|
MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1114045-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth Lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) and vulnerable adult (VA) met at the facility and after the VA left the facility, s/he lived with the SP and had a relationship with him/her. Date of Incident(s): Ongoing prior to February 6, 2026 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 was obtained during a site visit conducted on February 18, 2026; from documentation at the facility; and through five interviews conducted with three facility supervisory staff persons (P1, P2, and P3), a staff person (SP), and a staff person (S) who worked with the VA at a program operated by a different license holder. This investigator met the VA but the VA declined to provide information related to the investigation. The facility provided treatment services for individuals with opioid and stimulant use disorders. The facility was in a building that had two floors and there were client bedrooms on each floor. There was also a nursing office on the main floor. The facility had video cameras in the main areas but not in the nursing office. There was one overnight staff person who performed rounds and monitored the clients during the overnight. The VA was at the facility from December 30, 2025, to January 4, 2026, when the VA left against staff advice. The VA was diagnosed with bipolar disorder, anxiety, and post-traumatic stress disorder. According to the VA’s Comprehensive Assessment dated December 30, 2025, the VA said that s/he was not in a relationship. According to the VA’s Individual Abuse Prevention Plan, the VA was not susceptible to sexual abuse. The S and the Approved Visitor list from the S’s program dated February 5, 2026, provided the following information: · On February 4, 2026, the VA began receiving services from a new program and while completing paperwork with the S, the VA described a “desire” to move in with his/her “friend” after s/he completed treatment at the new program. The VA further told the S that the friend “actually works at a treatment center.” The S said that the VA had only been to one other treatment center, which was the facility. The S asked the VA if s/he and the SP were in a “relationship” and the VA said, “Yeah. We are.” The VA told the S that s/he and the SP went to “meetings and stuff” after the VA left the facility. The VA also told the S that after leaving the facility, s/he “stayed” at the SP’s “residence” and that prior to moving to the SP’s, the SP asked the VA if s/he was “going to be sober?” · On February 5, 2026, the VA listed the SP by the SP’s first and last name, as his/her “[girl/boy] friend” on the Approved Visitor list at his/her new program. · According to the S, the VA viewed his/her relationship with the SP as the only “supportive” relationship in his/her life. At some point after the VA told the S about the relationship, the VA asked the S what would happen if s/he knew the SP prior to coming to the facility. However, the S did not think that the VA or the SP knew each other prior and said that the VA only said this after the S told the VA that a staff person was not supposed to be in a relationship with a client. The VA was also “focused” on not getting the SP “in trouble” and was “really worried” about the SP. P1, the Former Client Concern, and the facility Internal Review provided the following information: · On January 6, 2026, a client (C1) told an unknown staff person that the VA was “sleeping” with the SP. C1 said that on January 3, 2026, s/he was upstairs when s/he heard the SP and the VA talking through the ceiling, while the VA and the SP were in the nursing office, stating that “they were going to hook up.” C1 also said that the VA was in the nursing office “often” with the SP. · The facility then spoke to two other clients (C2 and C3) who did not see any inappropriate contact between the VA or the SP. However, C2 said that the VA “hit on” the SP and that the VA was trying to “pursue” the SP. C2 also heard the VA on the phone stating that s/he was going to “hook up” with the SP after discharge or on the “outside.” Additionally, C2 said that at some point, the VA was cleaning with the SP “all night.” C3 also said that s/he was upstairs when s/he heard “noises” in the nursing office but C3 did not provide additional information regarding this. Additionally, the clients said that the VA called the SP his/her “baby.” [Note: This was reported to the Department of Human Services as required but at the time, there was not enough information to open a maltreatment investigation.] · On February 6, 2026, the S notified the facility that the VA told him/her that after s/he graduated from the S’s program, that s/he would be “moving in” with the SP, who the VA said that s/he met at the facility. · The facility then spoke to the SP who was “defensive” and “denied all allegations.” The SP said that s/he would “never sleep” with a client and would “never jeopardize” his/her job. The SP said that s/he “maintained [his/her] boundaries” with the SP and “was not sure” where the concerns came from. · P1 did not have any information that there was sexual contact between the VA and the SP while the VA was at the facility. P1 was not aware of the VA or the SP knowing one another prior to coming to the facility. · Staff persons were trained to not exchange phone numbers with the clients or tell the clients where they lived. P1 was not aware of the VA moving in with the SP after leaving the facility. The VA should not have known the SP’s last name and the SP’s employee badge would have only had the SP’s first name and last initial. · There were no prior concerns with the SP’s interactions with the clients. P2 said that the VA recently lost his/her family members so the VA was “probably desperate for connection.” The VA was “motivated for recovery.” At some point, the VA mentioned that s/he had a significant other but P2 thought it was someone from the “outside” and “not an employee.” P2 was not aware of the SP or the VA knowing one another prior to the facility and was not aware of them having a sexual relationship. P2 did not work with the SP and had limited interactions with the SP. However, P2 did not have any concerns with the SP. Staff persons were trained not to have relationships with clients, not to tell clients where they lived, and not to exchange phone numbers. P3 provided the following information: · On an unknown date, a staff person (P4) told P3 that C1 told him/her that there was “something going on” between the VA and the SP because the SP was “always” talking to the VA. P3 then spoke to the SP who told him/her that s/he was “not doing anything.” · P3 had not seen the VA or the SP interact and did not have any concerns with the SP’s interactions with clients. No other staff person told P3 any concerns with the SP’s interactions with the clients. P3 described the SP as “friendly” and “helpful” with the clients. · P3 was not aware of any reason why C1 or any client would provide inaccurate information or want to get the VA or the SP in trouble. · Staff persons were trained not to have relationships with clients and if a client was trying to be in a relationship with a staff person, the staff person was to notify their supervisor and tell the client that was “unprofessional.” The SP never told P3 about any client trying to be in a relationship with him/her, including the VA. Staff persons were trained not to give clients their phone numbers or their address. P3 was not aware of the VA living with the SP after the VA left the facility. P3 was not aware of the VA listing the SP on a visitor list at another facility and said that “should not be happening.” P3 was not aware of the VA or the SP having a sexual relationship. The SP provided the following information: · The SP denied being in any type of relationship with a client or former client including the VA and said that s/he was trained not to be in relationships with clients. The SP was not aware of any client trying to “flirt” with him/her. The SP “did not think” that any clients had his/her phone number. The SP denied that the VA lived with him/her and said that s/he did not see the VA after the VA left the facility. The SP denied talking to the VA about being in a relationship with him/her after the VA left the facility. The SP said that clients would “maybe” know his/her last name from his/her work ID. The SP did not know why s/he was listed on the VA’s visitor sheet at another facility as the VA’s significant other. · At times, staff persons would be in the nursing office with clients, including during medication administration. At some point, the VA talked to the SP in the office for a “little bit” regarding wanting to be “sober” and not on the “streets.” However, after a “little” while, the SP told the VA that s/he needed to clean the facility. The SP “did not think” the VA cleaned with him/her but said that at times, the clients would help staff persons clean. Additionally, the VA was only at the facility for two days and during that time, the SP’s interactions with the VA were “normal.” · The SP was not aware of why anyone would say that s/he was in a relationship with the VA but said that C1 was in a “gang” and may have wanted to “terrorize” the SP. · The SP did not know any of the clients prior to working at the facility. The Staff Behavior policy said that the facility strictly prohibited any sexual contact or personal involvement of a sexual nature between staff persons and clients, including former clients, for a minimum of two years following a clients discharge from services. Staff persons and clients were also prohibited from personal relationships, including friendships, or any other interactions outside of a therapeutic professional role. This included because such relationships may compromise professional boundaries and may place vulnerable adults at risk of exploitation or harm. Staff persons were prohibited from engaging in electronic communication with clients for a minimum of two years. Facility documentation showed that the SP, P1, P2, and P3 were trained on the Professional Boundaries and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA received services from the facility between December 30, 2025, and January 4, 2026. On February 4, 2026, the VA began receiving services at a new program and while there, the VA told the S that s/he and the SP were in a “relationship.” Additionally, information from the S showed that the VA listed the SP on his/her visitor list as his/her boyfriend/girlfriend and the VA had the SP’s first and last name listed despite information showing that the VA should not know the SP’s last name. The VA also told the S that after leaving the facility, s/he lived with the SP. The S said that after the VA told him/her about the relationship, the VA was “focused” on not getting the SP “in trouble” and was “really worried” about the SP. Additionally, C1 told the facility that s/he heard through the facility ceiling that the SP and the VA stated that they were going to “hook up.” C2 heard the VA state that s/he was going to “hook up” with the SP after discharge. The VA declined to provide information for this investigation and the SP denied being in a relationship with the VA and/or having any contact with the VA after s/he left the facility. No staff person had any concerns with the SP’s interactions, including with the VA, and there was no information that sexual contact occurred while the VA was a client at the facility. Therefore, without further information, there was not a preponderance of the evidence whether sexual contact occurred between the SP and 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, and breast.) In addition, although the VA told the S that s/he lived with the SP after s/he left the facility, that s/he and the SP went to “meetings and stuff” after the VA left the facility, that the VA told the S that s/he was in a relationship with the SP, and that the VA listed the SP as his/her girlfriend/boyfriend on a visitor list at his/her new program, given that there was no information provided regarding inappropriate interactions between the VA and the SP while the VA was receiving services at the facility, it was not determined whether the VA and the SP developed or engaged in a relationship while at the facility. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with necessary care or services. It was not determined whether 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.) Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. There were no similar incidents. The SP was placed on a leave of absence and the facility also provided additional training to the SP including professional boundaries and maintaining appropriate professional distance at all times. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken at this time.
|
