|
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: 1080231-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that a staff person (SP2) smoked marijuana with a vulnerable adult (VA) and then drove a vehicle while under the influence of marijuana when transporting the VA. During the course of the investigation, it was also reported that there was a second staff person (SP1) who smoked marijuana with the VA. Date of Incident(s): Ongoing prior to May 1, 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 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 May 29, 2025; from documentation at the facility; and through five interviews conducted with the VA, two facility staff persons (SP2 and P1), a supervisory staff person (P2), and the VA’s case manager (CM). Attempts were made via phone and U.S. mail to contact and interview a third staff person (SP1), but the attempts were not successful. The VA’s Support Plan, Coordinated Service and Support Plan Addendum, and Individual Abuse Prevention Plan updated in March 2025, provided the following information: · The VA lived independently in an apartment where s/he received support and services from his/her care team, respectively. The VA’s diagnoses included borderline personality disorder, major depressive disorder, seasonal affective disorder, osteoarthritis, chronic pain disorder, tobacco and alcohol use disorders, and diabetes. The VA also had a history of heart failure, self-injurious behaviors, migraines, polyneuropathic pain (pain caused by damage to multiple peripheral nerves), and decreased mobility. The VA enjoyed spending time with his/her cat, doing art projects, teaching art to people with disabilities, and serving as a spokesperson for mental health awareness in his/her community. Additionally, the VA was a “strong self-advocate” and valued “acts of kindness, honesty, and transparency.” The VA was not subject to guardianship. · The VA began receiving services from the facility on March 21, 2021, and received 19 hours a week of individualized home supports (IHS) with training on community living skills. The facility provided the VA with assistance in completing paperwork, organization, community integration, transportation to appointments and community activities, and supporting the VA with planning and meeting personal goals relating to his/her overall health and well-being. Through other agencies, the VA also received personal care services, homemaking services, meal delivery services, transportation services, positive supports, and case management. · The VA was of legal age to purchase and use marijuana and his/her plans did not provide any information that the VA was at risk if/when using marijuana. The VA provided the following information: · The VA received IHS from the facility but had a “history of problems” with the facility’s staff. When the facility began providing services to the VA, SP1 worked with the VA for a “few years” until the VA “fired” SP1 and requested new staffing from the facility. On unknown dates when working with the VA, SP1 would “deal” marijuana to “customers” while the VA waited in SP1’s vehicle. Additionally, SP1 “smoked [marijuana] with [the VA] once” which was approximately three years prior on the VA’s birthday. At that time, SP1 and the VA smoked in a parking lot about “a block away” from the VA’s residence, “got very high” before going to a nearby restaurant for dinner, and then the VA became “paranoid,” “scared,” and could “hardly eat” because s/he was “so stoned.” Ongoing after this, SP1 was “rude” and “unpleasant” when speaking with the VA, told the VA about SP1’s “sex life,” and “made fun” of the VA. SP1 was “angry at the whole world” and the (working relationship) between the VA and SP1 “broke down” until the VA “reached a point where [s/he] had to say something.” The VA then contacted and informed administrative staff that s/he did not want to work with SP1 anymore but did not provide any information as to why. About a week later, SP2 and P1 started working with the VA and SP1 did not have any further contact with the VA. · The VA received weekly support and services from SP2 and P1 for approximately two years. During this time, SP2 “almost always showed up stoned” for his/her shifts and “clocked in” at times when SP2 was not with the VA but in a parking lot near the VA’s residence “smoking” and “taking [his/her] time” to “show up or not.” When SP2 arrived at the VA’s residence, SP2 “just wanted to go to the park and smoke pot with [the VA],” “be high,” and was not helping the VA “get any work done.” Additionally on an unknown date, SP2 drove with a “marijuana pipe in [his/her] hand, lit and smoking” while the VA was in SP2’s vehicle. At some point after this, the VA became “frustrated” and “overwhelmed” with SP2 but did not tell anyone about these incidents because the VA was “afraid” of going to jail and “felt guilty” that s/he smoked with SP2, shared ongoing messages and “funny jokes” about marijuana with SP2, and “let [the situation] go on and on.” · In May 2025, the VA ended services with the facility and started receiving IHS from another provider. At an unknown time after this, SP2 called the VA’s phone and left a voicemail asking the VA if s/he was “happy now that [the VA] got [SP2] fired.” After listening to SP2’s voicemail, the VA was “emotionally distraught” and “very upset” that SP2 “blamed” the VA for losing his/her job. The CM provided the following information: · When the CM started working with the VA, SP1 had already worked with the VA for “quite a while” but “seemed to get along well” with the VA up until that point. Shortly thereafter, the VA contacted and informed the CM that s/he wanted new staffing from the facility due to an “argument” and “fall out” between SP1 and the VA. The VA also told the CM that SP1 was “mean” and “gave up” on the VA but did not provide the CM with any examples of this. Additionally, the CM was not aware of any incidents of SP1 using or being under the influence of any intoxicating substance while working with the VA. After speaking with the VA, the CM then contacted administrative staff who provided the VA with updated staffing (SP2 and P1) approximately one week later. · SP2 and P1 worked with the VA for almost two years. During this time, the CM was not aware of any concerns with the care that the VA received from P1 except that P1 was “late sometimes” when arriving for his/her shifts which was “typically” caused by the travel distance between P1 and the VA’s residences. The CM did not contact or inform administrative staff about this matter because the VA told the CM that the “issue was resolved” and “everything was fine.” In addition to this and prior to May 2025, the CM was also not aware of any concerns with the care that the VA received from SP2. Furthermore, the VA and SP2 had a “really good working relationship” and the VA “seemingly loved [SP2] until the day that [the VA] didn’t love [SP2] anymore.” · At the request of the VA, the CM contacted administrative staff during the first week of May 2025, to inform the facility that the VA was going to work with another provider for his/her IHS and would no longer need the facility’s services. Shortly thereafter, the CM scheduled a time to meet with P2 to return personal items belonging to SP2 and/or P1 that were left at the VA’s residence. During this meeting, P2 talked with the CM about recent concerns that were brought to the attention of administrative staff regarding SP2 smoking marijuana with the VA and transporting the VA while under the influence of intoxicating substances. P2 told the CM that “[the VA] was the one who bought the marijuana” and “maybe implied” that “something like this might have happened” while SP2 was working with the VA but then P2 later denied that any incidents like this occurred during this conversation with the CM. P2 also said that this situation was “similar” to how the VA acted towards SP1 prior to working with SP2 and “all this happened” because the VA was “mad” at “something [SP2] said about [the VA’s] cat.” · The VA’s last date of services provided by the facility was documented as May 1, 2025, and the VA started receiving IHS services from a different provider on May 12, 2025. After this, the VA received a voicemail from SP2 in which SP2 told the VA, “Thanks for getting me fired.” The VA was “worked up” after receiving SP2’s voicemail and shared it with the CM. The CM “thought” that SP2’s behavior was not “professional” and “inappropriate” but then “noticed” that there were “similar boundary issues” with “professionalism” prior to this after the VA showed the CM other communications between SP2 and the VA. · The VA had a history of having “troubles with boundaries” and then using “those crossed boundaries […] against” a person if the VA became “upset” with them or would “pin people against each other.” The VA also had a history of “getting worked up” and/or “upset very quickly” which impacted the VA’s behaviors and required support from the VA’s care team to resolve. Additionally, the VA “might overexaggerate” information if s/he was “upset” or if the VA’s “feelings were hurt.” SP2, P1, P2, and the facility’s Internal Review completed by P2 provided the following information: · For almost two years, SP2 and P1 worked with the VA and did not have any known conflicts or concerns with the services and supports that were provided to the VA during this time. SP2 and P1 “loved” working with the VA, the VA “loved” working with SP2 and P1, and the staff and the VA “got along so well.” The VA “expressed nothing but gratitude” to administrative staff regarding the care was provided by SP2 and P1. · On or around April 28, 2025, SP2 was working with the VA and requested to reschedule their next shift together from Thursday to Friday since another client was in the hospital and needed SP2’s assistance with transportation during that time. At first the VA was “okay” with SP2’s request to reschedule his/her shift but then later that day, the VA became “really weird” and got “upset” with SP2. Shortly thereafter, the VA’s cat “scratched” SP2 and SP2 told the VA that his/her cat was “mean.” Although SP2 was aware that “[the VA’s] cat was everything to [him/her],” SP2 was not aware that his/her comment about the cat would then further “upset” the VA and the VA “totally went off the deep end.” This resulted in a “serious argument” between SP2 and the VA in which the VA told SP2 that s/he did not want to work with SP2 anymore. SP2 then left the VA’s residence and did not work with the VA after this incident. · After SP2 left the VA’s residence, SP2 called and informed P2 about the incident. SP2 also told P2 that s/he did not want to work with the VA anymore because of the VA’s history of “verbal abuse” towards SP2 which was “typically” resolved after the VA “apologized” to SP2 in similar incidents prior to this. On May 4, 2025, the CM contacted and informed P2 that the VA “wished to work with another agency” but did not provide any information that there were concerns with staff performance or conduct when providing services to the VA. P2 stated that this situation was similar to when the VA became “upset” with SP1 for unknown reasons and requested that the facility provide different staffing to the VA. Shortly after the VA made this request, the VA then contacted administrative staff to “apologize” and request for SP1 to continue in providing support and services to the VA, but administrative staff decided that it was “best for all” to have SP2 and P1 work with the VA going forward. · During the time when the facility provided services to the VA, there were not any known incidents of staff persons using, distributing, and/or being under the influence of substances while working with the VA including times when staff transported the VA. SP2 stated that s/he and the VA exchanged “tons” of text messages or social media messages that “joked” about topics such a marijuana but SP2 denied smoking marijuana with the VA or using any substances prior to his/her shifts when working with the VA. Additionally, SP2 “got too close” with his/her clients and was “hurt” after finding out about this investigation from P2 and called the VA. SP2 then left the VA a voicemail to ask why the VA was attempting to “get [SP2] fired.” According to P2, SP2 and P1 were directed by administrative staff to not make any further contact with the VA after the facility stopped providing services to the VA. Additionally, P2 had concerns with staff maintaining “professional boundaries” that were consistent with the facility’s policies and expectations and stated that “sometimes” staff would “get to close” to a client and “act like the client was [his/her] friend.” · There was not a “set schedule” with consistent dates/times of when staff provided services to the VA, but a weekly schedule was to be arranged and communicated between each staff person and the VA that maintained the supports and service hours outlined by the VA’s plans with “flexibility” to the availability of the staff each week. Although there were unspecified times when SP2 or P1 were “late” for arriving to a shift with the VA or needed to “reschedule” a shift due to “life getting in the way,” there were not any known “complaints” or ongoing concerns of this happening that the facility was made aware of. Staff used time tracking software through an application that was downloaded onto their personal cell phones that recorded the dates, times, and locations of when a staff person started and ended their shifts. While working with the VA, there were not any known incidents of staff “misusing” the application to show that s/he worked a shift that the staff person was not present for. According to the facility's Drug and Alcohol Policy updated November 22, 2015, staff were “prohibited” from the use, possession, distribution, and being under the influence of drugs or alcohol or the misuse of prescribed medications while providing services to clients. Facility documentation showed that SP1, SP2, P1, and P2 received training on the VA’s plans; the facility’s Drugs and Alcohol Policy; and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although the VA stated that on multiple dates SP1 and SP2 smoked marijuana with the VA and/or were under the influence of marijuana while providing services to the VA that included transportation, the VA did not recall specific dates, times, and/or additional details regarding these incidents. Additionally, the VA was not subject to guardianship and of legal age to purchase and use marijuana. Furthermore, the VA’s plans did not provide any information that the VA was at risk when using marijuana. Consistent information was provided by the CM, SP2, P1, and P2 that there were not any known concerns with the care that the VA received by SP1, SP2, and/or P1 until the VA became “upset” with the staff and that prior to this, all staff had a good relationship with the VA. Additionally, SP2 denied smoking marijuana with the VA or being under the influence of marijuana while providing services the VA that included transportation. No information was provided that anyone else observed SP1 and/or SP2 smoke marijuana while working at the VA’s home. Given that conflicting information was provided by the VA and SP2 and that there was no additional information to refute or support either account, there was not a preponderance of the evidence whether the SP failed to supply the VA with care and services which were reasonable and necessary to maintain the VA’s physical health and 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 and determined that the facility’s policies were adequate and were followed by the staff persons. After the incident, the SP was retrained on the facility’s policies, including the facility’s updated Drug and Alcohol Policy. Action Taken by Department of Human Services, Office of Inspector General: On August 27, 2025, the facility was issued a $400 fine for failing to have completed two background studies via NetStudy 2.0.
|
