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AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated November 14, 2025, which must be destroyed. As a result of an administrative reconsideration, the original determination that a staff person (SP) was responsible for sexual abuse of a vulnerable adult was changed to inconclusive. The determination that the SP was responsible for neglect of a vulnerable adult was affirmed upon reconsideration. Given that the SP was no longer responsible for sexual abuse, the SP’s disqualification was rescinded. For additional information, see Administrative Reconsideration section of this document.
License Number and Program Type: 1107574-SUD (Substance-Use Disorder) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff persons (SP) sent a vulnerable adult (VA) images of him/herself depicting sexual poses and that the SP and VA had sexual contact at the facility. The VA later relapsed and left treatment early. Date of Incident(s): Prior to August 29, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c); and subdivision 17, paragraph (a): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility; and through ten interviews conducted with two facility supervisors (P3 and P4), and three staff persons (P1, P2, and P5), the VA’s probation officer (PO), the VA, two clients (C1 and C2), and the SP. The VA was diagnosed with major depression disorder and generalized anxiety disorder and was receiving treatment for a substance-use disorder that included methamphetamines and opioids. The facility was a 90 day, low-intensity, residential substance use rehabilitation treatment program that required five to eight hours of weekly programming. In addition to the facility programming, clients were to be working, volunteering, or attending school. The facility offered apartment-style living with two bedrooms, a shared kitchen, a living room, and a bathroom. Each apartment held up to three clients with one bedroom housing one client and the second bedroom housing two clients, based on seniority with the VA in the single room. Clients were able to have cell phones during treatment. The VA had the goal of remaining sober, finding employment, and finding stable housing. The VA began receiving services at the facility on June 10, 2025, and the SP started working at the facility not long after. The VA discharged on August 29, 2025. The VA provided the following information: · The VA had sex with the SP on an unknown date in August 2025 during the same weekend that the facility had a deep cleaning weekend. The VA felt guilty that s/he “allowed it to go on as long as [s/he] did” and for having sex in his/her bedroom. The VA was going through a hard time and talked to the SP about his/her personal life. At some point, the SP would not leave the VA alone. On the day that they had sex, the SP went into the VA’s bedroom and said, “Do you want to fuck me or no?” The VA said, “What do you mean? In here?” and the SP “just stared” at the VA. The VA then asked the SP if there was anyone else in the apartment and s/he said, “No.” The SP then approached the VA’s bed, and they had sex.
· On a previous date, the VA was laying on his/her bed when the SP entered the VA’s bedroom. The SP was acting “nonchalant” and asked the VA if s/he would give the SP a kiss. The VA said, “Okay, sure.” The SP leaned down and the VA kissed the SP. · The VA worked and slept a lot during his/her time at the facility, but the SP made time to have long conversations that “started the connection” that the VA and SP had. The SP would come to the VA’s apartment unit to talk, and they eventually exchanged contact information. The VA found the SP on social media, and they exchanged messages. The VA deleted some of the message strings. · After the incident, the SP started to “act weird” toward the VA, the VA began to not trust the SP, and the VA slowly “backed off” so that the SP would not feel uncomfortable. The VA felt “targeted” by the SP. The VA “relapsed” on methamphetamines on or around August 23, 2025, and did not tell anyone. · The VA eventually told P1 that s/he was “uncomfortable” with the SP and was afraid the SP would “say something,” so the VA told his/her roommate, C1 “everything.” P1 and P2 provided the following information: · According to P1, on August 20, 2025, the VA indicated that s/he felt “strange” about the SP and interactions with the SP were making the VA “uncomfortable.” One of the SP’s job duties was to do “rounds” at the facility to conduct safety checks on clients. The SP often “lingered” in the VA’s apartment, spending more time there than s/he “should,” making small talk with the VA. The VA felt the SP “staring” at the VA “awkwardly” and the VA felt it was “abnormal.” During this meeting, the VA denied anything “inappropriate” had been done or said. The VA said s/he felt “safe” but “uneasy.” P1 then informed P4. · P2 stated that on August 29, 2025, the VA said the SP was “stalking” the VA by talking a lot and texting through Facebook Messenger. The VA went on to say that s/he and the SP had sex in the VA’s bedroom. For approximately a minute, the VA scrolled through “dozens or hundreds” of messages exchanged between the VA and the SP, including two photos of the SP laying down and only wearing underwear. The SP initiated the messages with the VA and the VA responded, “Why?” The VA told P2 that they had exchanged messages on Instagram but that the VA deleted those messages and had blocked the SP on Instagram. P2 brought the VA to talk to P1, and they spoke for approximately an hour. · P1 provided information consistent with P2 and stated that the VA told P1 that s/he had been having an “ongoing romantic relationship” with the SP which started early August 2025. The VA told P1 that the SP and VA had had sex several weeks prior in the VA’s bedroom on a Saturday, during the “super clean” weekend, possibly the weekend of August 9 and 10, 2025. The VA told P1 that the SP “propositioned” the VA for sex and then “straddled” the VA. · P1 stated that the VA opened Facebook Messenger and showed P1 the SP’s profile. The VA scrolled through their shared messages “really fast,” but it was enough for P1 to see that there had been back and forth communication between the VA and SP. The messages sent via Facebook Messenger began on August 7, 2025, but the VA said that s/he had deleted other text messages and Instagram messages. The VA showed P1 “multiple sexual images” of the SP in “provocative positions,” wearing just undergarments. P1 saw a message sent from the VA to the SP that said, “I want to fuck you so bad,” and another where the SP gave the VA his/her phone number. The VA said that s/he knew it was “fucked up” to be talking to the SP. · The VA provided the SP’s phone number to P1, which matched the number that the facility had for the SP and then P1 notified P3. The VA told P1 that C2 had information about the incident. · According to P1 and P2, the VA said s/he would provide screenshots, but they did not receive any. P2 stated that the VA seemed “pretty distraught” with the situation and was initially “going along” with the situation but at this point, the VA hoped that the SP was terminated. P1 said that there was a “significant negative impact” on the VA psychologically, and P1 observed a mental “dysregulation” for the VA with the “broken trust” between a client and staff persons. P2 also said that the VA was also concerned that the SP would show up to his/her place of employment. P2 was “caught off-guard” by the information. · P1 and P2 stated that the VA wanted to leave the facility and discharged on August 29, 2025. · According to P1, staff persons were not to exchange any personal information with clients and were regularly trained on “healthy boundaries.” P3 provided information consistent with P1, P2, and the VA, and added the following: · P1 notified P3 on August 29, 2025, that the VA and the SP had contact through text messages and other social media platforms, and that they had also had sex at the facility. · P3 directed P4 to review video footage. There were a few dates when the incident could have happened, with August 6, 2025, being one of the possibilities as it also aligned with when the facility did their super clean event. On that date, the SP was in the VA’s apartment for ten to fifteen minutes, which was longer than would have been needed since a “room search” was not occurring. · C1 denied having information regarding a relationship between the VA and the SP and the SP denied the allegations when P3 spoke with him/her. P4 provided the following information: · On August 20, 2025, the VA told P4 about some concerns with the SP and how the SP recently began treating the VA “differently” after the VA “pulled back” on conversations with the SP. P4 then spoke with the SP and the SP assured P4 that nothing was going on with the VA and that the SP did not feel that the VA “crossed any boundaries.” On August 29, 2025, P2 informed P4 of an “inappropriate relationship” between the VA and the SP which included 1,000 text or Facebook messages and photos that P1 and P2 observed. Descriptions of the photos provided by P4 were consistent with descriptions provided by P1 and P2. · P4 reviewed facility video footage, which was placed at both ends of each residential floor. On the footage on or around August 6, 2025, the SP entered the VA’s apartment unit during room checks. C1, exited “right away” while the SP stayed in the apartment for 25 to 35 minutes and then later C1 returned. · The SP’s rounds were “pretty weird” because s/he sometimes spent five to seven minutes in one unit, which was longer than usual. Entire rounds usually took ten to fifteen minutes and the SP also had “quite a few trips” to the VA’s floor. All apartments were typically checked during the same rounds, but the SP would not always complete all units at once and would skip certain rooms, later returning to do them. The PO provided information consistent with the information provided by the VA and P1. C2, who did not see anything him/herself, stated that the VA told him/her that s/he “had been sleeping with” the SP and that the SP sent the VA pictures. The VA told C2 that s/he had sex with the SP in the staff person office, and later, that the VA “told on” the SP because the SP would not “fake” the VA’s urinalysis test. C2 later heard from a different client that the SP had sex with a client during rounds but a name was not given. The SP provided the following information: · The SP denied kissing or having sex with the VA. Staff persons were not supposed to have cell phone or social media contact with clients at the facility while they were receiving services or for a year or two after discharge. The SP had communication with the VA while s/he was at the facility because s/he realized that s/he knew the VA toward the end of his/her employment at the facility, but that interaction was “strictly like a friend.” The SP was trying to be a “supportive person” to the VA. · The VA found the SP on social media and s/he did not accept the friend request. The VA sent “a few” messages to the SP, which s/he responded back to and admitted s/he knew it was “crossing a boundary.” The SP stated that s/he never exchanged text messages or phone calls with the VA, and that s/he “blocked” the VA’s phone number. · The SP did not “recall” sending pictures of him/herself wearing just undergarments and clarified that “it did not happen,” and later denied sending “those kinds of pictures” to the VA, however, the SP did not deny that the pictures were sent. The SP stated that s/he often left his/her phone out, “unlocked all the time,” and that it was possible that his/her family members sent those images to the VA. · The VA messaged the SP that s/he wanted to “fuck” the SP, and the SP “shut it down.” The VA also asked for the SP’s home address and the SP did not provide it. The SP denied “physical contact” occurred with the VA other than a one-time hug and said that there was “no relationship.” · During the super clean, the SP spent 20 to 30 minutes with C1 in the apartment while the VA slept. C1 denied seeing anything inappropriate between the VA and the SP and said that the VA sent him/her text messages saying that s/he was going to throw the SP “under the bus.” C1 felt like the VA was making up a scenario to get the SP in trouble because the VA was “kicked out” of the program. C1 denied seeing personal text messages between the SP and VA. C1 stated that during the August 2025 super clean weekend, C1 may have left the room to go smoke a cigarette but was not gone from the apartment for very long. P5 denied having any information from C1 or C2 and stated that the information s/he was given was not about the VA and the SP and told C2 to direct any information s/he had to P3. P5 only heard information regarding the allegations from P1 and P3. Facility documentation showed that P1, P2, P3, P4, P5, and the SP were each trained on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information from P1, P2, and the VA showed that the VA and SP began exchanging text and Facebook messages and that according to the VA, it began in early August 2025. Some of these messages included photos of the SP that were of a sexual nature to the VA. The SP denied sending the messages but stated that it was possible that someone else sent the VA the messages and photos of the SP from the SP’s phone. Things progressed between the VA and the SP with the SP going into the VA’s apartment and asking the VA for a kiss, to which the VA agreed, and then later, the SP entered the VA’s apartment and had sex with the VA on the VA’s bed on or around August 6, 2025, which was the week of the cleaning week with August 9 and 10, 2025 being the weekend of the “super clean” week. The VA relapsed on August 20, 2025, and later, on August 29, 2025, told both P1 and P2 about the relationship with the SP. P1 said that the relationship between the VA and SP had a “significant negative impact” on the VA and P2 said that the VA seemed “pretty distraught.” Although the SP denied having sex with the VA, given that the SP had reason to minimize his/her actions for fear of consequences, that the VA provided consistent information to P1, P2, and to this investigator, and that P1 and P2 observed text messages and photographs sent to the VA by the SP that were of a sexual nature, and that it was reasonable that P1, P2, P3, P4, C1, and C2 would not witness every interaction between the SP and the VA including sexual contact, there was a preponderance of the evidence that the SP had sexual contact with the VA. In addition, given the VA’s history of substance use disorder, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA both now and in the future. Given this, that the VA stated the SP and the VA kissed, and that the SP and the VA had several messages sexual in nature including the SP sending the VA photos of the SP in only undergarments, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health and a failure to provide reasonable and necessary care and services. It was determined that sexual abuse and neglect occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast and 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, pl an, 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 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 sexual abuse that the SP was responsible for was not recurring maltreatment because it was determined the SP had sexual contact with the VA on one occasion but was serious maltreatment because it met the definition. It was determined that the substantiated neglect that the SP was responsible for was not recurring or serious maltreatment because it was a single pattern and did not meet the definition of serious maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility’s Internal Review stated that policies and procedures were adequate but were not followed. The event was not similar to a previous event involving this VA. Staff persons at the facility were retrained and the SP no longer worked for 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. Administrative Reconsideration: The disposition of the investigation is amended from substantiated as to sexual abuse of the VA by the SP to inconclusive as to sexual abuse of the VA by the SP. 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 Summary of Findings: P1 and P2 provided the following information: · According to P1, on August 20, 2025, the VA indicated that s/he felt “strange” about the SP and interactions with the SP were making the VA “uncomfortable.” One of the SP’s job duties was to do “rounds” at the facility to conduct safety checks on clients. The SP often “lingered” in the VA’s apartment, spending more time there than s/he “should,” making small talk with the VA. The VA felt the SP “staring” at the VA “awkwardly” and the VA felt it was “abnormal.” During this meeting, the VA denied anything “inappropriate” had been done or said, and the VA indicated s/he was not attracted to the SP. The VA said s/he felt “safe” but “uneasy.” P1 then informed P4. · P2 stated that on August 29, 2025, the VA said the SP was “stalking” the VA by talking a lot and texting through Facebook Messenger. The VA initially said the SP “wanted to” have sex “upstairs” and then corrected him/herself and said “we did” have sex upstairs in the VA’s bedroom. For approximately a minute, the VA scrolled through “dozens or hundreds” of messages exchanged between the VA and the SP, including two photos of the SP laying down and only wearing underwear. The SP initiated the messages with the VA and the VA responded, “Why?” The VA told P2 that they had exchanged messages on Instagram but that the VA deleted those messages and had blocked the SP on Instagram. The VA said C1 knew about the relationship. P2 brought the VA to talk to P1, and they spoke for approximately an hour. · P1 provided information consistent with P2 and stated that the VA told P1 that s/he had been having an “ongoing romantic relationship” with the SP which started early August 2025. The VA told P1 that the SP and VA had had sex several weeks prior in the VA’s bedroom on a Saturday, during the “super clean” weekend, possibly the weekend of August 9 and 10, 2025. The VA told P1 that the SP “propositioned” the VA for sex and then “straddled” the VA. · P1 stated that the VA opened Facebook Messenger and showed P1 the SP’s profile. The VA scrolled through their shared messages “really fast,” but it was enough for P1 to see that there had been back and forth communication between the VA and SP. The messages sent via Facebook Messenger began on August 7, 2025, but the VA said that s/he had deleted other text messages and Instagram messages. The VA showed P1 “multiple sexual images” of the SP in “provocative positions,” wearing just undergarments. P1 saw a message sent from the VA to the SP that said, “I want to fuck you so bad,” and another where the SP gave the VA his/her phone number. The VA said that s/he knew it was “fucked up” to be talking to the SP. · The VA provided the SP’s phone number to P1, which matched the number that the facility had for the SP and then P1 notified P3. The VA told P1 that C2 had information about the incident. According to P1 and P2, the VA said s/he would provide screenshots, but they did not receive any. P2 stated that the VA seemed “pretty distraught” with the situation and was initially “going along” with the situation but at this point, the VA hoped that the SP was terminated. P1 said that there was a “significant negative impact” on the VA psychologically, and P1 observed a mental “dysregulation” for the VA with the “broken trust” between a client and staff persons. P2 also said that the VA was also concerned that the SP would show up to his/her place of employment. P2 was “caught off-guard” by the information. · P1 and P2 stated that the VA wanted to leave the facility and discharged on August 29, 2025. · According to P1, staff persons were not to exchange any personal information with clients and were regularly trained on “healthy boundaries.” P4 provided the following information: · P4 reviewed facility video footage, which was placed at both ends of each residential floor. On the footage on or around August 6, 2025, the SP entered the VA’s apartment unit during room checks. C1, exited “right away” while the SP stayed in the apartment for 25 to 35 minutes and then later C1 returned a few minutes before the SP left. P4 said the SP did not appear disheveled when s/he left the apartment. The PO provided information consistent with the information provided by the VA and P1. The PO indicated that the VA told him/her the SP entered the VA’s room one day and offered to have sex with him/her. The VA never said whether s/he actually had sex with the SP but “continued on with [his/her] story and it sounded like maybe [s/he] did.” Amended Conclusion: A. Maltreatment: Sexual Abuse Information from P1, P2, and the VA showed that the VA and SP began exchanging text and Facebook messages and that according to the VA, it began in early August 2025. Some of these messages included photos of the SP that were of a sexual nature to the VA. The SP denied sending the messages but stated that it was possible that someone else sent the VA messages and photos of the SP from the SP’s phone. The VA indicated things progressed between the VA and the SP with the SP going into the VA’s apartment and asking the VA for a kiss, to which the VA agreed, and then later, the SP entered the VA’s apartment and had sex with the VA on the VA’s bed on or around August 6, 2025, which was the week of the cleaning week with August 9 and 10, 2025 being the weekend of the “super clean” week. The VA relapsed on August 20, 2025, and later, on August 29, 2025, the VA told P1 and P2 that s/he had a romantic relationship with the SP. P1 said that the relationship between the VA and SP had a “significant negative impact” on the VA and P2 said that the VA seemed “pretty distraught.” The SP denied kissing or having sex with the VA. However, the VA provided inconsistent information about his/her interactions with the SP and about where the interactions occurred. The VA initially told P1 on August 20, 2025, that nothing inappropriate occurred with the SP and that s/he was not attracted to the SP, but later indicated on August 29, 2025, that s/he had a romantic relationship with the SP since the beginning of August 2025, and that they had sex in the VA’s room. The VA told the PO the SP offered to have sex with the VA but never indicated whether or not they had sex. The VA told P2 that C1 knew about the VA’s relationship with the SP, but C1 indicated s/he did not see any inappropriate interactions between the SP and the VA and that the VA told C1 s/he made up a scenario about the SP because the SP would not lie about the VA’s urinalysis. C2 told the investigator that the VA said s/he had sex with an unidentified person in the staff person office and later said s/he “told on” the staff person because s/he would not “fake” the VA’s urinalysis test. Also, the VA stated to multiple persons that s/he “had sex” with the SP and told P1 the SP “straddled” him/her. However, there were no further details provided about the specific contact between the VA and the SP that would indicate whether any contact met the definition of sexual contact or sexual penetration. Given that, the conflicting accounts provided by the SP and the VA, that neither party was determined to be more credible than the other, and that no clients or facility staff persons observed inappropriate contact between the VA and the SP, there was not a preponderance of evidence whether the SP had sexual contact with the VA. It was not determined whether 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. Neglect The VA provided consistent information to P1, P2, and to this investigator that the VA and the SP exchanged messages on Facebook Messenger. P1 and P2 observed messages and photographs on the VA’s phone sent to the VA by the SP that were of a sexual nature, including photographs of the SP in only undergarments. The SP denied sending messages of a sexual nature to the VA but acknowledged communicating with the VA through Facebook Messenger and acknowledged s/he had crossed boundaries when s/he had done so. P1 indicated staff persons were not to exchange any personal information with clients and were regularly trained on “healthy boundaries.” Given the VA’s history of substance use disorder, it was reasonable that the VA would continue to need support to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA both now and in the future. There was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health and a failure to provide reasonable and necessary care and services. 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: (2) 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; (3) 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 (4) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained 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 neglect that the SP was responsible for was not recurring or serious maltreatment because it was a single pattern and did not meet the definition of serious maltreatment. The SP was not disqualified from providing direct contact services. Amended Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he is no longer responsible for maltreatment by sexual abuse of the VA and that the determination that s/he was responsible for maltreatment by neglect of the VA is affirmed. The SP was also notified that the SP is no longer disqualified for recurring and/or serious maltreatment at this time because the SP is no longer responsible for sexual abuse and the remaining substantiated maltreatment by neglect does not by itself meet the definition of recurring maltreatment. The determination that the SP was responsible for maltreatment by neglect is subject to appeal.
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