Minnesota

AMENDED MALTREATMENT INVESTIGATION MEMORANDUM

Office of Inspector General, Licensing Division Public Information

Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”

NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated June 20, 2025, which should be destroyed. As a result of an administrative reconsideration, the original determination that a staff person (SP1) was responsible for serious maltreatment was changed. The substantiated maltreatment for neglect was affirmed. However, it was determined not to meet statutory criteria to be determined as serious (or recurring) maltreatment. SP1’s disqualification was rescinded. For additional information, see the Administrative Reconsideration section starting on page 18 of this document.

Report Number: 202500946 Date Issued: June 20, 2025

Date Reissued: September 10, 2025

Name and Address of Facility Investigated:

180 Degrees St. Cloud

Disposition: Maltreatment determined as to neglect of an alleged victim by a staff person

License Number and Program Type:

1106751-CRF (Children’s Residential Facility)

Investigator(s):

Samantha Wueste/Scout Peterson Minnesota Department of Human Services Office of Inspector General

Licensing Division PO Box 64242

Saint Paul, Minnesota 55164-0242 samantha.wueste@state.mn.us 651-431-7728

Suspected Maltreatment Reported:

It was reported that two staff persons (SP1 and SP2) did not follow the facility’s policies and procedures or an alleged victim’s (AV) health and safety plans after the AV ran away from the facility which resulted in the AV being exposed and subjected to situations of abuse and exploitation that the AV was known to be vulnerable and “high risk” to.

Date of Incident(s): May 25 to 26, 2024; received by the Department of Human Services on February 3, 2025

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2):

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on February 20, 2025; from documentation at the facility and law enforcement (LE) records; and through eight interviews conducted with three facility staff persons (SP1, P1, and P4), two supervisory staff persons (SP2 and P2), one administrative staff person (P3), the AV’s case worker (CW), and the AV’s guardian (G) who was also the AV’s family member. Due to the nature of the incidents that occurred after the AV left the facility, this investigator did not interview the AV because s/he already provided information to the G and LE that was included below.

The facility provided emergency shelter and short-term residential services to youth ages 12 to 17 who experienced significant adversity, chemical or mental health conditions, family conflict, and/or were at risk or unable to return to their primary homes. The facility provided youth with individualized case management and services that included transportation, medication management, gaining/continuing education, building social support and independent life skills, and accessing community resources. The main level of the facility consisted of a secured entry way, staff offices, communal living spaces, and ten youth bedrooms which included a bedroom that the AV occupied when residing at the facility. At the time of the incident, the upper level of the facility was not space that was used by the program.

In addition to maintaining an active license required for program operation, the facility also obtained certification under the Family First Prevention Services Act (FFPSA) for Title IV-E funding that specialized in serving youth who experienced or were at-risk of sexual exploitation and trafficking. Therefore, the facility was required to provide “individualized,” “person-centered,” “trauma-informed care” that focused on the “physical and psychological safety” of a youth and “adjusted services” to support any “additional needs” which included the youth’s emotional and mental health needs. Additionally, the facility was to maintain an environment that “avoided aspects that may be retraumatizing” and provided “high-quality care and supportive services” for youth who experienced or were at risk of being victims to sex trafficking or commercial sexual exploitation.

The AV enjoyed basketball, making music, playing video games, and being outside. On May 9, 2024, the AV moved into the facility seeking temporary shelter and care while waiting for placement at a residential care center (RCC) located in Wisconsin. On June 3, 2024, the AV was discharged from the facility. The AV was 14 years old at the time of the incident.

The AV’s Multidisciplinary Assessment Report completed by RCC on April 10 through May 9, 2024, provided the following information:

· The AV had a history of “significant instability and trauma” throughout the first eight years of life that included “unsanitary” living conditions, homelessness, neglect, sexual abuse, and domestic abuse. The

AV’s diagnoses included reactive attachment disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, gender dysphoria, attention deficit hyperactivity disorder (ADHD), mild tobacco use disorder, and borderline personality traits. Additionally, the AV had dysphoria of his/her body image and weight that caused “disordered eating patterns” and consisted of cycles of food deprivation and “purging.” The AV also had a history of impulsivity, aggression, emotional dysregulation, high-risk behaviors, dissociative tendencies, suicidal ideation, and self-injurious behaviors (SIB).

· The AV’s history of abuse and neglect resulted in the AV being “deeply untrusting” of others, having a “fear” of “being controlled,” and perceiving adults as “unreliable sources of support and protection.” The AV was vulnerable to environmental and social “stressors” and “intrusive thoughts” which caused the AV’s “mood” to “significantly fluctuate” and impacted his/her behaviors.

· Due to the AV’s history and diagnoses, the AV required a “high level” of monitoring and support that included 24-hour supervision to keep the AV safe. The AV required staff persons who used “trauma informed practices,” remained “calm,” and encouraged “collaborative” problem solving with the AV. Furthermore, staff persons were to refrain from communication that was “controlling,” “harsh,” or “commanding” since this type of communication style “escalated” situations involving the AV, “increased defiance or frustration” from the AV, and could result in the AV harming him/herself or others.

The AV’s intake documents completed by the facility provided the following information:

· The AV’s Out of Home Placement Plan showed that county social services authorized “temporary placement” of the AV into the facility’s care during two separate time periods while the AV waited for admission into RCC. In February 2024 and prior to the AV’s first placement at the facility, the AV was placed into a local hospital’s Behavioral Health Unit for evaluation. During the AV’s hospitalization, the CW contacted the facility and explained the AV’s situation that included the AV’s past and recent history, diagnoses, and care needs to which the facility “agreed” to be able to manage and maintain for the interim period that was needed. On March 1, 2024, the AV was discharged from the hospital and directly placed into the care of the facility. On April 10, 2024, the AV was discharged from the facility to RCC for clinical assessments that were conducted from April 10 through May 9, 2024. During this time, RCC was transparent with the AV and his/her care team that the AV would not be admitted into RCC’s residential treatment program upon completion of these assessments until a bedroom became available for the AV to use which was estimated to be June 10, 2024. On and prior to May 8, 2024, the CW contacted the facility and provided updated information regarding the AV’s situation that included the AV’s assessment findings and treatment plans to which the facility “agreed” to be able to manage and maintain if the AV was authorized for temporary placement at the facility for a second time. On May 9, 2024, the AV was discharged from RCC and directly placed into the care of the facility to “ensure [the AV’s] safety and well-being needs were met” while waiting for space to become available at RCC.

· The AV’s Medical History Questionnaire completed by the AV’s medical health professional at the request of the facility dated May 8, 2024, showed the AV’s history of “significant trauma,” SIB that resulted in multiple and “recent” hospitalizations, and “increased” aggressive behaviors that were displayed by the AV in the home, school, and community settings. Additionally, the AV was prescribed 11 medications with a list of the dosage, frequency, and times that each medication needed to be administered to the AV in managing his/her health conditions that included five “psychotropic medications” (which treat mental health conditions and control, alter, and/or affect mental processes, emotions, and behavior). The AV

was also prescribed a daily dose of Ritalin (a medication that treated symptoms of ADHD) that was to be taken each morning. According to WebMD, this medication was “known” to often cause a “decreased” or “suppressed” appetite that would then “lessen” throughout the day as the medication started to “wear off.”

· The AV’s Client Record completed by SP2 dated May 9, 2024, showed that the G and the CW were listed as the AV’s emergency contacts. Additionally, SP2 was listed as the AV’s “facility case manager” who assisted in the oversight of the AV’s care while the AV received services from the facility and who maintained ongoing communication between the facility and the G and/or CW.

· The AV’s Safety Plan completed by the AV and SP2 dated May 10, 2024, provided staff persons with “warning signs” to when the AV was entering a “potential crisis situation” and how staff persons were to then respond in “redirecting” the situation from “escalating” further. When working with the AV, staff persons were to observe the AV’s “nonverbal cues,” use an “established safe word” if the AV showed signs of becoming “triggered” or “angry,” offer the AV activities that were listed within the plan as “healthy distractions,” and/or contact the G or CW for support or assistance. The plan also included that the AV was a “run risk” and “fire risk.”

· The AV’s Risk Reduction Plan completed by SP2 and P2 dated May 14, 2024, showed that the AV had a history of SIB, aggression, “manipulative” behaviors, abuse, being a victim of “bullying,” and “gaslighting” or “yelling” at others. Due to these factors, the plan stated that the AV required “enhanced supervision” from the facility to maintain the safety of the AV and other youth who also received services from the facility during this time.

· The Vulnerability Assessment and Sexual Abusive Behavior Screen completed by SP2 dated May 15, 2024, showed that the AV had a history of physical, emotional, sexual, and verbal abuse, as well as the AV had a history of emotionally abusing his/her “peers” during “arguments.” The AV also had a history of behaviors that “threatened” the safety of him/herself and/or others that included “running away” and “starting fires.” Due to these factors, the AV required “special precautions” or “particular staffing patterns” that would be provided by the facility through “heightened supervision.”

· The Sexual Exploitation/Trafficking Risk Assessment completed by SP2 dated May 15, 2024, showed that the AV had a history of homelessness, truancy from school, abuse and violence, SIB, and diagnoses related to the AV’s metal health. The results of the assessment showed that the AV was “high-risk” and “at risk” for sex trafficking and/or commercial sexual exploitation.

The facility’s Accountability Policy updated September 30, 2021, provided the following information:

· Due to the facility’s clientele and services provided, staff persons were to maintain “universal precautions” by “assuming” that “all youth” who received supports and services from the facility were “exposed to” and “affected by trauma.” In operating its programming this way, the facility viewed a youth’s “negative” behaviors as a means of communication that was “often” a “signal of distress or underlying fears.” Staff persons were to respond to such behaviors with “trauma informed,” “youth oriented,” “harm reduction engagement techniques” that responded to a situation while also building “strong, trusting, and empathetic” relationships with youth who received services from the facility.

· Staff persons were to use “supportive interventions” when responding to a resident’s behavior that helped the youth gain “awareness” and “accountability” of his/her actions; learn “limits” to what was “acceptable” behavior; learn “more productive” ways to communicate thoughts and emotions; “de-escalate unacceptable behavior;” and “experience adults” as “caring people” who wanted to help. If a resident showed “increased hostility, tension, or conflict,” staff persons were to “de-escalate” the situation by listening to the youth’s emotions and providing him/her with emotional and physical safety, “unconditional” respect and support, and options to respond to the situation. Furthermore, incidents involving “power struggles,” “misinterpretations,” feelings of being “unheard or unseen,” feelings of being “threatened,” and/or being emotionally “provoked” could make youth feel “unsafe” and result in “escalated” situations and behaviors.

According to the facility’s policy on Tracking the Whereabouts of Residents dated March 1, 2021, staff persons were to be “closely observing” or “directly engaging” with residents and providing “direct supervision” by sight and sound at “all times,” with an exception to when a resident was in his/her bedroom that then required time-sensitive health and safety checks.

According to the facility’s Safe Search Policy dated March 1, 2021, staff persons completed “safe searches” of youth and their belongings when admitting new residents into the facility or when residents returned to the facility after leaving the property. During these searches, residents were to show staff persons the contents of their pockets; remove their hats and/or run their fingers through their hair; remove their shoes, socks, and show staff persons the soles of their feet; remove their jackets and shake them out; show staff persons the inside of their bags; and shake the band of their bras (while clothing remained on), if applicable. Staff persons were to conduct these searches in a “respectful manner” and were “prohibited” from physically touching a resident at any time during the search. Additionally, residents had “the right to refuse” being searched “at all times” but staff persons were to then make “every effort” to talk with the resident about his/her “options,” find out why s/he did not want to complete the search, and/or ask a supervisory staff person to talk with the resident if needed. If a staff person’s attempts to resolve the situation were not successful, “refusal” of the search was then documented in the resident’s file and “could be a condition for non-admittance.”

According to the facility’s Resident Disappearance, Run or Unauthorized Departure Policy dated March 1, 2021, staff persons were to attempt to “de-escalate, redirect, problem-solve, and otherwise dissuade” youth from leaving the facility if a resident was “considering” running away. If these attempts to resolve the situation were not successful, staff persons were to develop a “safety plan” with the resident that included providing the youth with food, clothing, and resources to help maintain his/her safety. Furthermore, if the resident ran away from the facility, staff persons were to “immediately, within an hour” notify the resident’s emergency contacts and any “relevant parties” that included social workers and placing agents. Within two hours of the resident leaving the facility, staff persons were to contact a supervisory staff person and LE’s “Missing Persons Unit.” Additionally, staff persons were to obtain a case number from LE that was then kept in the resident’s file along with an incident report that was to be completed by staff persons.

P1, P2, P3, P4, SP1, and the facility’s Internal Review, Incident Report, Case Manager Notes (CMN)and the AV’s daily Shift Notes (SN) written by staff persons working with the AV provided the following information:

· The AV’s SN dated May 9 to 24, 2025, written by P4 and other staff persons not interviewed by this investigator contained multiple incidents of how staff persons responded to the AV and his/her behaviors by using “strategies” listed in the AV’s Safety Plan that included talking with the AV, “re-direction,” and

contacting the CM who then assisted with the situation or contacted the G and/or CW for additional support when needed.

· On Friday, May 24, 2024, the AV woke up approximately three hours earlier than his/her “typical” morning schedule because of a dental appointment that was scheduled that morning. The AV ate breakfast at approximately 5:50 a.m. and then left the facility at approximately 6:40 a.m. with the G who transported the AV to/from the appointment. The AV returned to the facility at approximately 2:30 p.m. but became “upset” shortly thereafter. Staff persons notified SP2 who then went outside with the AV to talk, called the G for additional support, and “resolved” the situation. At an unknown time between 3:30 to 4:30 p.m., the AV went back inside the facility, ate a snack, and then later declined his/her dinner before going to bed that night.

· On May 25, 2024, at approximately 8 a.m., the AV was sleeping when P4 arrived at the facility but woke up shortly thereafter. At approximately 8:55 a.m., the AV took his/her medications, participated in the morning group activities, and “even led the reading.” On or around 12 p.m., SP1 arrived at the facility and took some of the residents on a community outing while other residents, including the AV, remained at the facility with P4. During this time, the AV “declined” to eat his/her lunch when it was offered by P4 and played video games until SP1 and the other residents returned to the facility. Between 2:45 to 3 p.m., the AV stopped playing video games and asked P4 to eat lunch but P4 told the AV that s/he already declined to eat during lunchtime. P4 told the AV that s/he could have fruit if the AV was hungry or “wait a little bit” for snack time. The AV then became “upset,” “yelled” that s/he wanted to eat “lunch and not a snack,” walked into the kitchen, and took “leftovers” out of the refrigerator. SP1 went into the kitchen and told the AV that because it was not a mealtime, the AV was “not allowed to eat dinner” (the food items that the AV had taken out of the fridge) at this time. The AV told SP1 that s/he “did not care and would eat” and that staff persons could “just take away [his/her] privileges.” Shortly after this, SP1 took away the AV’s privileges since the AV was “not listening” to staff persons “during the morning and evening shifts.” SP1 and facility documentation did not provide any additional information of any prior incidents that occurred on this date relating to the AV’s behavior. The AV then left the kitchen and went into his/her bedroom. Around 3:45 p.m., the AV went outside but remained on the facility’s property. At 4 p.m., P4 left the facility after his/her shift ended and SP1 remained at the facility as the only staff person working that evening until P1’s overnight shift started at 10 p.m.

· At unknown times after P4 left the facility, the AV was outside with another unnamed resident (U) while SP1 supervised from a window inside the facility. SP1 noted that the AV was “acting suspicious” and “giving signals” that s/he was going to run away from the facility but SP1 did not attempt to “redirect” or “problem-solve” with the AV, reach out to the G or the CW for additional support in resolving the situation, or develop a “safety plan” with the AV as required by facility policies and the AV’s plans. The AV then walked into the facility and grabbed his/her backpack. SP1 asked the AV if there was “a reason” the AV needed his/her backpack, but the AV did not respond and went back outside while SP1 remained inside the facility observing the AV and the U again through the window. At approximately 5 p.m., SP1 saw the AV “sneaking through around the house” and told the AV that s/he was “not allowed” to go around the house unless given “permission” from staff persons to do so.

· At approximately 6:10 p.m., SP1 told the AV and the U to come inside to which they “initially refused” but then agreed to do so shortly thereafter. SP1 told the AV that s/he could not enter the facility until completing a “security scan” but the AV refused to let SP1 search his/her backpack at that time. SP1 told the AV that “since you are refusing me to go through your backpack, I can’t let you in.” SP1 then stated to

this investigator, “I’m just like, ‘I don’t care. I’m going to go inside.’ I’ll just give them time.” The U then went inside the facility while the AV walked away and left the facility. SP1 told this investigator that there were not any additional approaches SP1 attempted in responding to the AV when s/he did not want SP1 to search his/her backpack at that time. Additionally, it was later determined that the AV left the facility without any shoes on but information to why the AV did not have shoes was not recalled due to the significant amount of time that lapsed between the date of the incident and the date the report was made to DHS. [Note: Based on the facility’s Safe Search Policy and information that the AV’s “refusal” to let SP1 complete the search was specifically regarding the AV’s backpack, it was reasonable to assume

that the AV most likely removed his/her shoes when first completing the “safe search” prior to SP1 asking the AV to search his/her backpack.]

· According to SP1, the AV left the facility at approximately 6:15 p.m. and about ten minutes later, SP1 called LE and reported the AV as “a runaway” at that time. At approximately 6:45 p.m., SP1 called and told SP2 that the AV ran away from the facility and that LE had already been contacted with this information. SP2 then told SP1 that s/he would contact the G and the CW, but SP2 later told P2 that s/he only contacted the CW that evening. At approximately 10:46 p.m., SP1 noted that the AV had not returned to the facility upon ending his/her shift that night. Additionally, P3 stated that s/he was not aware of any police report or case number that resulted from SP1’s call to LE which was required for SP1 to obtain and then document in the AV’s file at the time of the incident.

· On May 25, 2024, at approximately 10 p.m., P1 noted that the AV was “on the run” when s/he arrived at the facility for an overnight shift that was scheduled from 10 p.m. to 10 a.m. P1 stated that s/he remained awake for the entirety of his/her shift and would have answered any incoming phone calls that were made to the facility during this time but later said there may have been issues with the facility phones at the time of the incident that had since been resolved. On May 26, 2024, at approximately 6:45 a.m., two law enforcement officers arrived at the facility and told P1 that the AV was located by the G and transported to a local hospital because the AV was sexually assaulted after leaving the facility the evening prior. P1 then told the officers that the G did not inform the facility that the AV was located or that the assault occurred. Shortly thereafter, P4 arrived at the facility for his/her shift and P1 went to the hospital to transport the AV back to the facility once s/he was discharged from the hospital’s care. Before the AV was discharged, hospital staff provided P1 “discharge instructions” that included medications that the AV was prescribed in treating the health concerns relating to the assault that occurred during the evening prior. At approximately 11:15 a.m., P1 and the AV then returned to the facility. Later that day, the AV told staff persons “a little about” what happened after leaving the facility and that s/he was “feeling like it was [his/her] fault.” The AV also told staff persons that s/he was “reliving” the incidents from the night prior “every time” that the AV closed his/her eyes and asked staff persons for “distractions” and “calming” activities to help with this.

· On May 26, 2024, P2 received a call from the G and the CW who each stated that they were not notified of the AV’s departure from the facility during the evening prior. Due to this “error in procedure,” P2 “offered” to “step in” and replace SP2’s role as the AV’s “active case manager” for the remainder of the AV’s placement at the facility, to which both the G and the CW agreed.

· According to the facility’s Internal Review completed by P3 dated February 4, 2025, the AV left the facility after refusing to complete a “security search” of his/her belongings when returning from an off-site activity but the facility’s SN entered for this date showed that the AV did not attend the off-site activity

that occurred on this date. Furthermore, information provided by SP1 and facility documentation showed that the AV went outside prior to running away from the facility but remained on the facility’ property and was supervised by SP1 during this time.

· According to the AV’s CMN that were completed by SP2, there had been multiple times prior to the incident when SP2 spoke to the AV regarding his/her behavior and contacted the G and/or the CW for additional support when needing help to “de-escalate” or resolve a situation involving the AV. Additionally, SP2 noted that the G was “very involved” and “looked out for [the AV's] well-being.”

LE records from St. Cloud Police Department (SCPD) and Sartell Police Department (SPD) provided the following information:

· On May 25, 2024, at 6:34 p.m., SP1 called SCPD’s non-emergency line to provide information regarding the AV leaving the facility. At this time, SP1 gave a physical description of the AV and told the dispatcher that the AV left the facility “on foot” at approximately 6:15 p.m. and that the AV did not have a cell phone with him/her. The call was then dispatched at 6:44 p.m. to a SCPD law enforcement officer (LEO1) who arrived at the facility at 6:54 p.m. to respond to SP1’s call and assist the facility in locating the AV. At 6:59 p.m., SP1 told LEO1 “to wait” in entering the AV’s departure from the facility as a “juvenile run” at that time. LEO1 then provided SP1 with a business card and a case number assigned to the call so that SP1 could update LE with additional information if needed. After speaking with SP1, LEO1 left the facility at approximately 7:03 p.m. [Note: SCPD’s Calls of Service records showed that no attempts were made by SP1 or the facility to later contact LE in updating the AV’s status to a “runaway” which would have then prompted a response from law enforcement officers to assist in locating the AV. Furthermore, SP1 did not provide any information to LE about the AV’s history, diagnoses, or health and safety concerns that were relevant to the situation and the potential risks that could result from the AV leaving the facility without having access to the supports and cares that s/he required.]

· On May 26, 2024, at approximately 3:30 a.m., the AV’s family member who lived with the G woke up after hearing a “knocking” on his/her bedroom window and went upstairs to get the G. The G immediately got out of bed and walked to the front door and saw the AV “soaking wet” and lying outside on the front steps of his/her residence that was located in Sartell. The G helped the AV inside, gave him/her a blanket, and attempted to talk with the AV to understand “what was going on” but the AV was having difficulty in communicating this information. At 3:40 and 3:46 a.m., the G called the facility to talk with staff persons but the G’s phone calls to the facility were not answered. During this time, the AV told the G that after s/he left the facility, s/he was assaulted by an unknown person in the community (C) who acted “nice” towards the AV and then “lured” the AV into his/her home. The G then called emergency services for assistance who arrived shortly thereafter and transported the AV via ambulance to a nearby hospital in St. Cloud.

· On May 26, 2024, at 4:22 a.m., two SCPD officers (LEO3 and LEO4) responded to a report of sexual assault against the AV who was in transit via ambulance to a local hospital. Upon arrival to the hospital, LEO3 and LEO4 met with the SPD officer (LEO2) who was dispatched to the G’s residence with emergency medical staff. After obtaining information and evidence from LEO2, LEO3 wanted to talk with the facility since Dispatch included information that SCPD responded to a previous call relating to the AV’s departure from the facility on the evening of May 25, 2024, prior to the assault. Dispatch notes showed that the AV left the facility on foot at approximately 6:15 p.m. and that a staff person (SP1) told the responding officer who arrived at the facility shortly thereafter that the facility “would wait to report [the AV] as a runaway”

at that time. LEO3 then called the facility three times to obtain additional information from staff persons but the calls were not answered by the facility at this time. LEO3 then went into the hospital room where the AV was receiving care and spoke to the AV and the G, who was also present in the AV’s hospital room at the time.

· At approximately 5:27 a.m., the AV provided a recorded statement to LEO3 relating to the assault and the events prior to and proceeding this incident which was then shown to be an accurate account of information that was validated by evidence and information collected by LE throughout their investigation. At an unknown time during the evening of May 25, 2024, the AV left the facility on his/her own without telling a staff person but did not provide additional information to why s/he left the facility. After leaving the facility, the AV walked approximately 1.3 miles to a nearby lake and sat under a bridge that was next to the lake. Shortly thereafter, the AV was approached by the C who then introduced him/herself to the AV. The AV thought the C was being “nice” to him/her and the AV told the C his/her name, age, and that s/he had ran away from a local shelter. The C asked the AV if s/he wanted to walk with him/her to a friend’s residence that was located nearby and the AV agreed to walk with the C. The C’s friend was not home at that time so the C and the AV then walked to other places around the community that included a gas station and the C’s residence. During this time, the AV was offered tobacco and marijuana, as well as the C took the AV’s money that was in the AV’s backpack. Later that night while watching a movie at the C’s home, the AV was physically subdued and restrained by the C, verbally threatened, sexually assaulted, and was told by the C that s/he could not leave the home. At an unknown time after this, the AV was able to “escape” from the C’s residence and then walked approximately 5.2 miles in the rain to the G’s residence for help. After speaking with LEO3, the AV was examined and treated by hospital staff before being discharged back to the facility’s care later that morning.

· On August 13, 2024, the C was convicted of a felony for criminal sexual conduct- 3rd degree- penetration under 18- use coercion, with sentencing for the C’s conviction served on December 20, 2024. On December 20, 2024, the Stearns County Attorney concluded the hearing with the following statements: “[The facility] contacted police and informed them that [the AV] was not at the shelter. They didn't report [him/her] as missing though. [The AV’s] guardian was never informed that [s/he] was not at the shelter. Police were not out looking for [the AV]. The structures and systems that were in place to protect [the AV] failed [him/her] that day. Don't let this system be another failure.” Additionally, the AV was 14 years old and the C was 26 years old at the time of the incident.

The CW, the G, the G’s phone records, and a photo of a note that was given to the G by LEO4 on May 26, 2024, provided the following information:

· Before the AV was admitted into the facility’s care, the CW provided supervisory staff persons with the AV’s past and recent history, diagnoses, vulnerabilities, safety risks, and health needs prior to each placement that included the AV’s Multidisciplinary Assessment Report prior to the AV arriving at the facility on May 9, 2024. Supervisory staff persons then “assured” the CW and the G that the facility would be able to provide interim shelter and care for the AV until placement at RCC was available. On May 9, 2024, the AV arrived at the facility with the G to complete an intake process that was overseen by P2 and SP2. Given the AV’s history and diagnoses, concerns of the facility being able to meet the AV’s supervision needs were “specifically addressed” by the G and the CW prior to the facility admitting the AV into its care and included an “agreement” that staff persons would contact LE, the G, and the CW “immediately” if the AV left the facility’s property. Additionally, staff persons were able to contact the G

or the CW during any other situations that involved the AV if staff persons needed assistance or support that could then be provided verbally over a phone call, through a video call, and/or in-person depending on what was needed to help resolve the situation.

· The information provided by the G to this investigator was consistent with the information that was provided by LE records regarding the incidents that occurred on May 25 to 26, 2024. Additionally, at an unknown time while the G was at the hospital with the AV and SCPD officers, LEO4 spoke with the G to obtain additional information related to the AV that was needed. During this conversation, the G became aware that a staff person called LE after the AV’s departure from the facility but told the responding officer to “wait” in identifying the AV as “a runaway” at that time. The staff person did not follow up or contact LE after this to update the AV’s status to a “missing person” or as “a runaway” when the AV did not return to the facility later that night. Since it was “so chaotic” and “overwhelming” at the time due to “everything going on,” the G asked LEO4 to summarize this information so that s/he could follow up with the facility accordingly once things were “quieter.” LEO4 then provided the G a handwritten note regarding Dispatch notes that related to the facility’s call placed the evening prior which read, “180 Degree’s staff called at 18:59 (7 p.m.). Reported that [the AV] had left but did not need to enter them at this time. Did not call back.” The G then provided a copy of the note to this investigator.

· When the G asked the AV why s/he ran away from the facility, the AV told the G that SP1 was “being rude” to him/her and another resident which made the AV want to leave the facility. The AV did not provide any additional information regarding this but told the G that s/he then took his/her backpack and packed some clothing items and “some cash” that the AV took from his/her “bin of personal items” which was to be kept secured and only accessible to staff persons. The AV did not provide information on how s/he accessed this bin but told the G that s/he took approximately $40 of cash prior to leaving the facility which was the only item that would have been “confiscated” if the AV allowed SP1 to search his/her backpack shortly thereafter. The AV was aware that if s/he decided to leave the facility, the AV did not have access to shelter, food, transportation, a means of communication, or other basic items of necessity besides that “small amount” of cash that the AV could then use if needed.

· The CW maintained a casefile for the AV that included a record of all communication between him/herself and the facility. The CW did not receive a voicemail or an email from SP2 on May 25, 2024, to notify the CW that the AV left the facility and was not contacted by the facility on this date prior to the incident regarding any concerns relating to the AV that needed additional support from the CW. Additionally, the facility did not contact the CW the following morning when staff persons were made aware that the AV was in the hospital after being sexually assaulted. Furthermore, an invoice was obtained from Verizon Wireless that showed all incoming and outgoing calls that were made to/from the phone number belonging to the G on May 25 to 27, 2024. The invoice contained information regarding each call that was placed or received during this time that included the date, time, the phone number of the other caller, the length of the call, and if the call was incoming or outgoing. The invoice showed that there were no incoming calls from the facility’s phone number or phone numbers associated with SP1 or SP2 on May 25 to 26, 2024, during the timeframe from when the AV left the facility to being admitted to the hospital. The invoice showed that the G called the facility on May 26, 2024, at 3:40, 3:46, and 7:34 a.m. Staff persons present at the facility did not answer the G’s calls until 7:34 a.m. After this, there was ongoing back and forth communication between staff persons and the G that were listed on the invoice for the remainder of this period.

· The AV did not have a history of making false allegations and was considered to be an accurate reporter of information.

SP2 provided the following information:

· SP2 provided information to this investigator that was consistent to the information in facility documentation except for who was responsible in calling the G after the AV left the facility. SP2 was not present at the facility on the date that the incident occurred but recalled that SP1 contacted him/her shortly after the AV ran away from the facility that evening. SP1 asked SP2 how s/he should respond to the situation and SP2 told SP1 to first call and notify LE and then call the G. SP1 told SP2 that s/he had already contacted and reported this information to LE as required. SP2 told SP1 that s/he would then contact the CW using his/her “work phone.” After speaking to SP1, SP2 stated that s/he called the CW but could not remember if s/he left the CW a voicemail since it was a “holiday weekend” and SP2 “knew” the CW would not be “in-office” at that time to receive and respond to his/her message. SP2 had “frequent” contact with the CW and “planned” to email the CW over the weekend after talking with the morning shift staff persons and the AV regarding the incident and/or call the CW on “Tuesday morning” (May 28, 2024) when the CW returned to his/her office to “follow up” with the CW about the AV’s departure from the facility along with other concerns regarding the AV’s behavior that SP2 had “recently” contacted the G and CW about “days” prior to the incident.

· SP2 was not scheduled to return to the facility until after the weekend on May 27, 2024, but spoke to P2 the morning prior when P2 called to tell SP2 about the incidents relating to the AV and the phone calls that P2 received from the G and the CW about not being informed by the facility that the AV left. SP2 told P2 that s/he called the CW’s office number but did not call the guardian, even though an unknown staff person entered information on the facility’s Incident Report showing that SP2 called the G at 1 a.m. on May 26, 2024, to inform the G that the AV ran away from the facility. Furthermore, the G and CW were informed about the incidents that occurred after the AV left the facility on May 25 to 26, 2024, prior to SP2 being aware of these incidents. This did not allow SP2 the “time or opportunity” to contact the facility in the morning and “follow up” with staff persons and the AV “as planned” before sending an email to the CW so that the incident could be addressed along with other concerns during a phone call between SP2 and the CW once the CW returned to office. SP2 stated that facility policies regarding “runaway” situations at that time were for staff persons who were on-site to notify guardians, LE, and the on-call supervisor but these policies were later updated after this incident.

The AV’s Medical Administrative Record (MAR) showed that prior to the incident on May 25, 2024, on or around 9:30 p.m. on 16 consecutive nights during the AV’s placement at the facility, staff persons administered five prescribed medications to the AV that included three psychotropic medications. On eight of these evenings, the MAR showed that SP1 administered the AV’s nightly medications which helped manage the AV’s sleep, depression, anxiety, and PTSD-associated nightmares [Note: Information regarding what each medication treated was information obtained from the G and the CW since forms relating to this information were not fully completed by the facility as required which was a violation of Minnesota Rules, part 2960.0080, subpart 11, item B, which states that the license holder must contact a newly admitted resident's prescribing medically licensed person to verify information regarding prescribed medication that included the symptoms that the medication alleviated and the symptoms that would warrant consultation with the physician]. On the evening of May 25, 2024, SP1 completed the MAR for the AV’s nightly medications and wrote the AV was not able to take his/her medications because the AV was “offsite” or “on run” during this time.

The facility’s personnel and training records showed that all staff persons who provided information for this investigation were trained on the Maltreatment of Minors Act, the facility’s policies and procedures, and the AV’s plans prior to the incident.

Relevant Rules and Statutes:

Minnesota Statutes, section 245A.25, subdivision 1, paragraph (a), clause (1) subdivision 3, paragraphs (a-d) and

(f-h) subdivision 5, paragraphs (a-f), stated the requirements that a children's residential facility setting must meet to be certified in compliance with FFPSA for the purposes of Title IV-E funding that included a residential setting

specializing in providing care and supportive services for youth who have been or are at risk of becoming victims of sex trafficking or commercial sexual exploitation.

Minnesota Rules, part 2960.0080, subpart 17, item A, stated that the license holder must submit critical incident reports to DHS Licensing within ten days.

Conclusion:

A. Maltreatment:

The AV was diagnosed with multiple mental health conditions and had a history of “significant instability and trauma,” abuse, “high-risk” and self-injurious behaviors, emotional dysregulation, and elopement. The AV’s intake documents that were completed by the facility showed the AV’s history, diagnoses, health and safety needs, and vulnerabilities that the facility accepted responsibility in providing care and support to during the AV’s placement at the facility. Additionally, assessments completed by SP2 showed that the AV experienced and/or was “high risk” to sexual trafficking and/or commercial sexual exploitation to which the facility maintained certification in compliance with FFPSA that specialized its programming in serving youth with this history and/or vulnerability of being victim to. Due to these factors, the facility was responsible to provide the AV with “individualized” cares and supports that included “trauma-informed care,” adequate supervision, maintaining the AV’s emotional and mental health needs, providing “physical and psychological safety,” and managing the AV’s medications. Furthermore, facility policies required staff persons to “assume” that “all youth” who received services and care from the facility were “exposed to” and “affected by trauma” such as the AV, and therefore, were trained on “trauma informed,” “youth oriented” practices that the AV required.

Consistent information was provided by the G, the CW, and facility documentation that due to the AV’s history and diagnoses, the facility was to provide the AV with “heightened supervision” that included an “agreement” of contacting LE, the G, and the CW “immediately” if the AV left the facility’s property. The AV’s Safety Plan also required staff persons to contact the G or the CW for additional assistance and support that could be provided to the AV verbally during a phone call, using a video chat, and/or in-person if staff persons were not able to “redirect” or “de-escalate” a situation relating to the AV or his/her behaviors.

Consistent information was provided by the G, the CW, facility documentation, and LE records that on May 25, 2024, at approximately 6:15 p.m., the AV left the facility with SP1’s knowledge who then contacted SCPD’s non-emergency line at 6:34 p.m. with general information relating to the AV and his/her departure from the facility. SP1 then called SP2 at approximately 6:45 p.m. and told SP2 that the AV ran away from the facility and that LE was already contacted with this information. SP2 told SP1 that s/he would contact the CW, with discrepancy on who was responsible for calling the G due to conflicting information provided by SP1 and SP2. At approximately,

6:54 p.m., LEO1 arrived at the facility in response to SP1’s call but SP1 told LEO1 “to wait” in reporting the AV as a “juvenile run” at that time and did not make any additional contact with LE after the AV did not return to the facility later that night. Additionally, there were no attempts made by staff persons to contact the G prior to or after the AV left the facility, with the G being unaware that there were any concerns with the AV’s behavior, health, and/or safety until the AV arrived at the G’s home in “the middle of the night.” It was later determined that after the AV left the facility, the AV was sexually assaulted by the C who was then criminally charged, convicted, and sentenced for sexually assaulting a minor (the AV) during the evening of May 25, 2024.

A total of five calls were placed by the G and LEO3 to the facility between 3:40 a.m. and 5:27 a.m. on May 26, 2024, but the calls were not answered by P1 who was working at the facility during this time. The facility was not aware of the AV’s whereabouts or condition until SCPD officers arrived at the facility at 6:45 a.m. and told P1 that the AV had been located by the G and was currently receiving care at a local hospital after being sexually assaulted.

Regarding SP1’s actions:

Facility documentation that included the AV’s SN and intake documents provided information that the AV had dysphoria related to his/her body image and that s/he was also prescribed a daily morning medication that “often” caused a “decreased” or “suppressed” appetite that then “lessened” throughout the day as the medication “wore off.” Additionally, on the day prior to the incident, the AV’s daily schedule that included mealtimes were not consistent with his/her “typical” schedule because of an early morning dental appointment which resulted in the AV eating breakfast before 6 a.m., eating a snack when returning from his/her appointment, and then declining dinner that evening before going to bed. On May 25, 2024, P4 noted that the AV also declined to eat lunch when offered that day but was then hungry and asked for lunch at approximately 2:45 p.m. later that afternoon. Despite the AV’s known health needs, dental work being completed on the day prior that could have resulted in mouth tenderness/pain, and the AV not eating dinner the evening prior or lunch that afternoon, the AV was not permitted by staff persons to eat food items that were considered a meal because of the timing of day and for declining to eat when a meal was offered. When the AV showed signs of being “upset” with the situation, verbally expressed to staff persons that s/he was hungry, and then went into the kitchen to get food from the refrigerator, SP1 also went into the kitchen and again told the AV that s/he was “not allowed to eat dinner” at that time which resulted in the AV telling SP1 that s/he “didn’t care” about the time and was going to eat. SP1 then noted that the AV “lost [his/her] privileges” shortly thereafter for “not listening” to staff persons without any other prior incidents relating to the AV’s behavior being documented that day.

According to SP1, who was the only staff person working from 4 to 10 p.m. later that day, the AV was “acting suspicious” and “giving signals” that s/he might run away from the facility but SP1 did not respond to this situation in a manner that reflected the AV’s plans or facility policies that included attempts to “redirect” or “de-escalate” the situation, “collaboratively” problem-solve with the AV, contact the G or the CW for assistance, and/or develop a “safety plan” that would help keep the AV safe if s/he left the facility. Furthermore, SP1 told the AV to come inside the facility but then did not allow the AV to enter the facility when the AV refused to let SP1 search his/her backpack even though the AV had not left the facility’s property and was supervised by SP1 during this time. Despite the facility’s Safe Search policies, the AV’s history, and SP1 being aware that this was already an “escalated” situation with the AV, SP1 told this investigator that no additional approaches were attempted in responding to the AV’s refusal to be searched at this time. SP1 then watched the AV walk away from the facility after an “escalated” situation that was not resolved while also being aware that the AV did not have access to the care and supports that the facility was responsible in overseeing and providing to the AV that was required for the AV’s health and safety, as well as for the safety of others.

Although SP1 stated that s/he called LE within ten minutes of the AV leaving the facility and reported the AV as “a runaway” to LE at this time, this information was not consistent with the Incident Report completed by SP1 later that night and detailed records maintained by SCPD. SP1 documented that s/he called SP2 at 6:45 p.m. and that the AV was already reported to LE as “a runaway” at that time. SP1 did not disclose any information that LE responded to the call and arrived at the facility shortly thereafter, nor did SP1 document the case number that LEO1 provided to SP1 as required by facility policies. Additionally, LE records showed that SP1 called LE and provided the dispatcher with general information relating to the AV and his/her departure from the facility but did not disclose any information pertaining to the AV’s history or mental health and did not report the AV as a “runaway” at this time. Furthermore, LE records consistently showed that within 20 minutes of SP1’s call to LE, LEO1 arrived at the facility to assist with the situation which was within 40 minutes of the AV’s departure from the facility but SP1 told LEO1 “to wait” in entering the AV as a “juvenile run” at that time, without any additional contact made by SP1 to LE in updating the AV’s status to “a runaway” when the AV did not return to the facility later that night.

The AV’s MAR dated May 9 to 24, 2024, showed that the SP administered five medications that included three psychotropic medications to the AV on eight nights during this time. Therefore, SP1 was aware that the AV had mental health conditions that required monitoring and medication management provided by the facility which the AV would not be able to receive unless the AV was located and/or returned to the facility. When SP1 was ending his/her shift at approximately 10:46 p.m. that night without receiving any updated information on the AV’s whereabouts or general condition, SP1 did not attempt to contact the G, the CW, LE, and/or supervisory staff persons to make sure the AV was safe or located despite being aware of the AV’s history, diagnoses, and being “high risk” and “at risk” for sexual exploitation and/or other potentially harmful situations. Furthermore, the AV did not have any basic resources such as shoes, food, money, shelter, transportation, or means to contact anyone after leaving the facility and that were needed to maintain general health and safety.

Despite the discrepancy between SP1 and SP2 on who was responsible for contacting the G, the facility’s policies at the time of the incident stated that the on-site staff person (SP1) was responsible in contacting the AV’s emergency contacts “immediately within an hour” that included the G and the CW. Furthermore, the G and/or the CW were contacted prior to the AV leaving the facility when SP1 was not able to “redirect” or resolve the following incidents that were noted by SP1 but only continued to “escalate” further: when SP1 took away the AV’s “privileges” after the incident in the kitchen at 3 p.m.; when the AV showed “signs” of running away from the facility during the hours that then followed this; and/or when the AV “agreed” to come into the facility after “initially” refusing to do so but then would not allow SP1 to search his/her backpack. Not only were the situations handled in a manner that was inconsistent with the AV’s plans and assessments, facility policies, job trainings that were provided by the facility prior to this incident; and the standards of a professional caregiver in a facility that was licensed by the Department of Human Services and certified under Minnesota Statutes, section 245A.25; SP1 responded to the AV in a manner that was “known” to “escalate” the situation and the AV’s behaviors that could result in the AV harming him/herself and or others.

Therefore, there was a preponderance of the evidence that there was a failure to provide the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so.

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health

when reasonably able to do so; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Regarding SP2’s actions:

The G, the CW, SP2, P2, P3, and facility documentation provided consistent information that SP2 was the AV’s facility case manager who was responsible for oversight of the AV’s care and supports while receiving services from the facility that included completing the AV’s intake documents and maintaining ongoing communication with the G and the CW. The AV’s intake documents, SN, and Case Manager Notes dated May 8 to 24, 2024, showed that the SP2 consistently and “frequently” maintained these responsibilities that were recorded and/or

stated by SP2, the G, the CW, P4, and other staff persons who worked with the AV during this time but were not interviewed by this investigator.

Information from SP1, SP2, the CW, and facility documentation showed that on May 25, 2024, the facility did not notify the G that the AV ran away from the facility as required. Additionally, the CW stated that s/he did not receive a voicemail or an email from SP2 showing that s/he attempted to contact and notify the CW of the AV’s departure from the facility. SP2 and facility documentation provided consistent information that SP2 called the CW at an unknown time after 6:45 p.m. when SP1 called and told SP2 that the AV left the facility. SP2 did not remember if s/he left the CW a voicemail but “knew” that the CW would most likely not be in-office to receive the voicemail since it was a “holiday weekend.” (Note: Minnesota county government offices, including Stearns County, were typically open 8 a.m. to 4:30 p.m., Monday through Friday, and closed during weekends and on U.S. federal holidays that included Memorial Day which was on May 27, 2024.) SP2 said s/he “planned” on contacting the CW by sending an email the following day once s/he talked with staff persons for an update on the situation or calling the morning of May 28, 2024, when the CW returned to his/her office since SP2 had additional concerns with the AV’s “recent” behaviors that were already being discussed between SP2, the CW, and the G. However, SP2 was not able to notify the CW as “planned” because on the morning of May 26, 2024, the CW was informed of the AV’s situation before SP2 was aware of what happened. Additionally, since SP2 directed SP1 to call and inform the G that the AV ran away from the facility and was told by SP1 that LE was already contacted with this information, and there was not any additional contact from on-site staff persons with concerns relating to this incident, SP2 was not aware that the AV had not been located and/or did not return to the facility that night.

Although there was discrepancy between SP1 and SP2 in who was responsible in notifying the G that the AV left the facility, facility documentation showed that SP2 consistently contacted the G and/or the CW during past incidents when needed and that facility policies required SP1 to “immediately” notify the G of the AV’s departure from the facility. Therefore, there was not a preponderance of the evidence that SP2 failed to provide the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so.

It was not determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2):

When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

SP1 was trained on the facility’s policies and procedures, the Maltreatment of Minors Act, and the AV’s care plans prior to the incident. Although SP2 was the appropriate supervisory staff person for SP1 to contact after the AV left the facility, there was not a preponderance of the evidence that showed SP2 was responsible for contacting the G which would then mitigate SP1’s responsibility in doing so. Facility documentation showed that SP1 was required to notify the G “immediately” after the AV left the facility, as well as prior to this incident when SP1 was responding to multiple incidents relating to the AV’s behavior that was noted by SP1 but not responded to in a manner that was consistent with the AV’s plans and assessments and facility policies.

SP1 was responsible for the direct care and supervision of the AV when the incident occurred and in responding to the prior situations that led up to the AV leaving the facility. Additionally, shortly after the AV’s departure from the facility, SP1 did not report the AV as “a runaway” when a law enforcement arrived at the facility to assist the facility in locating the AV and did not contact LE later in the night when the AV had not yet returned. Therefore, SP1 was responsible for maltreatment of the AV.

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 SP1 was responsible was “serious” maltreatment because it then resulted in criminal sexual conduct against a child. On August 13, 2024, the C was convicted of a felony for criminal sexual conduct against the AV that occurred on May 25, 2024, after the AV’s elopement from the facility.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but not followed. The facility updated all policies related to this investigation and then retrained all staff persons on the updated policies. Additionally, SP2 was no longer working in a supervisory position after this incident.

Action Taken by Department of Human Services, Office of Inspector General:

SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal.

On June 20, 2025, the facility was issued a Correction Order for the violation outlined in this report and for failing to submit a critical incident report form.

On June 20, 2025, the facility was issued an Order to Forfeit a Fine for failing to report maltreatment as required.

Certification:

The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.

Administrative Reconsideration:

The disposition of the investigation is amended to reflect that the substantiated maltreatment by neglect for which SP1 was responsible does not meet the criteria to be considered serious maltreatment. To the extent that the language in the Administrative Reconsideration conflicts with the language in the remaining part of the Amended Investigative Memorandum, the language in the Administrative Reconsideration controls. The disposition was amended based on the following:

Amended Conclusion:

C. Recurring and/or Serious Maltreatment:

Minnesota Statutes, section 245C.02, subdivision 16, states:

Minnesota Statutes, section 245C.02, subdivision 18, states:

On August 13, 2024, the C was convicted of a felony for criminal sexual conduct against the AV that occurred on May 25, 2024, after the AV’s elopement from the facility. However, because SP1’s actions did not directly result in criminal sexual conduct to the AV, the maltreatment was not determined to meet the criteria to be considered serious.

Amended Action Taken by Department of Human Services, Office of Inspector General:

SP1 was notified that s/he was no longer disqualified from any 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 SP1 was responsible for maltreatment by neglect is subject to appeal.

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