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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: 1069140-HCBS (Home and Community-Based Services) Investigator(s): Carla Harvieux 651-431-6616 carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) bought alcohol and tetrahydrocannabinol (THC) wax for a vulnerable adult (VA), touched the VA inappropriately, drove recklessly under the influence of a substance with the VA as a passenger, and brought community persons (CPs) to the VA’s residence. Date of Incident(s): Prior to November 25, 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 law enforcement records; and through interviews conducted with facility staff persons (P1 and P2), the VA, and the VA’s case manager (CM). The VA declined to complete an in-person interview with this investigator but agreed to a telephone interview. Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters. The SP called this investigator outside of business hours but did not leave a message and did not respond to additional attempts to contact him/her by telephone. The SP provided information in the facility’s Internal Review, and it was included below. The apartment where the VA resided and received home and community-based services from the facility will be referred to as the facility in this report. The VA received about four hours of services a day to help him/her develop independent living skills. Facility documentation showed that the VA was diagnosed with a developmental disability, oppositional defiant disorder, attention deficit hyperactivity disorder, mood disorder, and schizoaffective disorder. The VA’s Individual Abuse Prevention Plan (IAPP) showed that the VA was vulnerable to all maltreatment and staff persons were to immediately intervene if the VA was in an abusive situation or imminent danger. Regulating emotions and talking about sensitive matters were difficult for the VA and s/he might need extra time to process information. No documentation showed whether the VA had a history of substance use or a history of providing inaccurate information. However, the VA was not old enough to legally use THC wax or alcohol in Minnesota. The VA had a great smile and was friendly. Interviews with this investigator, facility documentation, the facility’s Internal Review, and records from the law enforcement agency and information from a law enforcement officer (LEO), provided the following: · In an interview with this investigator, the VA said that the SP bought alcohol for him/her two or three times, but the VA was not sure where the SP bought it or what kind it was. The SP, the VA, and community persons whose identities the VA did not provide, drank the alcohol in the facility. In addition, the SP bought THC wax for him/herself but shared the wax with the VA several times and smoked it with him/her in the facility and while driving to take the VA on community outings during the SP’s shifts and outside of the SP’s working hours. The VA was scared when the SP drove and smoked the wax because the SP drove faster than the speed limit. According to the VA, the SP was a bad influence and did not teach the VA life lessons as staff persons should. · According to information the VA provided in the Internal Review, the VA said that the SP brought “hard” alcohol with him/her when s/he worked a shift at the facility. The SP gave the alcohol to the VA, and s/he drank it, but the VA could not recall what kind of alcohol it was or its brand name. The SP seemed to be under the influence of a substance during the shift. In addition, the SP sometimes had THC wax and vape pens which s/he used when the VA was present. On at least two occasions, the SP shared the THC wax with the VA, and the VA experienced physical effects from using the wax, but s/he did not describe the effects. In addition, on a date the VA could not recall, s/he went to sleep while the SP was driving them on a community outing. When the VA woke, the SP was driving approximately 100 miles an hour in a 60 mile an hour zone and was engaged in a “road rage” incident with the driver of a semi-truck that lasted between 30 to 45 minutes. The VA feared for his/her safety. On a date the VA could not recall, the SP placed his/her hand on the outside of the VA’s upper leg but stopped touching the VA when the VA asked him/her to. The SP’s actions ended that day, and the VA had no additional concerns regarding touching him/her. The VA expressed reluctance when providing information about the SP’s actions because s/he did not want the SP to get in trouble. · The CM stated that the VA provided consistent information over time to him/her regarding the SP. The CM confirmed that the VA told him/her that the SP bought “hard” alcohol and THC wax for him/her, and consumed alcohol while s/he was on shift many times at the facility while the SP was responsible for the VA’s care. The VA recounted an incident that occurred when the SP smoked THC wax while transporting the VA, during which the SP had “road-rage” behavior toward another driver and added that the SP forcefully opened a door at the VA’s residence, causing the door to hit the VA and push him/her into a wall. In addition, the VA said that the SP placed his/her hand near the VA’s knee several times and then moved his/her hand up the outside of the VA’s thigh. However, the VA denied that the SP touched his/her genitals or tried to kiss him/her. The VA made it clear to the CM that the SP’s touches were unwelcome. The VA was sometimes scared of the SP’s behavior and felt that the SP was unpredictable. A law enforcement agency was made aware of the VA’s concerns. The VA had no known history of providing inaccurate information. · The SP did not complete an interview with this investigator, but information s/he provided in the Internal Review showed that when s/he began working with the VA, s/he focused on becoming the VA’s “friend” first to develop rapport, then began goal-oriented work. The SP worked with the VA two days a week for about four hours a day and denied that s/he spent time with the VA outside of scheduled working hours and denied that s/he took the VA on outings to the metro area. However, the SP saw the VA at locations in the community when s/he and the VA happened to be at the same place but described those contacts as incidental. The SP denied that s/he used any substances while s/he was with the VA, denied that s/he provided any substances to the VA, denied that s/he touched the VA’s leg, denied that s/he brought anyone to the facility, and denied that s/he engaged in road rage incidents when the VA was present. · Records from the law enforcement agency and information from the LEO showed that on November 25, 2025, the agency became aware of these concerns and began an investigation. The agency investigated the concerns in this report but took no further action. · P1 and P2 provided consistent information that the facility took the VA’s concerns seriously and each stated that if true, the SP’s actions were inconsistent with the facility’s policies and procedures. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: A. Maltreatment: The VA’s diagnoses included a developmental disability and mental health disorders, and s/he was vulnerable to all forms of maltreatment. The VA might have difficulty regulating emotions and/or talking about sensitive matters, but no information showed whether the VA had a history of substance use or providing inaccurate information. The VA gave limited information to this investigator but in the Internal Review, the VA said that the SP brought unspecified “hard” alcohol with him/her to work at the facility, then gave the alcohol to the VA, who drank it. In addition, the SP sometimes used THC wax and vape pens when the VA was present, and shared THC wax with the VA twice. On a date the VA could not recall, the SP drove recklessly when the VA was a passenger and engaged in a “road rage” incident that lasted 30-45 minutes while using THC wax. The VA stated that the SP previously placed his/her hand on the outside of the VA’s upper leg but removed it when the VA asked him/her to, and s/he had no additional concerns regarding the SP touching him/her. The VA provided consistent information over time to multiple persons, but s/he was concerned that his/her statements might cause the SP to get in trouble. The VA was not old enough to use THC wax or alcohol in the state of Minnesota. The CM stated that the VA provided consistent information over time to him/her regarding the concerns and provided an accounting of the information that was largely consistent with information the VA gave in the Internal Review. The VA had no known history of providing inaccurate information. In the Internal Review, the SP said that s/he worked with the VA for about eight hours a week. The SP might see the VA incidentally in the community, but denied that s/he spent time with the VA outside of work, that s/he took the VA on outings to the metro, that s/he used substances when the VA was present, gave them to the VA or used them with him/her, that s/he touched the VA’s leg, and that s/he drove recklessly when the VA was with him/her. Records from the law enforcement agency and information from the LEO showed that the agency investigated the concerns in this report but took no further action. Regarding sexual abuse: The VA said that the SP touched the outside of his/her leg once in an inappropriate way on a date that s/he could not recall but the SP stopped when the VA asked him/her to. Given that touching the outside of the leg did not meet the definition of sexual contact and that the law enforcement agency investigated the allegations in this report but took no further action, there was a preponderance of the evidence that the SP did not have sexual contact with the VA. It was not 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 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). Regarding neglect: In the Internal Review, the SP said that s/he did not spend time with the VA outside working hours, denied that s/he gave substances to the VA or used them with him/her, and denied that s/he engaged in road rage incidents when the VA was present. However, the VA provided consistent information over time to multiple persons regarding the SP’s use of THC wax, alcohol, and vape pens, and said that the SP gave the VA alcohol which the VA drank, and provided, then used THC wax with the VA. The VA said that the SP drove faster than the speed limit when the VA was a passenger which scared the VA, and s/he experienced physical effects from using the wax the SP gave him/her. Given the aforementioned, and that the VA was not old enough to use legally use substances, there was a preponderance of the evidence that there was a failure to provide the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s health or safety. 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 policies and procedures and was responsible for the VA’s care when the incidents occurred. 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 recurring because the SP provided substances to the VA on multiple occasions but was not serious because the VA did not require care of a physician. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but not followed. The incidents were not similar to past events. The SP was no longer employed at the facility at the time this report was written. 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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