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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: 1068661-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) purchased items (marijuana products, nicotine products, and alcohol) for a vulnerable adult (VA) that were illegal for the VA due to his/her age. Date of Incident(s): June to September 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 September 26, 2024; from documentation at the facility; and through six interviews conducted with the VA, a housemate (HM), three facility staff persons (the SP, P1, and P2), and a guardian (G). The VA enjoyed spending time with his/her family, playing video games, and going for walks. The VA’s diagnoses included fetal alcohol syndrome, conduct disorder, major depressive disorder, attention-deficit hyperactivity disorder, anxiety disorder, and intellectual disability. At the time of the investigation, the VA was 20 years old. The VA’s plans showed the following information: · A Functional Assessment stated that when the VA shopped, staff persons were present to ensure the VA did not purchase something s/he was not supposed to due to the VA being “impulsive.” (Information showed that the VA often purchased food, marijuana, and nicotine. When this occurred, his/her guardian was supposed to pick up the marijuana and remove it from the VA’s possession.) A family member managed the VA’s finances. · An Individual Abuse Prevention Plan stated that staff persons assisted the VA in spending or making purchases and tracking purchases made. A Program Abuse Prevention Plan showed that the facility served three individuals, including the VA. The facility was a one-level home with a full basement. The VA provided the following information. The SP purchased “tobacco and weed” for the VA “multiple times” because the VA “asked [the SP] to.” On at least one occasion, the HM was present when the purchases were made at a smoke shop near a Hy-Vee store. The SP paid for the items and the VA paid the SP back using a Venmo payment account. The VA believed this occurred “over 10” times. On occasion the VA overpaid the SP, and the SP repaid the VA the extra amount. Around August 2024, the SP refused to purchase anything else for the VA and asked the VA not to tell anyone about the previous purchases. P1, a management person, stated that according to the facility’s policies, staff persons were not supposed to buy items for clients or purchase items from clients. However, on multiple occasions the SP purchased items for the VA that the VA was not old enough to legally obtain. The VA showed P1 screenshots of the VA’s Venmo account that showed payments between the VA and SP. When P1 heard that the HM was present when at least one item was purchased, s/he spoke to the HM who confirmed s/he was present when the SP purchased an item for the VA and that the SP was “forced to do it” because the VA “wouldn’t stop asking or bugging [the SP] until [s/he] agreed to do it.” The facility provided this investigator multiple screenshots from the VA’s phone showing ten Venmo payments to the SP between June 26 and August 4, 2024. Payments from the VA to the SP’s Venmo account ranged from $25 to $80. Some of the payments from the VA to the SP included emojis (pictures of pizza, a cup of coffee, etc.) and others stated the payment was for “nic-o-tine [sic],” “ajoint [sic],” “lost mary [sic] (a brand of disposable vape) & edibles,” “5g,” “new nic [sic]” and “liquor.” On three of those dates, the SP repaid the VA some money with a notation such as “change,” or “left over.” P2 provided the following information: · When P2 heard that the SP purchased items that were illegal for the VA to have due to his/her age, s/he questioned the VA, and the VA said that the SP purchased nicotine and alcohol for the VA. When P2 cleaned the VA’s room, s/he found (unidentified) “illegal” items that were removed and given to his/her supervisor (determined to be P1). · The SP was aware of the VA’s program and issues because they were included in the VA’s paperwork. In addition, the SP was trained regarding the facility’s policies and procedures prohibiting staff persons from purchasing items for or from the clients. According to the HM, the VA “pressured” the SP into making purchases for the VA, including “Delta-9 THC products.” (Delta-9 tetrahydrocannabinol is the primary psychoactive compound in cannabis and hemp plants. THC can be found in gummies and vape pens.) The HM was present “a few times” when the SP made the purchases for “gummies and edibles” for the VA at a smoke shop by a Hy-Vee. The VA showed the HM when the VA “got money” or “wanted to buy stuff” including edibles and vape pens and showed the HM “receipts” s/he had for transferring money to the SP via Venmo. The VA also asked the HM to make purchases for the VA and sent the HM money via Venmo; however, the HM refused and returned the money to the VA. The G said that the VA was able to accurately report events yet “sometimes gets mad about things” and “adds on” but there was generally “truth to it.” Specific to these allegations, the G believe the VA was telling the truth. The SP provided the following information: · In September 2024, the SP “snitched on” the VA for “sneaking out at night.” As a result, the VA retaliated and told others that the SP supplied “THC products” to the VA. · If the VA was told “no” or did not get what s/he wanted, s/he threatened to “run-away” or snuck out to get what s/he wanted, which was usually marijuana. The HM had a medical card to get marijuana and the VA broke in the HM’s room and stole the HM’s products. The VA also stole a vape pen from the SP and another staff person (P3). Staff persons were only aware that the VA stole these items when they “deep cleaned” the VA’s bedroom. · The VA had an “old iPhone” and was not able to use “Apple Pay” and had no credit or debit card, so the SP allowed the VA to use the SP’s “Venmo card” to get “food or drinks.” When asked why s/he allowed the VA to use his/her Venmo card, the SP said that staff persons were told to “pick our own battles” regarding how to engage with the VA and what to tell him/her yes or no about. If the VA was told “no,” s/he would “snap instantly” and threatened to leave the facility or kill him/herself, police, or staff persons. · The VA’s family members sent him/her money and the VA transferred the money to the SP’s Venmo account. When asked why the VA did not have his/her own Venmo card, the SP said the VA “kept trying to get one.” · The SP denied purchasing nicotine, any marijuana/THC products, or alcohol for the VA. When asked about the screenshots regarding the Venmo payments between the VA and the SP, the SP said s/he had “no idea” where they came from. · The SP admitted s/he was trained regarding the facility policy regarding client funds and property and that s/he was “not supposed to do that.” · The SP was not aware of anyone witnessing him/her purchasing anything for the VA at a smoke shop and said purchases at the smoke shop were only made for him/herself. The SP’s Job Description stated s/he was responsible for keeping track of person served funds and receipts and document all money spent including cash, debit cards, and/or checkbook, and to “obtain receipts when possible or make one when not available.” The facility’s policy regarding Management of Individual Funds and Property stated that staff persons will not borrow money from or lend money to a client and will not sell merchandise to a client. According to Minnesota law, individuals must be 21 years old to legally purchase alcohol, tobacco and related products, and marijuana/cannabis related products. Facility information showed that staff persons were trained regarding the VA’s program plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Between June 26 and August 4, 2024, the VA paid the SP via Venmo to purchase items for the VA such as tobacco products, alcohol, and marijuana/THC products for the VA. All those purchases were illegal because the VA was under 21. Although the SP denied making any of those purchases for the VA, the HM said that s/he was present “a few times” when the SP purchased “gummies and edibles” for the VA, and screenshots from the VA to the SP confirmed the payments with descriptions that showed these things were purchased. In addition, on three of those occasions the SP returned some money to the VA for overpayments. Given the screenshots and the HM witnessing some purchases and that the SP assisted the VA to engage in illegal activity, there was a preponderance of the evidence that the SP did not provide reasonable and necessary care and services to the VA. 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: (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 regarding the VA’s program plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment 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. It was determined that the substantiated neglect for which the SP was responsible was not “serious” maltreatment because the VA did not sustain an injury that required the care of a physician. However, it was recurring maltreatment because the SP made purchases of illegal products for the VA on multiple occasions. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed regarding client funds. Additional training for staff persons was provided regarding the management of client funds. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for 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.
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