|
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: 1073647-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen Suspected Maltreatment Reported: It was reported that a staff person (SP) failed to supervise a vulnerable adult (VA) which resulted in the VA having sexual contact with the SP’s child (C). Date of Incident(s): December 2024 to September 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 October 15, 2025; from documentation at the facility and law enforcement records; and through six interviews conducted with the VA’s guardian (G), the VA’s case manager (CM), a facility supervisory staff person (P1), two facility staff persons (P2, and the SP), and the VA. The C was not interviewed for this investigation but was interviewed by a person who specialized in the forensic interviewing of children of possible sexual abuse. That information is included below. The VA was diagnosed with post-traumatic stress disorder (PTSD), anxiety, reactive attachment disorder (RAD), intellectual disability, and unspecified behavioral and emotional disorders. The VA required assistance with transportation and appointments and needed reminders to complete grooming and daily household tasks. The VA enjoyed playing games, going for walks, swimming, cooking and talking with family and staff persons. The VA’s Individual Abuse Prevention Plan said that the VA “lacked impulse control and understanding of boundaries and relationships.” The VA had a history of verbal and physical abuse towards others, and due to his/her diagnosis, the VA was unable to identify potentially dangerous situations. The VA lacked “a good understanding of boundaries and relationships” and in the past dated persons who were older with criminal backgrounds. The VA was “very vulnerable to sexual abuse as [s/he] lacked impulse control and had difficulty with appropriate boundaries. Staff will document and observe any unusual injuries, markings, flinching, and/or behavioral changes. Staff will assess [the VA] for any signs of maltreatment. Staff will discuss with [the VA] healthy relationships and concerns [s/he] may express, or they may observe.” The VA’s Coordinated Service and Support Plan (CSSP) said, “We [the facility] fully monitor who has access to the lower floor of the home and only [the VA] and staff persons are allowed there.” The VA’s Self-Management Assessment said that the VA required staff person supervision while in the community for more than thirty minutes but did not have supervision requirements while at the facility. [Note: There was no information in the VA’s plans that the VA had any history of sexually abusing others including minors.] The facility was a family home in a residential neighborhood with a main floor, which had three bedrooms, one bathroom, a kitchen/dining area and living room. Upon entering the home, there were stairs going to the lower level, which curved to the left at the bottom. The lower level had a living room, a large laundry and storeroom, one bedroom at the end of a long hallway, one bathroom and an office. The VA’s bedroom was in the lower level, and s/he was the only resident who resided downstairs. There were three cameras in the facility. One camera was in the upstairs living/dining area, a second was in the lower level overlooking the living room and the third was in the storeroom, overlooking both the storeroom and the laundry room. The VA provided the following information: · The VA did not have supervision requirements at the facility, but had a rights restriction that said s/he could not use the telephone unless staff persons were by the VA “listening.” The VA was not allowed to go to stores or walk around town alone, but staff persons sometimes allowed the VA to walk to church and to a nearby store alone. · The SP started work at the facility in August 2024 and brought the C with him/her to work. The C was not allowed in residents’ bedrooms, and the VA was not allowed to use any electronics the C brought to the facility. Two other staff persons also brought their children to work on occasion, and they followed the same rules. · When the C was at the facility with the SP, the SP did not check on the C “at all.” The C watched television in the basement of the facility, and the VA was “practically the babysitter.” If the C and the other children were at the facility, the VA was with them and the SP and other staff persons were upstairs doing “shift change,” on their phones, talking about “personal matters,” or sitting outside in the garage. The VA sometimes went upstairs to check if staff persons were done and s/he was told, “No. Get back downstairs.” · On an unknown date, P1 and the SP asked the VA to walk the C from school to the facility so the C “knew the route.” The SP told the VA that the first time the VA would ride with the SP to pick the C up from school, and then the VA and the C would walk to the facility while the SP drove. Then the next day, the VA and the C would do a “trial run” and walk to the facility without the SP. The VA agreed to this because the C was “like a sister/brother” to the VA. The VA did not ever have a chance to walk the C back from the facility due to the incident. · In June 2025, the VA spent time with the SP and the C at the SP’s home. In July 2025, P1 approved the VA to stay overnight two nights at the SP’s home, but the VA did not think P1 obtained permission from the G. · The VA thought s/he was supervised appropriately at the facility, but did not think the SP supervised the C because the VA was “always there.” The VA felt like s/he was the “[big brother/sister], [mom/dad] or friend” to the C. The VA was “practically” in charge of the C and the C told the VA to “shut up” and “go away” even though the basement was the VA’s space. The C, who was 10 and 11 years old at the time of the incidents, provided the following information during his/her forensic interview, to the LEO, P1, and the SP: · On October 1, 2025, the C told the SP and then P1 that beginning in December 2024 and ending around September 2025, the C had sexual contact with the VA on multiple occasions when the C was at the facility with the SP. The C said the contact occurred in the VA’s bedroom, the lower-level living room, the laundry room, and/or storage room at the facility. · On October 20, 2025, the C completed a forensic interview and provided information that was consistent with the information the C provided to the SP and P1. The C stated s/he told P1 about what happened with the VA after P1 told the C that s/he arranged for the VA to walk the C to the facility after school. The C stated that the SP told him/her that when s/he was at the facility, s/he was not allowed to go into the room where staff persons “clocked in and out,” was not allowed to have food or beverages on the lower level, could not be “too loud” and was not allowed to watch certain shows on the television upstairs. The C also stated that there were cameras located in some of the rooms that the incidents occurred in. The C stated the SP “never knew” what was going on. Law enforcement reports provided the following information: · On October 1, 2025, at 5:40 p.m., law enforcement officers (LEO) responded to the facility for a report of a sexual assault. The LEO spoke with the SP who told the LEO that the VA had “molested” the C and that the contact began in December 2024, while the C was at the facility when the SP worked. · When the LEO spoke to the C, the C also stated that the contact occurred “around twelve times” and that the VA told the C to “keep it a secret.” · The LEO then spoke with the VA who denied the sexual contact, and said the C was “like a [brother/sister]” to the VA. · The VA was arrested and charged with felony criminal sexual conduct – 2nd degree. P1 and P2 provided the following consistent information: · On October 1, 2025, around 5:30 p.m. the SP called P1 and told him/her that the VA had sexual contact with the C when the C was at the facility. The SP then drove to the facility and both the SP, and the C provided P1 the same information. P1 then called P2 and asked P2 to check the cameras at the facility to see if any of the contact was on camera. P2 checked the cameras and found that they were either not working or manually unplugged on days the SP worked, and the C was with him/her. · The VA did not have supervision requirements at the facility but required staff supervision in some public settings. The VA went to church and on walks unsupervised, but a staff person went with the VA to stores. The VA had a rights restriction with devices that could access the internet after the VA met strangers online for the purpose of having “intercourse,” but neither P1 nor P2 were aware of the VA having a history of inappropriate sexual interactions. · P1 stated that s/he expected staff persons to check on residents in the facility “at least” every hour regardless of the resident’s supervision requirements. · On an unknown date, P1 spoke with the VA and asked the VA to walk the C from school to the facility so the C “felt [s/he] had more freedom.” P1 asked the VA to show the C a “good, safe, fast path” from his/her school to the facility because the VA enjoyed walks. P1 thought the C and the VA had a good relationship. P1 planned to speak with the G about this, however the VA was arrested so the VA never walked with the C. · P2 stated the VA had the “mental acuity” of someone “a few years younger than [him/her]” and P1 said the VA functioned at a “thirteen- to fifteen-year-old range mentally.” The VA was “immature” and had many questions about how to complete basic tasks like cooking, cleaning and chores. P1 thought the VA was “emotionally stunted” and often had “big crushes” on individuals of the opposite gender. · Due to work staff scheduling conflicts, P1 approved the C to come to the facility with the SP when the SP worked, and the C usually did so after school. P1 told the SP that the C was only allowed in the “common areas” of the facility, and was not to go into residents’ bedrooms, the office area, or the basement bathroom. Common areas included the living rooms, kitchen, dining room, laundry room and storeroom. · The facility did not have a specified visitation policy because residents were allowed to have “whoever they wanted” at the facility. P1 told staff persons that if someone visited them at the facility, the visitor could not have a criminal record and had to stay in the upstairs living room. P1 stated the owner of the facility was aware that staff persons children joined them at the facility, and did not have any requirements regarding them being there. · Neither P1 nor P2 had concerns with the SP’s supervision of the VA. The SP provided the following information: · The VA required staff person supervision if s/he went to a store but did not require supervision at the facility. · In December 2024, due to scheduling conflicts with the SP’s work schedule, the C came to the facility with the SP “a couple of times” during a school break. After that, the C came to the facility one or two times a month. The C was usually at the facility after school for approximately thirty minutes and usually stayed in the kitchen and had a snack before they left, but sometimes spent the entire day on days the C was sick or there was no school. · P1 approved the SP bringing the C to work with him/her because the C was “unable” to be home alone. The C had to stay in “common areas,” and was not allowed in residents bedrooms, in the office or the basement bathroom. Common areas included the upstairs and downstairs living rooms, laundry room, storeroom, and outside. The C often spent time with the VA watching television or playing video games in the downstairs living room. When the C was downstairs, the SP checked on the C “at least” every hour · When the SP worked, s/he checked on residents every hour, unless the residents plans required checks more often. · The VA spent time with the SP’s family outside of the facility, which P1 approved. In October 2024, the VA went trick or treating with the SP and his/her family, and on July 4, 2025, the VA spent the day and slept overnight at the SP’s home. The SP did not know if P1 obtained permission from the G. · The C did not feel comfortable walking to the facility after school alone, so the SP, P1, and the VA agreed that the VA would walk the C back to the facility on days the SP was unable to get the C from school. P1 spoke with the C about this, and both days the VA was supposed to walk the C to the facility, the C had “significant” behaviors at school and had to be picked up early. The VA never walked the C to the facility because shortly after the decision was made, the VA was arrested. · The SP did not see any inappropriate interactions between the VA and the C and did not believe s/he failed to supervise the VA at the facility, because the VA did not require supervision. The SP thought s/he “completely failed” the C. The G was aware of the allegations and stated that the VA was “mentally like a twelve-year-old” and presented “better” than s/he was. The G could not remember the VA’s supervision requirements at the facility and did not have previous concerns with the facility. The CM was aware of the allegations, and did not have previous concerns with the facility. P2 stated that the facility did not have any policies and procedures related to visitors/staff persons family members at the facility. P1, P2, and the SP each stated that they were trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Information obtained via interviews showed that staff persons were trained, however, the facility was unable to provide documentation to show that staff persons were trained, which was a violation of Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2) states in part that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation and training as required under section 245D.09, subdivisions 3 to 5 including the date the training was completed, the number of hours pers subject area, and the name of the trainer or instructor. Relevant Rules/Statutes Minnesota Statutes, section 245D.09, subdivision 1, states in part that the license holder must provide the level of direct services support staff supervision and assistance, to ensure the health, safety, and protection of rights of each person, and be able to implement the responsibilities assigned to the license holder in each person’s support plan or support plan addendum. Minnesota Statutes, section 245D.11, subdivision 3, states in part that the license holder must establish policies and procedures that promote service recipient rights by ensuring data privacy according to the Minnesota Government Data Practice Act and the Health Insurance and Portability and Accountability Act. Conclusion: A. Maltreatment: The VA lived in a residential program operated by the license holder. When the VA moved into the facility, the facility was aware that the VA “lacked impulse control and understanding of boundaries and relationships.” The VA did not have supervision requirements at the facility and was the only resident who had a bedroom in the lower level. The VA’s CSSP said, “We [the facility] fully monitor who has access to the lower floor of the home and only [the VA] and staff persons are allowed there.” Information obtained was consistent that P1 approved for the SP and other staff persons to bring their children to the facility while they worked. The facility did not have a formal supervision policy outlining expectations when the C and other children came to the facility, and there was no documentation provided to support staff persons had been trained on facility policies and procedures, which was a violation as outlined above. The C often spent time in the lower level of the facility watching television and playing video games. Consistent information was provided that over the course of eight months, the VA had sexual contact with the C in multiple rooms of the lower level, while the C was at the facility with the SP when the SP worked. These actions resulted in the VA being arrested and charged with Felony Criminal Sexual Misconduct – 2nd Degree. Although the VA did not have supervision requirements while at the facility, and there was no information in the VA’s plans that the VA had any history of sexually abusing others, including minors, the VA was receiving services in a licensed facility for which staff persons were responsible to ensure the health, safety and protection of rights of each person and establish policies and procedures that promoted service recipient rights by ensuring data privacy according to the Minnesota Government Data Practice Act and the Health Insurance and Portability and Accountability Act. Given this, and that there was no policies or procedures in place to ensure supervision of staff persons children while they were at the facility, that there was a failure to follow the VA’s plans to “fully monitor who has access to the lower floor of the home” which allowed persons other than the VA and staff persons to be in the VA’s personal space which resulted in criminal charges for the VA, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care or services. 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 adults 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 facility routinely allowed staff persons, including the SP, to bring their children to the facility while they worked and did not have policies or procedures in place to ensure the health, safety and protection of rights of each person and/or promote service recipient rights by ensuring data privacy while the children were at the facility. This was a violation of Minnesota Statutes, section 245D.11, subdivision 3. In addition, the VA’s CSSP said, “We [the facility] fully monitor who has access to the lower floor of the home and only [the VA] and staff persons are allowed there.” Given that on multiple occasions over the course of eight months, the C was allowed on the lower floor with the VA without the supervision of a staff person, this was a violation of Minnesota Statutes, section 245D.09, subdivision 1. Although the SP was responsible for the care and supervision of the VA at the time of the incidents, the SP obtained permission from P1 for the C to be at the facility and it was routine practice to allow staff persons children to be at the facility while the staff person worked. This, in addition to the facility’s failure to maintain compliance with Minnesota Statutes, resulted in the VA sexually abusing the C over the course of eight months. Therefore, individual responsibility was mitigated, and the facility was responsible for the maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible was “serious” maltreatment because it resulted in the VA being charged with Criminal Sexual Misconduct – 2nd Degree regarding the C. Action Taken by Facility: The facility completed an Internal Review and determined that facility policies and procedures were adequate and followed. The VA no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: On December 19, 2025, the license holder was ordered to forfeit a fine of $5000 as a result of the substantiated serious maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
|
