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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: 1070933-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA). Date of Incident(s): Prior to December 2, 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): 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. Summary of Findings: Pertinent information was obtained during site visits conducted on December 16, 2025, and January 12, 2026; from documentation at the facility and/or law enforcement records; and through interviews conducted with facility staff persons (P1 and the SP), and the VA. Facility documentation showed that the VA had a developmental disability, and his/her diagnoses included attention deficit hyperactivity disorder and bipolar disorder. The VA’s MNChoices Assessment showed that the VA had a history of providing inaccurate information and might make up stories or manipulate the truth to gain sympathy and attention from others. The VA did not understand the consequences of being “untruthful” and needed reminders of the “consequences of his/her actions.” The VA’s Individual Abuse Prevention Plan (IAPP) showed that the VA was vulnerable in relationships, did not recognize the risks posed by others, and might not quickly tell others of concerns. The VA was vulnerable to sexual abuse, did not understand sexuality, was likely to cooperate in an abusive situation, and was unable to be assertive. If someone took advantage of the VA, s/he might not understand and might seek out abusive situations or cooperate in them. The VA enjoyed spending time with his/her friends and had a great sense of humor. Interviews with this investigator, facility documentation, the facility’s Internal Review, and records from the law enforcement agency provided the following: · P1, a supervisory staff person, said that on November 23, 2025, s/he learned that the SP previously took the VA to the SP’s residence to help him/her assemble an item, then the SP bought something for the VA. At some point, the SP told the VA that the SP’s relationship with the SP’s significant other (SO) was strained, and multiple staff persons (P2, P3, and P4) each told P1 that they overheard the SP say that the VA was sexy and attractive. P1 talked with the VA about the concerns raised by P2, P3, and P4, and the VA told P1 that s/he went to the SP’s residence, but the VA did not feel uncomfortable with the SP and enjoyed spending time with him/her. According to P1, staff persons were not permitted to take facility residents to their residences. The facility became concerned about the SP’s boundaries with the VA and began gathering information regarding the SP’s relationship with the VA. The facility learned from a community person who knew the VA, that the VA told the community person that the SP had sexual intercourse with the VA. The SP worked at the facility for about a month. · The VA said that s/he did not want to discuss his/her relationship with the SP with this investigator, but s/he saw him/herself as an equal with the SP, and s/he did not think that the SP took advantage of him/her. · The SP said in an interview with this investigator and a law enforcement office (LEO) that soon after s/he began working at the facility, the VA overheard phone conversations between the SP and the SO and then tried to physically and emotionally help the SP. Initially the SP’s relationship with the VA was professional, but over time, the relationship changed, and the SP felt that if s/he did not “do stuff” with the VA, s/he might lose his/her job. The SP’s relationship with the VA began to change and s/he and the VA “fell in love.” According to the SP, the VA was assertive and initiated sexual contact between them, and the SP had sexual intercourse with the VA four separate times/dates at the facility between 9:30 and 11 p.m. in the VA’s bedroom, when the SP was the only staff person on shift at the facility. The SP felt that s/he could not say “no” because s/he had mental health diagnoses that impaired his/her ability to make decisions. During the relationship with the VA, the SP mentally “dissociated” him/herself from his/her actions. The SP thought that the VA was very high functioning and did not seem to be a vulnerable adult. The SP was surprised that the VA lived in a facility, and s/he did not intend to “hurt” him/her. The SP did not have contact with the VA after his/her employment at the facility ended and s/he denied that s/he had a sexual relationship with other facility residents. 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. The SP began working at the facility in October of 2025, and completed all required training between October 28 and 31, 2025. Conclusion: A. Maltreatment: Facility documentation showed that the VA had a developmental disability, was vulnerable to sexual abuse, did not understand sexuality, was likely to cooperate in an abusive situation, and was unable to be assertive. If someone took advantage of the VA, s/he might not understand and might seek out abusive situations or cooperate in them. P1 said that in late November of 2025, s/he learned that the SP took the VA to the SP’s residence, that P2, P3, and P4 heard the SP say that the VA was sexy and attractive, and that there were concerns that the SP had sexual intercourse with the VA. The VA did not provide information regarding his/her relationship with the SP but felt that the SP did not take advantage of him/her. In an interview with this investigator and the LEO, the SP said that the VA was assertive and initiated the sexual relationship with him/her, and s/he and the VA fell in love. The SP thought that the VA functioned at a high level and did not seem like a vulnerable adult. The SP and VA had sexual intercourse four times in the VA’s bedroom at the facility, but the SP felt that s/he was unable to tell the VA no and did not intend to hurt the VA. Although the VA did not provide information about his/her relationship with the SP, given that the SP stated that s/he had sexual intercourse with the VA four times in the VA’s bedroom during the SP’s shifts at the facility, there was a preponderance of the evidence that the SP had sexual contact with the VA. 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 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). 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 on the Reporting of Maltreatment of Vulnerable Adults Act. 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 abuse for which the SP was responsible was recurring and serious because the SP had sexual contact with the VA on multiple occasions. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The SP was no longer employed 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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