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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 Numbers and Program Types: 1073715-H_CRS (Home and Community-Based Services-Community Residential Setting) – Facility A 1073714-H_CRS (Home and Community-Based Services-Community Residential Setting) – Facility B Investigator(s): Jason Pehler/Beth Virden jason.pehler@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) called vulnerable adults (VA1 and VA2), “[R-word]” and/or “Dogs.” Date of Incident(s): October/November 2023 and January 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 (b), clause (2): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 9, 2025; from documentation at the facility; and through eight interviews conducted with staff persons (the SP and P2), supervisory staff persons (P3-P5), and housemates (H1-H3). The DHS investigator met VA1 and VA2 but did not complete interviews due to their limited communication skills. VA1’s and VA2’s guardians (G1 and G2, respectively) were notified of this investigation but did not provide information. Attempts were made by telephone to contact and interview an additional staff person (P1), but P1 did not respond by the completion of this investigation. P1 provided some information at the outset of the investigation, which was included in this report. VA1, H1, and H2 lived at Facility A. VA2 and H3 lived at Facility B. Facilities A and B were single-family homes operated by the same license holder. The SP worked at both Facilities A and B. VA1’s support plans, including Individual Abuse Prevention Plan, stated the following: · In 2021, VA1 moved into Facility A seeking support and services relating to his/her diagnoses, which included autism spectrum disorder and speech disorder. Facility A provided VA1 with 24-hour staffing and daily supports and supervision to ensure his/her basic health and safety needs were met. · VA1 understood short, simple requests but was unable to hold a conversation. If VA1 was upset, s/he communicated by using gestures, sounds, and movements. VA1’s goal was the learn more words. · VA1 was susceptible to abuse from others and might not recognize or defend against potentially dangerous situations. Staff ensured VA1’s safety and reported concerns on VA1’s behalf. VA2’s support plans, including Individual Abuse Prevention Plan, stated the following: · In 2021, VA2 moved into the Facility B and his/her diagnoses, included developmental disability and autism spectrum disorder. Facility B helped VA2 with his/her daily living skills. · VA2 used gestures and vocalizations to communicate his/her likes/dislikes and feelings. · VA2’s “loud vocalizations” might “irritate” others and make him/her a target for retaliation. VA2 was susceptible to abuse from others and might be unable to defend him/herself if needed. Staff monitored VA2’s interactions, intervened when needed, and reported concerns on VA2’s behalf. P1-P5 provided the following information: · P2 said that in October/November 2023, the SP trained him/her to work at Facility B. At one point, when speaking about the housemates, the SP told P2, “They listen like dogs.” VA2 was about 10-15 feet away when the SP said this. VA2 did not react but was within earshot. P2 believed the SP’s statement was “gross” and told P4. P2 did not hear the SP make any similar statements since. · P4 said that s/he and P5 met with the SP and the SP “admitted” to making the statement about “dogs” but explained that s/he was trying to teach P2 how to speak to housemates with limited communication skills. · P5 said that the SP explained that s/he told new staff to use “short … directives” when speaking to the housemates, like you might use with a dog. For instance, “Come here. Sit down. Put your shoes on.” The SP said that s/he was not calling the housemates, “dogs.” P5 said that the SP’s language was not consistent with training and at that time, the SP agreed to no longer use such language. · In April 2025, P1 told an administrative staff person that in January 2025, the SP told P1, while in the same room as VA1, “You can tell [VA1] whatever, like a dog. [VA1’s] fucking [R-word].” · Also, in April 2025, P3 told an administrative staff person that s/he remembered receiving a call from P1 in January 2025. The SP was training P1 at the time and said something to P1, like, “[VA1] is just like a dog. So, if you tell [VA1] to sit, [s/he] will sit. If you tell [VA1] to eat, [s/he] will eat.” P3 told P5, who said that s/he would “take care of it,” but to P3’s knowledge, P5 did not do anything about it. P3 was not aware of P1’s concern that the SP used the R-word during this time. · P4 and P5 each said that there was “drama” among staff at the facility, which might contribute to the allegations brought forth in April about the SP’s conduct in January 2025. P1 and P3 were “best friends” and no longer working at the facility. P4 and P5 were each only aware of the incident that occurred in October/November 2023 and were never informed of similar concerns since then. P4 and P5 each said that, in knowing the SP, they did not believe the SP would say the R-word. The SP said that regarding the incident in October/November 2023, s/he did not call anyone a “dog.” Instead, the SP was saying that when speaking to a dog, you must be “firm” and “loving” and “simplify your words,” which was like how staff should talk to the housemates. At that time, the SP did not know his/her statement was inappropriate; however, once s/he learned from P4 and P5 that it was inappropriate, s/he never said it again. The SP did not recall saying the R-word. The SP believed the allegations about January 2025 were made because there was “all the drama” among staff. H1, H2, and H3 each said that they had no concerns about living at the facility. When the SP’s name was brought up to H1 and H2, they did not state any concerns about the SP. H3 said that s/he never heard a staff person say anything “rude.” Facility documentation stated that the SP and P1-P5 received training on the Reporting of Maltreatment of Vulnerable Adults Act. The SP and P1-P4 also received training on VA1’s and/or VA2’s support plans depending on who they worked with. P5 did not provide direct care services to VA1 or VA2. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), states, in relevant part, that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion: Information was provided that in October/November 2023, the SP made a statement about talking to the housemates like they were “dogs” and that this was said within earshot of VA2, which was a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). At that time, the SP agreed to no longer use such language Additional information was provided that in January 2025, the SP again made a statement about “dogs” and called VA1, “[The R-word].” However, the SP denied this allegation and P2, P4, P5, and H1-H3 had no related information or concerns. P2, P4, and P5 were only aware of the incident in October/November 2023 and were not informed of any similar incidents since. Although P3 said that s/he received a call from P1 regarding the SP’s statements in January 2025, P3 was not informed about P1’s concern the SP used the R-word at that time. The SP, P4, and P5 believed the allegation was related to “drama” among staff. Although the alleged use of the R-word was concerning and would be inconsistent with the care of a professional caregiver in a facility licensed by the Department of Human Services, there was not a preponderance of the evidence whether the SP made one statement about “dogs” in 2023, or whether the SP continued to make such statements, including the R-word, which was repeated or malicious language and/or engaged in the treatment of a vulnerable adult, which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: Facility A and B completed internal reviews and determined that policies and procedures were adequate but not followed regarding the statement about “dogs” in 2023 and the reporting of suspected or known maltreatment. Staff received additional training, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, a correction order was not issued for the violation outlined above.
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