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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: 1107574-SUD (substance use disorder) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA) while the VA received services from the facility. Date of Incident(s): Prior to July 31, 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 (c); and subdivision 17, paragraph (a): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 for this investigation was obtained remotely, including documentation from the facility and through seven interviews conducted with the VA, the SP, a management staff person (P1), a facility staff person (P2), the VA’s probation officer (PO), a client (C1) who was the VA’s roommate at the facility, and another facility client (C2). A facility staff person (P3) provided information to facility management on August 20, 2025, which was included below. The VA received services from the facility between December 17, 2024, and April 2, 2025. The SP was employed at the facility during that time. The VA’s Comprehensive Assessment Summary showed that the VA was diagnosed with depression, anxiety, and insomnia. The VA’s Client Detail Report showed that the VA had “alcohol dependence.” The VA’s Treatment Plan Review showed that the VA was motivated “for change” and had a desire to move to Alaska. P1 provided the following information in the Managerial Investigation Report and to this investigator: · Prior to August 1, 2025, C1 told P1 that the SP and the VA text messaged one another while the VA received services at the facility, but the contents of the messages were not disclosed to P1. As a result, P1 talked to the VA and the SP, and they both denied texting one another. · On August 1, 2025, P2 talked to P1 and told P1 that while P2 was at a “bar” on or around July 26, 2025, P2 saw the VA and the SP at the bar, and both appeared to be “intoxicated.” P2 talked to the SP and while the VA was present, the SP told P2 that s/he performed “oral sex” on the VA while the VA received services from the facility, but the SP did not provide a date. The SP also told P2 that the VA was currently living with the SP. · While the SP was employed at the facility, P1 did not have concerns related to the SP’s interactions with the VA and no staff person brought concerns forward regarding the SP. · When P1 investigated the matter, C2, who was in the room just below the VA, told P1 that s/he heard “moaning” sounds from the VA’s room and heard the SP’s voice, but C2 did not see the SP go into or out of the VA’s bedroom. C1 stated that in April 2025, C1 saw a Facebook message, on the VA’s phone, that the SP sent to the VA that contained the SP’s phone number. When C1 was asked what else the message said, C1 stated that s/he “didn’t read it that well.” C1 did not have any concerns related to the SP’s interactions with the VA and did not believe that the SP treated the VA differently than other clients. P2 provided information that was consistent with the information s/he provided to P1 and told this investigator that when the SP told P2 at the bar about the sexual contact the VA and the SP had while the VA was receiving services at the facility, the VA “agreed with it.” On an unspecified date, C1 told P2 that s/he saw the VA riding in the SP’s vehicle during the time that the VA was receiving services from the facility (C1 did not provide this information to the investigator). P2 described the SP as being “overly friendly” with clients because the SP shared personal information with clients, such as information about the SP’s home life. The VA stated that s/he did not have sexual contact with any staff person at the facility, that s/he did not go to a bar in the area with any staff person, that s/he did not communicate via text or Facebook with any staff person, that s/he had never lived with a staff person, had not been to a staff persons home, and that no staff person provided transportation of a personal nature to the VA while s/he received services from the facility. The PO stated that s/he had not talked to the VA within the past three to four months and when s/he last talked to the VA, the VA did not say anything about being in a relationship with a staff person at the facility. The facility’s Professional Conduct Policy stated that staff persons were expected to demonstrate “professional behaviors” and “create a professional relationship with all clients.” The policy also stated that staff persons were prohibited from having sexual contact with clients. The police department Case Report Detail provided the following information: · At 12:47 a.m. on July 20, 2025, law enforcement was dispatched to an address in St. Cloud, Minnesota. The reason law enforcement was called the VA was “making concerning comments about harming [his/herself] and others.” When the VA became increasingly agitated (yelling), the VA was “arrested for disorderly conduct” and taken to a hospital for his/her “severe alcoholism.” · The report also documented, “I located [the VA’s] address from previous call for service” to the SP’s address and that the VA was a “resident.” · Law enforcement also “learned” that the SP was the VA’s significant other, but the report did not identify who said that. · When the SP was interviewed, the SP said that s/he “did not watch” the VA “the entire day as [s/he] has been trying to break up with [him/her] and have [him/her] leave” the SP’s residence. C2 provided information to this investigator that was consistent with the information s/he provided to P1: C2 provided the following additional information to this investigator: · On August 20, 2025, P3 and C2 were in the office together when C2 noticed a wall that contained pictures of current staff members. When C2 did not see the SP’s picture, P3 told C2 that the SP was no longer employed by the facility. C2 said, “[S/he] was weird…not with me,” but with the VA. · When P3 asked C2 for more information, C2 said that s/he heard the SP and the VA “engaging in sexual activity” in the VA’s room. C2 described it as a “moaning” sound, said that it happened more than one time and that each time it lasted about 20 minutes. At the time, C2’s room was within proximity to the room the VA occupied. C2 did not see the SP enter or exit the VA’s room. · While the VA and the SP were in the VA’s room, C2 heard the SP ask the VA who was in the room (the room C2 occupied) and the VA said, “It’s [C2] don’t worry, [s/he] won’t say anything.” C2 was able to “confirm” that the voices s/he heard were the SP’s and the VA’s voices. C2 described the walls at the facility to be “paper thin.” · C2 did not remember the date, but asked the SP if s/he was in a relationship with the VA. Although the SP did not confirm anything to C2, the SP told C2, “Please don’t tell anybody.” On an unspecified date in March 2025, the VA told C2 that s/he had been to the SP’s home and that the VA, and the SP had sexual contact at the facility. · When P3 asked C2 why C2 had not said something earlier, C2 said, “Because it was none of my business.” The SP provided the following information: · When the SP was asked to provide information in terms of areas where staff might not be exhibiting professional boundaries with clients, the SP stated that there was one occasion on an unknown date when the SP, P2, and another client were in the office. While P2 sat at a desk, the client was on the other side of the desk and the SP was behind P2. The SP noticed that while P2 used his/her phone and was looking down, P2 said, “Oh by the way, I’m not entering your phone number into my phone.” The SP described the incident as being “awkward” and believed that P2 was entering the client’s phone number into the SP’s phone. The SP did not know whether P2 and that client communicated with one another via phone. · The SP acknowledged that s/he might “overstep a bit” in terms of the information s/he shared with clients. The SP gave an example in which s/he had a medical situation that s/he shared with clients. · The SP denied any type of personal communication with the VA, via phone or social media, telling anyone in public that s/he had sexual contact with the VA, going to “the bar,” that the VA lived with the SP, that the VA was at the SP’s home, having sexual contact with the VA, and giving the VA a ride in the SP’s vehicle for personal reasons. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to July 1, 2025. Conclusion: According to P2, P2 saw the VA and the SP at a “bar” in July 2025 and when P2 talked to the SP and the VA, the SP told P2 that s/he had sexual contact with the VA at the facility and the VA agreed that it happened. The SP also told P2 that the VA was living with the SP. Prior to P2 communicating this information to P1, the C told P1 that the SP and the VA were text messaging one another while the VA received services at the facility, but P1 was not able to determine this happened because the VA and the SP denied it. P1 did not have concerns related to the SP’s interactions with clients. Although others providing information about the SP and the VA having a relationship and sexual contact while the VA was receiving services at the facility, given that the SP and the VA each denied having sexual contact with one another, telling anyone in the community that they had sexual contact, that they lived with one another, that they communicated via text or social media while the VA received services from the facility, and that the VA had been to the SP’s residence, and that there was no further information regarding the SP’s and the VA’s relationship while the VA received services from the facility, there was not a preponderance of the evidence whether the SP had sexual contact with the VA or failed to provide the VA with reasonable and necessary care and services. It was not determined whether sexual contact or neglect occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast; 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 although policies and procedures were adequate but not followed. Additional training was provided to all staff. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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