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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: 1129361-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Samantha Wueste Minnesota Department of Human Services 651-431-2278 Samantha.wueste@state.mn.us Suspected Maltreatment Reported: It was reported that on multiple occasions a supervisory staff person (SP) purchased alcohol for and/or drank alcohol with a vulnerable adult (VA) who had a known history of alcohol abuse. During the course of the investigation, it was discovered that the SP also used marijuana while working at the facility. Date of Incident(s): Ongoing prior to January 10, 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 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 was obtained during a visit conducted on January 28, 2026; from documentation at the facility; and through four interviews conducted with the SP, two administrative staff persons (P1 and P2), and the VA’s case manager (CM). Attempts were made by phone to contact and interview four additional staff persons (P3-P6). P3, P4, and P6 each did not respond to the requests. P5 initially responded to the request for an interview but then did not respond further. Due to the VA’s diagnoses, the VA was unable to provide information for this investigation. The SP and P6 had a personal relationship. The VA enjoyed doing art projects and spending time with his/her family members. The VA’s diagnoses included major depressive disorder, attention-deficit hyperactivity disorder, anxiety disorder, asthma, fibromyalgia, unspecified memory loss, and Ehlers-Danlos syndrome (EDS, a genetic condition that weakened a person’s connective tissues). The VA was not subject to guardianship and was of legal drinking age. The facility was a ranch style home in a rural area that was on a hill overlooking a lake, where the VA lived with three housemates (H1-H3). On March 11, 2025, the VA moved into the home seeking supports and services that included health management, meal preparation, community integration, transportation, assistance with activities of daily living, and support from staff persons to work towards his/her personal goals. [Note: Prior to November 1, 2025, the home belonged to and was operated by a different license holder not affiliated with the facility and who provided similar licensed programming and services to the VA and his/her housemates at that time.] The CM and the VA’s care plans including the Support Plan dated February 25, 2025, completed by the VA’s county case management aide and provided to the CM and the SP on June 17, 2025; the Individual Abuse Prevention Plan dated December 4, 2025, completed by the SP; and the Intensive Support Services Assessment- Self Management Assessment (SMA) dated December 5, 2025, completed by the SP provided the following information: · The VA had a 24-hour plan of care with 1:1 staffing five hours a day during the daytime hours. · The VA “often” “struggled” with managing his/her mental and/or physical health and had a history of emotional dysregulation, impulsiveness, “difficulties” in falling asleep, self-isolation, and an inability to independently complete tasks of daily living. According to the VA’s SMA, the VA also had an “excessive” history of alcohol abuse and did not have the “control to stop” his/her use of alcohol. The VA relied on staff support and assistance with managing this “identified risk” to his/her health/safety. Staff persons were to provide the VA with a “safe and supportive” living environment, “encourage” the VA to “not participate in drinking habits,” monitor the VA for signs of alcohol use, and document any incidents that involved alcohol use. · The CM stated that the VA had a “long” history of alcohol misuse that was discussed with the SP when the VA moved in. “Part of the role of the home,” was to help the VA “limit” his/her alcohol use without “just taking [the VA’s] rights away” by using a “harm reduction approach.” The VA’s ability to adequately mange his/her own funds was also a known risk that was discussed with the SP and staff persons were to help the VA make purchases that were based on what the VA “needed vs. wanted” that maintained the VA’s health/safety.
P1 and P2; the facility’s Staffing Schedule dated January 1 to 31, 2026; and the facility’s Incident Report and Internal Review completed by P1 dated January 12, 2026, provided the following information: · On January 9, 2026, P3 and P4 worked at the facility with the VA and H1-H2 during the evening shift from approximately 2 to 10 p.m. The SP then worked at the facility during the overnight shift (January 9 to 10, 2026) from approximately 10 p.m. to 7 a.m. P5 was also “regularly” scheduled to work at the facility during the overnight shift with the SP including this date. However, P1 stated that it was discovered during the facility’s internal review, that after P5’s training in September and October 2025, no staff persons had seen P5 working at the facility with the SP during the overnight shifts as scheduled and confirmed as occurring by the SP. · On January 10 and 11, 2026, multiple staff persons (P3-P5) each contacted and notified P1 that on January 9, 2026, the SP purchased a “very large bottle” of alcohol for the VA which the SP gave to the VA upon his/her arrival to the facility to work the overnight shift (January 9, 2026). At an unknown time later that night, the SP drank alcohol with the VA. P3 and P4 each also stated that the SP had done this prior. P1 then contacted two additional staff persons, who “regularly” worked with the SP “for several years” prior to the facility’s change of ownership, to obtain information about the incident and/or any concerns with the SP’s behaviors or interactions. Consistent information was then provided to P1 that there were multiple incidents in which the SP provided alcohol and/or marijuana to the VA and H1 and/or used these substances with clients and was under the influence while working at the facility. Multiple staff persons told P1 that “this situation had been going on for a long time” but staff did not report these concerns “sooner” for “fear of retaliation.” · On January 13, 2026, P1 went to the facility and talked with the clients about the allegations. Initially, the clients were “hesitant” to talk with P1 about these concerns due to “fear of getting in trouble” and/or “getting [the SP] in trouble and making [him/her] upset.” Shortly after, the SP arrived at the facility to return items to his/her office so P1 approached the SP and asked him/her to talk. During the conversation, the SP denied possessing and/or using any substances while working at the facility. However, the SP did acknowledge that s/he had purchased alcohol for the VA on multiple occasions. Shortly after this, the SP left the facility and did not return thereafter. On January 20, 2026, administrative staff persons observed and removed items within the SP’s office that included “a small container with marijuana, a pipe with marijuana, rolling papers, three marijuana vapes, and a smoke buddy.” The facility provided this investigator with screenshots of text messages that the SP sent H1 on January 16, 2026, at 8:56 a.m., where the SP “expressed” his/her “gratitude” for H1’s “friendship” and asked H1 to not let other staff persons “fill [H1’s] head with lies” about the SP. The SP then wrote that s/he was “sure everybody’s wondering why [the SP] got fired and specific, it was for smoking pot with people” and that the SP “knew it was coming […] and honestly glad it did.” H1 did not respond and showed P1 the text messages. The SP provided the following information: · The SP worked at the facility for ten years. The SP was responsible for completing “all sorts of things” including meeting with each client’s care team to review the client’s current level of care and needs and to update the support and services that s/he received if necessary. After the change of ownership, the SP helped P1 update the client care plans which included updating the VA’s care plans on December 4 and 5, 2025. The SP said that H2 and H3 were the “only” clients who had a history of chemical dependency and H2 was the “only” client who was “actually” diagnosed with a substance use disorder. The SP said s/he was not aware of the VA’s history or risks related to alcohol use, that the VA was to “avoid” or “refrain” from alcohol consumption, and/or that staff were to help monitor and support the VA in limiting alcohol. The SP stated that this was “all new” information that was “never” included in the VA’s care plans previously and the facility “just put in there” “with [the SP’s] name” at some point after mid- January 2026, when the SP was no longer working at the facility which was “bull shit.” · The use and/or possession of recreational drugs including marijuana and other items that were “technically legal” for persons of a legal age to purchase/consume were “not legal on the [facility’s] premises” or “allowed” within the home. However, the VA, H1, and/or H3 “always” requested for staff persons to drive them to a local dispensary where the clients each purchased cannabis products with their own funds which were not “shared” with others and were only consumed by each client, respectively, “typically” within an outdoor area near the facility. There were also times when the VA requested to go to a liquor store to purchase alcohol so the SP drove the VA to the liquor store. On multiple occasions, the VA used his/her own funds to buy items that contained alcohol and were later consumed by the VA at the facility. However, there were also times when the VA asked the SP to buy him/her alcohol without having sufficient funds to make the purchase him/herself. So the SP used his/her own money to purchase/provide the VA with the items s/he requested which “usually” consisted of “Mike’s Hard Lemonade” and/or “bottles of vodka.” The SP did not recall how many times this occurred or specific dates but stated that s/he purchased alcohol for the VA “multiple times” because the VA was a “nice” person who was “just hard up [for money]” and that it was the VA’s “right” to drink alcohol if s/he “wanted” to since the VA did not have “a judgement” or “restriction” in place relating to alcohol consumption. The SP said s/he was aware that “[professional] boundaries” between him/herself and the VA “started to get a little crossed” but the “boundary crossed” was the SP’s actions of “gift giving.” · On January 9, 2025, the SP was working at the facility with the VA and H1-H3 during the overnight shift. At some point “in the middle of the night,” the SP turned on music and cooked food in the kitchen while the VA “laughed,” drank alcohol, and told the SP “[his/her] stories” within the common living areas of the home. H1-H3 each remained in their bedrooms except for times when they used the bathroom and/or periodically approached the living room/kitchen to see what the VA and the SP were doing before returning “to bed” shortly thereafter. The VA “drank all the time” but the SP “loved” the VA and enjoyed spending time with the VA on “nights like that” which “maybe” caused others to “think” that the SP drank alcohol with the VA “even though” the SP would “never dream of doing that” and had not consumed any alcohol containing products “for years” due to personal reasons. The SP denied any times when s/he was under the influence of any substance while working at the facility that included using marijuana products during or before his/her shifts. · The SP stated that there were interpersonal conflicts between him/herself and others which included P6, H2, and H3 who each made “false reports” about the SP, “slandered [the SP’s] name,” and/or “spread vicious lies” about the SP “around” the community. Additionally, there were multiple county service workers who did “not like,” “hated,” and/or “had it out for” the SP for unspecified reasons that caused the VA to “fear retaliation” or impact his/her ability to work in licensed settings. The facility’s Program Abuse Prevention Plan dated November 1, 2025, stated that “all” clients were monitored to assist with maintaining sobriety. However, three of the facility clients (including the VA) were not subject to guardianship and consumed marijuana within a “designated smoking area” that was “at least” 25 feet away from the home to help maintain the safety of each client and “minimize disruption” to others. Additionally, each client was assessed by his/her care team to establish a level of care that was needed to maintain a client’s health/safety which included identified risks and how each risk was to be addressed by the facility using “proactive and reactive” support strategies. According to the facility’s Drug and Alcohol Policy, “all” company buildings and property and/or any settings where clients received care or services from staff persons were to remain as drug, alcohol, chemical, and smoke-free environments. While on the facility’s premises or when providing care to persons receiving services, staff persons were prohibited from being under the influence or the use, possession, sale, manufacture, and/or distribution of illegal or recreational drugs that included cannabis; chemicals that included alcohol and mood-altering substances; and/or excessive use of prescription medications causing impairment. The facility’s Client Rights policy stated that clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Facility documentation showed that the SP received training on the VA’s care plans; the facility’s policies, including the Client Rights and the Drug and Alcohol Policy; and the Reporting of Maltreatment of Vulnerable Adults prior to the incident. The SP also received training on his/her job position and responsibilities. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a) stated that 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. Conclusion: A. Maltreatment: The SP stated that s/he purchased and provided the VA with alcohol on multiple occasions. However, the SP denied consuming alcohol or being under the influence while working at the facility with clients. Although the SP also denied using marijuana during/before his/her shifts, the SP had reason to minimize his/her actions and sent a text message to H1 on January 16, 2026, that s/he was no longer working at the facility because s/he was “smoking pot with people” and “knew it was coming […] and honestly glad it did.” Additionally, administrative staff persons later observed and removed items within the SP’s office that included “a small container with marijuana, a pipe with marijuana, rolling papers, three marijuana vapes, and a smoke buddy.” Therefore, it was more likely that the SP used marijuana with clients while working at the facility. The SP’s actions of providing the VA with alcohol and/or marijuana and being under the influence while working with clients was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, a violation of the facility’s Drug and Alcohol Policy and the VA’s plans, and a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Given the VA’s “excessive” history of alcohol use; his/her inability to “control to stop” his/her use of alcohol; his/her goal to limit alcohol use; and staff person’s responsibility to “encourage” the VA to “not participate in drinking habits,” monitor the VA for signs of alcohol use, and document any incidents that involved alcohol use, providing the VA with alcohol was not accidental or therapeutic conduct. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with 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: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained regarding the VA’s program plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP stated that s/he was not aware of the VA’s history or risks related to alcohol use, that the VA was to “avoid” or “refrain” from alcohol consumption, and/or that staff were to help monitor and support the VA in limiting alcohol. The SP said this was “all new” information that was “never” included in the VA’s care plans previously and the facility “just put in there” “with [the SP’s] name” at some point after mid- January 2026, when the SP was no longer working at the facility which was “bull shit.” However, the CM stated that s/he discussed the VA’s history of alcohol abuse with the SP when the VA moved into the facility (March 2025) and there was no information to support the SP’s belief that the VA’s plans were changed after the SP no longer worked at the facility. In addition, the SP’s credibility was diminished by denying his/her use of marijuana but then having marijuana and paraphernalia taken out of his/her office and texting H1 acknowledging his/her smoking marijuana. Therefore, it was more likely that the SP was trained and knew of the VA’s history and staff persons responsibility to help the VA refrain from alcohol use. 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 for which the SP was responsible was not “serious” maltreatment because the VA did not sustain an injury that required the care of a physician. However, it was recurring maltreatment because the SP provided alcohol to the VA on multiple occasions. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed regarding client funds. Additional training for staff persons was provided regarding the management of client funds. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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