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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1069788-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson/Beth Virden Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was discovered “dirty” and “surrounded by trash” inside the VA’s house and that a staff person (SP) left the VA unsupervised with an unknown community person, who was later identified as the SP’s significant other (SO). Date of Incident(s): December 5, 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 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through five interviews conducted with the VA’s guardian (G) who was also the VA’s family member, facility staff persons (the SP and P1), a facility supervisory staff person (P2), and the SP’s significant other (SO). The VA was not interviewed due to his/her limited communication skills. [Note: The VA, the SP, and P1 were family members.] The VA’s support plans stated the following: · The VA lived in his/her own home and was “very kind” and wanted to stay healthy and active. The VA’s diagnoses included severe intellectual disability and deafness. The VA communicated with others using signs and gestures. · The facility provided the VA with one staff person (the SP) as the VA’s live-in primary caregiver. The SP provided the VA with 24/7 in-home support and supervision and helped with the VA’s transportation and meal preparations, medications and healthcare, and all hygiene tasks, including showering. P1 provided respite care services for the VA when the SP needed short term caregiver relief or time off for vacations. “It is essential for [the VA] to have 24/7 supervision and 1:1 staffing.” · The VA was unable to identify potentially dangerous situations and was susceptible to abuse from others. Staff were to accompany the VA in the community and verbally redirect him/her from potentially dangerous situations. “In the event of an emergency health event, [the VA] would be entirely dependent on others to call emergency services and help [him/her] navigate the emergency. The plan for unavailable staffing that may put [the VA’s] health or safety at risk consists of [the SP], who is [the VA’s] live-in caregiver and is available 24/7. If [the SP] is unavailable, [P1] would be available … If all other options have been exhausted, [the VA’s case manager] should be notified.” [Note: The VA’s support plans reviewed for this investigation did not state if the VA could be unsupervised inside his/her house for a time.] A law enforcement report provided the following information: · On December 5, 2025, at 11:46 a.m., the G contacted law enforcement officers (LEO) asking for a wellness check at the VA’s house. The G said that there had been several unidentified vehicles outside of the VA’s house and the G wondered if the SP was allowing other people to live at the VA’s house. Earlier that day, the SP texted the G and said that the VA was staying at P1’s house while the SP attended a funeral that day. The G believed there was no one at the VA’s house and wanted the LEO to accompany him/her for a walk-through and wellness check. The G had a key to the VA’s house and was authorized to enter. · When the LEO and the G arrived at the VA’s house, there were two vehicles in the driveway, which were not registered to the SP or the VA. The LEO knocked on the front door but received no response. The LEO unlocked the door and entered with the G. “A short time later, noises could be heard upstairs and [an unknown person] stood at the top of the steps.” · The person immediately identified themselves as the SP’s significant other (SO) and said that s/he occasionally stayed at the VA’s house and helped the SP with the VA’s care. The SO said that the SP was not there and that the VA was upstairs. The G was “shocked” by this because of the SP’s earlier text stating that the VA was staying at P1’s house. The G started gathering some of the VA’s belongings with the intent of bringing the VA to the G’s house. · The LEO checked the kitchen cabinets and refrigerator and saw they were adequately stocked with food. Regarding the VA, the LEO observed, “I did not notice any immediate signs that [the VA] had been neglected.” The LEO waited until the G and the VA left and then left after them without incident. At the outset of the investigation, a facility supervisory staff person provided information that the G told him/her that when the G discovered the VA upstairs on December 5, 2025, the VA was “sitting inches from a television … [and] was dirty and surrounded by trash.” The G told the DHS investigator that s/he did not have any concerns with “[the VA’s] condition” on December 5, 2025. “Nothing we saw was inappropriate.” The G was not aware of any harm occurring while the SO was with the VA. The G said that the VA was unable to provide information about events or answer questions due to his/her disability. P2 said that the SP was to provide in-home support to the VA and should not have left the VA without a caregiver when s/he went to the funeral on December 5, 2025. The SO said that s/he did not live at the VA’s house but occasionally visited. The VA knew the SO “very well” and recognized the SO whenever s/he visited. On December 5, 2025, the SP needed to leave for a funeral and asked the SO to stay at the house with the VA. This was the first and only time the SP left the VA with the SO. When the G arrived at the VA’s house with the LEO, the SP had been gone for about three hours. The SO said that the VA was “fine” and there was food in the refrigerator, and “no concerns” overall. [Note: The SO was not a facility staff person and did not have a background study clearance to work at the facility, and the facility did not provide records that the SO ever received training on the VA’s support plans or the Reporting of Maltreatment of Vulnerable Adults Act.] The SP provided the following information: · On December 5, 2025, the SP planned to attend a family member’s funeral. The plan had been for the VA to go with the SP, but it was snowing “a lot” outside and the SP did not like driving with the VA as a passenger when it was snowing. The SP decided to leave the VA at the VA’s house because it was “safer,” and the SP asked the SO to stay with the VA and look after him/her. The VA had never met the SO prior to this day. · When the G arrived unexpectedly at the house, the VA was upstairs in his/her bedroom, which had the VA’s toys and papers on the floor. “Those are [his/her] things” (the VA’s property) on the floor. The bedroom and the VA were not dirty or surrounded by trash. The VA took a bath on December 4, 2025, and was not dirty on December 5. · The SP believed s/he was gone from the house for about one and a half hours, and the SO was with the VA during that time. P1 said that s/he attended the same funeral as the SP on December 5, 2025, and therefore, was not available to provide respite care for the VA. The SP and P1 did not bring the VA to the funeral because there was a snowstorm, and the roads were not in good condition. P1 was not aware of prior concerns or times when the VA was left alone with the SO. Facility documentation stated that the SP received training on the VA’s support plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. Minnesota Statutes section 245D.081, subdivision 2, paragraph (a), clause (1), states that license holder must ensure the designated coordinator provided oversight of the license holder's responsibilities assigned in the person's support plan and the support plan addendum. Conclusion: It was reported that on December 5, 2025, the SP left the VA unsupervised at the VA’s house with the SO for at least three hours. The SP said that the timeframe was one and a half hours. Information was provided that while the SP was away, the G discovered the VA “dirty” and “surrounded by trash” in the VA’s bedroom. The SP was to provide the VA with 24/7 supervision and 1:1 staffing and if the SP needed time off, s/he was to contact P1 for respite care services. The conduct of leaving the VA with the SO, who was not a trained staff person and did not have a background study clearance to work at the facility, was inconsistent with the VA’s support plans and a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). In addition, the designated staff person did not provide oversight to ensure that the license holder’s responsibilities, regarding the VA’s supervision as assigned in the VA’s support plan and support plan addendum, were being provided, which was a violation of Minnesota Statutes section 245D.081, subdivision 2, paragraph (a), clause (1). Although information was initially provided about the VA being dirty and surrounded by trash, the LEO did not have similar concerns, and the G told the DHS investigator that s/he did not have concerns or see anything “inappropriate.” There was no information that the VA was harmed when s/he was with the SO. Therefore, there was not a preponderance of the evidence whether the conduct of leaving the VA unsupervised with the SO represented a failure to supply care or supervision, which was reasonable and necessary for the VA's health and safety. 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 but not followed by the SP. The SP provided a lack of support to the VA, left the job when on the clock, and put the VA at risk by not providing care. There was no information about similar incidents involving the SP and/or the VA. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On March 12, 2026, the facility was issued a Correction Order for the violations outlined in this report. A copy of this report was forwarded to the Office of Inspector General-Program Integrity Oversight Division for their review of possible financial fraud.
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