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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: 1114045-SUD (Substance Use Disorder) Investigator(s): Scout Peterson Suspected Maltreatment Reported: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA) while the VA received services at the facility. It was also reported that the SP gave the VA cocaine and Suboxone that the VA was not prescribed. Date of Incident(s): Ongoing between May and June 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 three interviews conducted with the VA, a facility staff person (P1), and a supervisory staff person (P2). Attempts were made to via phone and certified mail to contact and interview the SP. An interview was scheduled, but the SP did not answer at the prearranged time and the SP did not respond to subsequent attempts. Attempts were also made via phone to contact and interview another client (C) but the C did not respond to the requests. In June 2025, the Department of Human Services received a report of possible maltreatment that the SP and the VA had an “inappropriate” relationship that included sexual contact. At that time, the SP and the VA each denied having sexual contact and the report was not assigned for investigation. On October 31, 2025, the Department received new information and the report was assigned at that time. The VA resided at the facility from March 10 to June 17, 2025, to receive services and supports for substance use disorder and mental health concerns. The VA was diagnosed with schizoaffective disorder, attention deficit hyperactivity disorder, posttraumatic stress disorder, panic disorder and generalized anxiety disorder. Regarding a sexual relationship between the SP and the VA while the VA received services at the facility: Documentation from the facility showed that on May 18 and 25, and June 1, 2025, the VA went on an eight-hour Saturday pass respectively. Each pass was pre-approved, and the VA stated s/he planned to spend the time with his/her friends. The VA provided the following information: · On June 17, 2025, the VA "graduated" from the facility and told staff persons that s/he was going to a sober living program, but instead went to live with the SP. Around that time, when the facility asked the VA about being a relationship or having sexual contact with the SP, the VA denied any relationship because s/he was still involved with the SP. The VA stayed with the SP for an unknown amount of time s/he said s/he could not recall because s/he was “out of it” [high] on drugs provided by the SP. The VA later became homeless. At the time of this investigation, the VA had not spoken to the SP in “a few months.” · On an unknown date, the VA and the SP were in the SP’s office and got into a “disagreement.” The SP told the VA that s/he would stop helping the VA pass his/her UAs and send him/her back to jail. The VA started to braid the SP’s hair to ease the tension between them which then led to the SP having sexual intercourse with the VA for the first time. · On June 7, 2025, the VA went to a bait shop with the SP in the facility van and they had sex in the van. The VA stated that s/he and the SP had sex “at least” 15 other times while s/he lived at the facility including in the SP’s office, the laundry room, the VA’s bedroom, and the SP’s car and house. When the VA got 8-hour passes to leave the facility, the SP picked him/her up and took him/her to the SP’s house, where they had sex. The VA provided screenshots of text messages and a screen recording of his/her call log that showed: · On June 3, 2025, the SP sent text message to the VA exchanging phone numbers. Between June 9 and June 17, 2025, when the VA was discharged, there were over 15 calls and facetimes (video calls) between the SP and VA, some including the C and other friends of the VA. During that same time, the SP and VA text messaged each other every day. The contents of the text messages sent by the SP to the VA included, “I wish I was laying [sic] next to you,” “what happens if I’m pregnant … you did nut in me,” “its you and I against the world,” and “I’m glad that we took a chance at us.” The SP also referred to the VA as “baby” multiple times and sent the VA nude photos of him/herself. · On June 9, 2025, the VA and the C texted about the SP. The VA stated that “only [the SP] knew” the VA had a phone and picked the VA up when the VA went on passes. The VA also send the C three photos of the SP; in two photos the SP was naked and in the third photo the SP was aiming a gun. P2 provided the following information:
· On June 6, 2025, the SP was in the client sleeping area which was not permitted. P2 saw the SP exiting the sleeping area and the SP told P2 that s/he was there to talk to the VA. · On Saturday, June 7, 2025, at 11:35 a.m., P2 sent an email to P3 and P4 that stated s/he witnessed “inappropriate” behavior between the VA and SP. Later that day, P1 texted the SP who was on his/her way to the facility and asked the SP to stop to get bait for a fishing outing they had planned for the afternoon. The SP did not stop on her way, and when s/he got to the facility, the SP told P2 that s/he needed to pick up a company credit card to use to purchase the bait. The SP then invited the VA to go to the bait shop with him/her and they left together. P2 stated that staff persons were not allowed to take clients off-site unless it had been pre-approved by the clients’ team. P2 added that the SP should not have taken the VA and that if the SP did not want to go to the bait shop alone, s/he could have taken another staff person with him/her. · On other unknown dates, P2 saw that the VA and SP spent “a lot” of time together in the SP’s office with the door closed. Additionally, the VA grabbed the SP’s waist and they frequently went places together inside the facility and on the grounds where there were no cameras such as outside behind a garage, in the SP’s office, and in the clients’ sleeping quarters. There were other times in which the SP visited the VA at the facility or stayed late with him/her when s/he was not scheduled to work. · P2 had additional concerns about the SP’s interactions that extended beyond his/her time of employment at the facility. Because the concerns occurred after the SP no longer worked at the facility, they were not included in this investigation. P1 provided the following consistent information in the email and in an interview with this investigator: · On Sunday May 31, 2025, around 10 p.m., P1 went to the facility to bring food to other staff persons. P1 thought the SP was only scheduled to work from 8 a.m. to 4 p.m. that day but was still at the facility sitting outside with the VA and another client (C) when P1 went to the facility. P1 added that s/he noticed that the SP stayed late or returned to the facility after his/her shift was over to visit the VA. · On June 7, 2025, P1 saw the SP and VA go to the laundry room together where there were no cameras. P1 thought it was “inappropriate” because the VA did not have any laundry in his/her hands and was not doing laundry at the time, therefore there was no reason for him/her to go to the laundry room with the SP. · That same day, P1 and another staff person planned on taking the clients on an outing to go fishing. The SP texted P1 and P2 that s/he was coming in to assist with the outing, so P1 asked the SP to pick up bait on his/her way. The SP arrived at the facility and said s/he did not stop on his/her way because s/he needed get a company credit card. P1 thought that it was because the SP wanted a reason to take the VA out with him/her. When the SP announced s/he was leaving to go to the bait shop, the VA asked if s/he could go with the SP. P1 and P2, who was sitting next to P1, both said they did not know if it was allowed, and the SP decided to allow the VA to accompany him/her, and they went to the bait shop. P1 added that the SP’s behavior was “unnecessary, “very suspicious,” and “highly inappropriate.” · On Sunday, June 8, 2025, at 3:49 p.m., P1 sent an email to P3 and P4 with “concerns” regarding behavior between the SP and VA. Information in the SP’s personnel file showed that on June 9, 2025, s/he was interviewed about an “inappropriate romantic relationship and poor boundaries” between him/herself and the VA. The SP stated that s/he never behaved “inappropriately” in the workplace and never had relationships with clients. The facility’s Staff Behavior policy stated that sexual contact or “personal involvement of a sexual nature” between staff and clients, including former clients, was prohibited. Staff persons were also prohibited from engaging in personal, non-professional relationships and/or personal social media connections or electronic communications of any kind with clients and former clients. Regarding the SP giving the VA cocaine and Suboxone that the VA was not prescribed: According to the VA’s intake information, the VA told staff persons that s/he was incarcerated for sixteen months until his/her admission to the facility and used Suboxone, which s/he did not have a prescription for while incarcerated. Between March 12 and May 27, 2025, the VA had 29 urinalysis tests (UAs). The VA’s first samples were initially reactive to buprenorphine (an opioid medication) and norbuprenorphine (a metabolite of buprenorphine) due to his/her use of those substances prior to moving to the facility. The VA’s samples were nonreactive to all tested substances, except on for four occasions: April 21 and 22, May 6, and June 11, 2025, which was reactive to THC, and one on May 27, 2025, that was reactive to benzoylecgonine (a metabolite of cocaine), THC, and ethylglucronide and ethylsulfate (metabolites of alcohol). The VA’s prescriptions did not include any opioid, THC, or alcohol. The VA stated that during the time s/he lived at the facility, s/he made progress with his/her sobriety and mental health, until s/he “ended up” in a relationship with the SP. The relationship was a way for the VA to “get high,” and the VA’s mental health “went downhill” after s/he started using drugs that s/he got from the SP including marijuana, cocaine, and Suboxone. The VA said the SP kept a lock box of confiscated drugs in his/her office and gave the VA drugs “sometimes every day” including cocaine, methamphetamines, and marijuana that had been confiscated from other clients, and Suboxone that s/he was not prescribed. The SP helped the VA provide nonreactive urine samples and changed the VA’s chart to show negative test results. The SP also gave the VA a phone that s/he used to communicate with the SP. The VA’s text messages showed that on June 9, 2025, the VA and the C texted about the SP. The VA stated that “only [the SP] knew” the VA had a phone, that the SP brought the VA marijuana and picked him/her up on passes. An administrative staff person (P5) completed the Internal Review which stated on June 5, 2025, the SP altered the VA’s UA results, and omitted or deleted the May 27, 2025, test result mentioned above that was reactive for THC, cocaine, and alcohol. P5 was not aware of any information that the SP gave the VA drugs, including Suboxone, until this investigation. No one at the facility reported concerns to P5 or any other supervisory staff person that P5 was aware that the SP gave the VA any drugs, including Suboxone. P1 and P2 did not have information about the SP providing Suboxone or other substances to the VA. The facility’s Safe Medication Assistance and Administration Policy stated that only medications deemed necessary and ordered by a medical provider would be administered and that controlled substances, whether for storage or disposal, must be kept locked and only accessible to persons and staff authorized to administer medication. Additionally, unlicensed staff may administer medications only after successful completion of a medication administration training. Information provided by the facility showed that the SP, P1, and P2 were trained on the Staff Behavior policy, the Safe Medication Assistance and Administration policy, medication administration, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Regarding a sexual relationship between the SP and the VA while the VA received services at the facility:
Although in June 2025, the VA and the SP each denied having sexual contact, at that time they were still involved in a relationship and had reason to provide inaccurate information and minimize their actions. However, after the VA and the SP no longer spoke, the VA provided information that was supported by text messages between the VA and the SP, that the VA and the SP had sexual contact on more than one occasion. Screenshots provided by the VA also showed that the SP sent the VA nude photos on more than one occasion. The SP did not provide information for this report, however, given the information provided by the VA that s/he had sexual contact with the SP, that P1 and P2 had concerns about the SP’s boundaries with the VA, and that the VA had text messages with the SP that included information regarding sexual contact and naked photos of the SP, there was a preponderance of the evidence that the SP, who was a facility staff person, had sexual contact with the VA who was receiving services at the facility. It was determined that sexual abuse 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 at 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.) Regarding the SP giving the VA cocaine and Suboxone that the VA was not prescribed: The VA stated that the SP gave him/her Suboxone, marijuana, cocaine, and methamphetamines while s/he lived at the facility and that the SP helped him/her pass UAs by giving him/her nonreactive urine for tests and by changing test results in the VA’s chart. P5 stated that on May 27, 2025, a UA for the VA was reactive for THC, cocaine, and alcohol, in contrast to other samples throughout the VA’s time at the facility that were non-reactive or reactive for THC only. P1 and P2 had no information regarding the SP providing drugs to the VA. The SP did not provide information for this report. However, given the information provided by the VA that s/he got drugs, including Suboxone and cocaine, from the SP; and that information provided by the VA and P5 was consistent that the SP altered the VA’s UA results, and that on at least one UA the VA tested positive for cocaine, it was more likely that the VA’s information that the SP gave the VA drugs was accurate. The VA was at the facility seeking supports and services for substance use disorder and mental health concerns, therefore, the SP supplying the VA with illegal and/or prescription drugs for which the VA did not have a prescription for was a failure to supply the VA with care or services which were reasonable and necessary. 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 on the facility’s Staff Behavior policy and the Reporting of Maltreatment of Vulnerable Adults. 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 sexual abuse and neglect for which the SP was responsible was serious and recurring maltreatment. The SP had sexual contact with the VA on more than one occasion and the SP was responsible for two separate findings of maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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