitifed in the report. Two additional vulnerable adults (VA7 and VA8) resided at Facility B when the incidents occurred but their names did not match names provided in the report and they were not interviewed. On May 27, 2025, Minnesota Department of Human Services began an investigation into the concerns in this report. Date of Incident(s): December of 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 June 11, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, and P4), a community person (CP1), VA1, and persons on the VAs’ teams. This investigator met VA2, but s/he declined to provide information regarding this report and in a phone call, VA3 declined to be interviewed by this investigator. At the time of the site visit, VA4, VA5, and VA6 no longer received services from the facilities and attempts to contact them were unsuccessful, but their respective team members provided information for this report that was included below. Documentation from the facilities showed that the VAs’ diagnoses included developmental disabilities and mental illnesses, and some VAs had a history of substance use or attempting to harm themselves. The VAs had no rights restrictions and interacted with community persons of their choosing at the facilities and in the community. No information showed that the VAs were endangered by the actions of community persons who visited the facilities. Staff persons were to check on VA1 once hourly to ensure his/her safety and redirect him/her or obtain additional care for VA1 when needed. VA1 was vulnerable to physical and sexual abuse according to his/her plans and depended on staff persons to encourage him/her to maintain boundaries in the community. If staff persons observed VA1 in a vulnerable situation, they were to immediately intervene and remove VA1 from it. No information showed whether VA1 had a history of repeatedly calling 9-1-1 or attempting to avoid supervision from staff persons at Facility A or in the community. VA2 had a history of verbally aggressive behavior toward staff persons and individuals which might cause individuals to behave aggressively toward him/her. VA2 wanted staff persons to help him/her keep his/her bedroom neat and clean, and wanted assistance to eat healthier foods. VA3 might become upset when things did not go his/her way and might have difficulty communicating. VA3 might raise his/her voice to staff persons or call 9-1-1, then provide inaccurate information regarding his/her care to first responders. If staff persons were concerned that VA3 had suicidal ideation and had a plan, they were to call 9-1-1 and remove any items VA3 might use to harm him/herself, from his/her bedroom. If VA3 did not verbalize a plan to harm him/herself, staff persons called a crisis intervention program to assist VA3. VA3 often had intense fears of death or dying, and felt safer in hospitals than s/he did at Facility A. In December of 2024, VA3 experienced many symptoms of mental illness and staff persons and VA3 each called 9-1-1 on multiple occasions. VA4 had a history of engaging in aggressive behavior toward staff persons and individuals. VA4 wanted to learn how to manage his/her feelings better and hoped to achieve a greater level of independence. No information showed whether VA4 had a history of calling 9-1-1. VA5 had a history of physically aggressive behavior with staff persons and individuals when s/he felt challenged and might bang on doors or pace before s/he became upset. Staff persons were to redirect VA5 to a preferred activity, validate his/her feelings, or give him/her space when it was requested and safe to do so. VA5 might decline to take his/her medications as prescribed, and when s/he did, staff persons were to notify a facility health care professional for assistance. When VA5 did not take medications as prescribed and had behaviors that could not be redirected that posed a danger to him/herself or others, staff persons might call 9-1-1 for assistance which sometimes resulted in VA5 getting injections of medications at the emergency department of a hospital. VA6 had a history of harming him/herself or others and staff persons were to contact a crisis intervention program for assistance when VA6 verbalized intentions to harm him/herself or others. VA6 might think that others were taking his/her belongings and call 9-1-1 instead of expressing his/her concerns to staff persons and staff persons were to check on VA6 every two hours when they knew s/he was upset to prevent him/her from calling 9-1-1. If staff persons thought that VA6 was actively using substances, they were to check his/her bedroom for them and search the bedroom thoroughly if needed. When VA6 was calm, staff persons were to remind him/her which events were emergencies and required calls to 9-1-1. If VA6 was unable to achieve safety after staff persons made multiple attempts to redirect his/her behaviors, they were to call 9-1-1 for assistance and continue redirecting VA6 while waiting for first responders to arrive. The VAs’ plans showed that VA1’s staffing ratio was one to four and for VA2, it was one to two. VA3’s, VA4’s, VA5’s, and VA6’s staffing ratio was two to four. The VAs in this report enjoyed participating in a variety of activities including taking walks in the neighborhood, going to stores, drawing pictures, and listening to music. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · CP1 said that in late 2024, a community person (CP2) visited vulnerable adults at Facility A, without staff persons’ knowledge. CP1 thought that CP2 had a history of engaging in illegal activities and should not have been able to visit the VAs without supervision. Regarding Facility B, CP1 thought that staff persons called 9-1-1 to manage the VAs’ behaviors instead of creating plans to address the VAs’ needs. In addition, VA5 called 9-1-1 frequently and CP1 thought that VA5’s team should implement a rights restriction to discourage VA5 from calling 9-1-1. CP1 felt that staff persons did not provide transportation for the VAs, that staff persons “held” the VAs’ mail, and that the VAs at the facilities might have non-therapeutic contact with each other when staff persons did not supervise them. · VA1 said that living at Facility A went well most of the time, and his/her biggest issues there were that staff persons did not listen to his/her concerns, that the food at the facility was not the food s/he preferred, and that s/he had to share a shower with others. Facility A was not “spotlessly” clean, but it was okay. VA1 knew VA2 and VA3 and said that an individual whose name s/he did not recall that previously resided at Facility A frequently called 9-1-1, but the individual had to leave Facility A because s/he was physically aggressive toward others. VA1 had no concerns regarding his/her safety or supervision at the facility after the individual moved. No information showed that VA1 was subject to guardianship. · VA2 and VA4 declined to complete interviews with this investigator and VA3, VA5, and VA6, did not respond to this investigator’s attempts to contact them. No information showed that VA2, VA3, or VA6 were subject to guardianship or had case managers. VA5 and VA6 resided at Facility B in December of 2024, but did not receive services from the facilities at the time of the site visit. · VA4’s case manager said that VA4 did not voice concerns regarding the facility to him/her and seemed happy. VA4 did not have any plans to move from the facility and wanted to remain there. The case manager had no concerns regarding VA4’s care and no information showed that VA4 was subject to guardianship. · VA5’s guardian said that VA5 had a mental illness that made it difficult to care for him/her. When VA5 was upset, s/he was unable to focus or calm. P1 was easy to work with, and while some of the staff persons might not have completed documentation as thoroughly as they could have, they did their best and kept the facility clean. Staff persons prepared home cooked meals for the VAs and seemed to care for them. When VA5 was upset, it helped him/her refocus if someone could sit with him/her while s/he calmed but sometimes VA5 could not be redirected and staff persons had to call 9-1-1 because s/he required additional care that could not be provided in a community setting. The guardian did not think that anything that occurred at VA5’s residence was maltreatment and had no concerns regarding the care that VA5 received at the facilities. The guardian was grateful for the care provided to VA5 and thought that community persons and law enforcement agencies did not know the “whole story” about the facilities and the individuals who resided there. · VA6’s family member (FM) said that s/he was very involved in VA6’s care and had frequent contact with him/her. The FM thought that Facility B was the best place VA6 ever lived and added that VA6 was well supervised there. VA6 had a history of substance use and might try to leave facilities without supervision, but the staff persons at Facility B tried to keep VA6 safe and if s/he left the facility, staff persons followed him/her and looked for him/her in the community if s/he left without their knowledge. Facility B was clean, and neat when VA6 resided there, and s/he had nutritional food to eat. Staff persons at the facility assisted VA6 to clean his/her bedroom, had good relationships with him/her, and cared about him/her. The FM thought that VA6 called 9-1-1 frequently because VA6 had been told multiple times that s/he was to call 9-1-1 when s/he was in danger. VA6 often felt that s/he was in danger, and so s/he called 9-1-1 many times, then did not understand why “people” were angry with him/her for calling. The FM had no concerns regarding VA6’s care and no information showed whether VA6 was subject to guardianship. · P1 and P2 (P2 was an administrative staff person), provided consistent information that staff persons were instructed to follow the VAs’ plans and call 9-1-1 as specified by the plans. P1 said that there were always at least two staff persons at the facilities daily and none of the VAs had one to one staffing. The VAs’ plans provided guidance to staff persons about the best ways to redirect each VA and how to supervise each of them. P1 said that staff persons provided transportation for the VAs as needed and did not hold the VAs’ mail. The VAs might have unsupervised contact with each other when staff persons were busy assisting others or completing household tasks. P1 and P2 had no concerns regarding the VAs’ cares at the facilities but were previously aware of the issues raised by CP1 regarding 9-1-1 calls. · P3 (a facility supervisory staff person) and P4 worked with the VAs in December of 2024. P3 said that staff persons called 9-1-1 for assistance when they were unable to redirect VAs and keep them safe at the facilities, but P3 was unsure how often 9-1-1 was called or for which VAs. However, P3 knew that VA6 experienced a great deal of anxiety and often called 9-1-1 from his/her personal cell phone, to which s/he had full access. Sometimes after VA6 called 9-1-1, representatives from a law enforcement agency contacted staff persons to advise them that VA6 called 9-1-1 and asked whether there was truly an emergency or whether VA6 could be redirected. · P4 said that s/he did not remember calling 9-1-1 for any of the VAs in December of 2024, but was aware that staff persons and VAs sometimes called 9-1-1. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: CP1 said that there were concerns about the way staff persons at Facility A and B supervised VAs in their care. During the investigation, it was learned that two persons identified by CP1 were not staff persons employed at the facilities or individuals who received services from the facilities according to P1. DHS began an investigation into the care provided to VA1, VA2, VA3, VA4, VA5, and VA6 in May of 2025. Information was consistent that the VAs’ diagnoses included developmental disabilities and mental illnesses. Some of the VAs had a history of substance use and/or self-harm and staffing ratios varied for the VAs, but none had one to one staffing, and none had rights restrictions. The VAs’ plans showed that staff persons were to try to redirect the VAs when they were upset but could call 9-1-1 for assistance if redirection was unsuccessful or the VAs’ behaviors posed a danger to themselves or others. VA1 said that s/he thought that staff persons did not listen to him/her, and s/he did not always like the food that was served at the facility, but generally s/he had no concerns regarding his/her safety or supervision. VA2 and VA4 declined to complete interviews, and VA3, VA5, and VA6 did not respond to attempts to contact them. However, VA4’s case manager had no concerns regarding VA4’s care and VA4 wanted to reside at Facility A. VA5’s guardian said that staff persons might call 9-1-1 when VA5 did not respond to redirection and required greater care than the facilities could provide. The guardian was grateful for VA5’s care and had no concerns. The FM described Facility B as the best place VA6 had lived and said that VA6 was supervised there. If VA6 left Facility B without supervision, staff persons followed him/her and searched for him/her in the community. The FM thought that VA6 often called 9-1-1 when s/he felt that s/he was in danger, but VA6 had no concerns regarding VA6’s care. P1 and P2 each stated that staff persons were to follow the VAs’ plans and call 9-1-1 as specified, and P1 and P3 said that staff persons provided transportation for the VAs, and did not hold their mail. P3 and P4 provided consistent information that staff persons called 9-1-1 for assistance when VAs were unsafe and could not be redirected, and P3 added that VA6 often used his/her cell phone to call 9-1-1 when s/he was anxious. P3 said that the VAs could have guests at the facilities and interact with community persons of their choosing without direct supervision from staff persons. Although there were concerns that community persons had unsupervised contact with the VAs and that frequent 9-1-1 calls were made from the facilities, given that the VAs’ interactions with others were not limited, that the VAs had no rights restrictions, that the VAs’ plans instructed staff persons to call 9-1-1 as needed, and that no information showed that staff persons did not redirect the VAs or that the VAs were not supervised adequately, there was not a preponderance of the evidence whether there was a failure to provide the VAs with care that was reasonable and necessary to obtain or maintain their health or safety. 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 which determined that their policies and procedures were generally adequate and were followed at the time of the incidents. In March of 2025, the facilities began revising the plans of the individuals who received services there to focus more on preventing crises from occurring and re-training staff persons on successful communication when crises occurred. The facilities developed a new procedure for crisis intervention that considered the individuals plans of care and needs. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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