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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: 1111232-HCBS (Home and Community-Based Services) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) drove a vulnerable adult (VA) while under the influence of alcohol. Date of Incident(s): Unknown 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 site visit conducted on March 20, 2026; from documentation at the facility; and through three interviews conducted with the VA, the SP, and the VA’s case manager (CM). The VA was not subject to guardianship. The VA’s diagnosis included anxiety, bilateral hearing loss, mild intellectual disability, and seizure disorder. The VA used cochlear implants, and his/her apartment was equipped with an alarm system as well as a doorbell to assist in notifying the VA of visitors and/or emergencies. The VA enjoyed spending time with family, going for walks, watching television and playing board games. The VA lived in an apartment with his/her significant other. The VA’s apartment is also referred to as the facility throughout this report. The VA’s Support Plan said the VA received integrated community supports (ICS) two in-person hours and one remote hour from the facility per day, that included eating and meal preparation, health interventions, household management, learning, meaningful activities, and self-preservation. The VA used a city bus pass to get to and from work and around the community and accessed funded transportation for medical appointments. Staff persons offered reminders and support to the VA to independently schedule transportation as needed. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to self-abuse due to anxiety and had a history of self-injurious behaviors and struggled to recognize unsafe situations when s/he felt anxious and/or pressured. The facility’s Drug and Alcohol Policy said that the workplace was “free from the effects of drugs, alcohol, chemicals and abuse of prescriptions medications,” and that the policy applied to all employees, subcontractors and volunteers. The VA provided the following information: · On an unknown date, “last year,” the VA smelled alcohol on the SP when the SP drove the VA. The VA knew it was alcohol because s/he had a friend who had an “alcohol problem” and the VA smelled alcohol on his/her friend, and smelled the same smell on the SP. · When the SP drove, the VA felt “uncomfortable” because the SP “slid” to the right side of the road and drove over the speed limit. The SP drank coffee when s/he drove, but the VA thought there was alcohol in the coffee because the VA saw “little shot glasses” under the SP’s seat but did not see a label on them. The VA did not see the SP pour the liquid into his/her coffee. · The VA said this happened one time and s/he did not have concerns with any other staff persons. The SP provided the following information: · The facility provided services to the VA for two hours daily, which mainly consisted of the VA telling staff persons what s/he needed assistance with, and creating a plan for the week. The VA was responsible for arranging his/her own transportation, although staff persons sometimes drove the VA if it was too cold for the VA to walk or if the VA forgot to arrange his/her transportation. The SP thought the last time s/he drove the VA was approximately two weeks prior and driving the VA was “not consistent.” · The SP said s/he “never drank in [his/her] life” for both personal and religious reasons and never had alcohol in his/her vehicle. The SP denied driving the VA while under the influence of alcohol or any other substance. · The SP did not believe the VA was an accurate provider of information because s/he was not “consistent.” The CM said that on March 9, 2026, the VA said that on an unknown date, the VA saw the SP pour a “shooter” of alcohol into the SP’s mug and saw bottles of alcohol in the SP’s vehicle. The VA initially said that on one occasion, s/he “thought the SP was drinking” but later clarified that s/he smelled alcohol multiple times on the SP, but “didn’t really know” if the SP was under the influence of alcohol. The CM thought the VA was an accurate provider of information. The CM had not smelled alcohol on the SP in their previous interactions. Personnel files showed that the SP was trained on the VA’s plans, facility policies and procedures, and the Reporting Maltreatment of Vulnerable Adults Act. Conclusion: Although the VA told this investigator and the CM that on one occasion,” last year,” s/he smelled alcohol on the SP when s/he drove the VA and that the VA saw small containers that s/he believed to be alcohol in the SP’s vehicle, the SP denied the allegation.
Given the conflicting information and lack of details regarding the incident, there was not a preponderance of the evidence as to whether the SP drove the VA under the influence of alcohol. 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 found that policies and procedures were adequate and followed. The facility updated the Transportation Policy and as of April 1, 2026, transportation was no longer provided by facility staff persons. All staff persons were retrained on the Drug and Alcohol policy to reinforce existing expectations regarding staff person conduct. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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