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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: 801891-SUD (Substance Use Disorder) Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) engaged in a nontherapeutic relationship with a vulnerable adult (VA) while the VA was receiving services at the facility, including texting “nude” pictures of the SP to the VA. Date of Incident(s): Ongoing between March and June 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. Prior to May 15, 2026, the Minnesota Statutes, section 626.557, definition of “sexual abuse” stated the following: Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c): 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' include the primary genital area, groin, inner thigh, buttocks, and breast. On May 15, 2026, the definition of “sexual abuse” was changed to state the following: Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c), clauses (1) and (2): Any contact with the vulnerable adult that is not therapeutic conduct, and a reasonable person would consider a sexual act or any nonconsensual sexual interaction with the vulnerable adult, including but not limited to: · making, viewing, or sharing sexual images or videos with or of the vulnerable adult; and · using oral, written, gestured, or electronic communication that is sexually harassing, including but not limited to unwelcome sexual advances or requests for sexual favors. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 2, 2026; from documentation at the facility; and through seven interviews conducted with the VA, facility clients (C1 and C2), facility staff persons (the SP, P1, and P2), and a supervisory staff person (P3). The facility provided residential substance use disorder treatment to adults. The VA’s treatment plans stated that in February 2026, s/he moved into the facility seeking help to recover from his/her substance use disorder and to remain sober. The VA struggled to stay sober despite wanting to do so. The VA was “empathetic” and “kind,” and liked playing his/her guitar and collecting records and books. The facility provided the VA with treatment and therapy and medication management. On June 8, 2026, the VA relapsed and was discharged from the facility prior to completing the facility’s treatment program. The VA provided the following information: · The VA was initially unsure whether to provide information about the allegations and said, “I don’t want to ruin someone’s life.” The VA asked for time to think about the situation and talk with his/her support system before deciding. A few days later, the VA called this investigator and said that s/he decided to be “honest” about what happened with the SP. · The VA said that “months before” moving into the facility s/he lived at a different substance use disorder treatment program (herein, referred to as the SUD program) where the SP worked and the VA first met the SP. The SP and the VA interacted “cordially” during the VA’s stay. When the VA successfully completed treatment and graduated from the SUD program, the SP gave his/her work email to the VA and told the VA to stay in touch. The VA and the SP then exchanged emails regarding how the VA was doing with his/her sobriety. At one point, the SP emailed the VA from the SP’s personal email. These emails were “normal” and nothing non-therapeutic. · In February 2026, the VA relapsed and moved into the facility for services. The VA wanted to be “in recovery” from substance use and “to change” his/her behaviors. The SP worked at the facility and the VA knew this, but it was not why the VA chose to go to the facility. At that point, the VA had no romantic interest in the SP. “It didn’t cross my mind.” [Note: The SP worked at both the SUD program and the facility.] · At the facility, the VA initially resided in a high intensity treatment program and during that time, s/he did not see the SP or have access to his/her cellphone. After 30 days, or around mid-March 2026, the VA moved into a lesser intensity program within the same facility and at that point, the VA saw the SP. The SP worked one weekend a month supervising clients and administering medications. · The VA also received access to his/her cellphone and almost immediately the SP emailed the VA, and they exchanged phone numbers. The SP then became “really intense” and “really interested” in starting a romantic relationship with the VA. The SP told the VA that s/he would disclose their relationship to the facility, which would then make it “okay” and they would not be doing anything “wrong.” The VA said, “It was easy to fall into” a relationship with the SP and the VA “felt good” receiving attention from the SP. · The VA and the SP never had any physical or sexual contact. However, they exchanged about 200 to 300 text messages over the course of the VA’s stay at the facility between mid-March and June 7, 2026. During that same timeframe, the SP texted the VA about 10 to 15 “nude” pictures of the SP. The VA knew the pictures were of the SP because the SP’s face was visible in some of them. The VA sent one “nude” picture of him/herself to the SP. [Note: More information about the texts, emails, and pictures is provided below.] · The VA said that more than once, s/he tried to end the relationship with the SP but that each time, the SP continued to text the VA and/or send pictures, which then resumed the relationship. This pattern continued over the course of the VA’s stay at the facility between mid-March and June 7, 2026. · On June 7, 2026, the VA learned that the SP was married, which made the VA “stressed” and “uncomfortable.” The VA did not like knowing that s/he received “nude” pictures of someone else’s spouse. “I felt kind of embarrassed … foolish” because of the whole situation. The next day, June 8, the VA was “in a desperate moment” because of the situation and the VA relapsed. As a result of the relapse, the facility “kicked [the VA] out” prior to completing treatment. On June 9, 2026, the VA was arrested for violating his/her probation by not remaining in treatment. · The SP and the VA had not had contact since June 7, 2026. [Note: At the time of this investigation, the VA was incarcerated and had limited access to his/her cellphone except by special request to the jail administrator. The VA made a request but had limited time to take screenshots of the SP’s emails and texts for this investigation, and so the information provided was limited and did not include the entirety of their communications.] The screenshots of texts and emails between the VA and the SP included the following: · March 10, 2026 – The SP emailed the VA from an email address which was not captured in the screenshot; however, it appeared to be the SP’s SUD program work email because the SP’s first and last name, position title, and the SUD program work address and phone number were at the bottom of the email. The SP asked the VA if s/he liked living at the facility. The SP also indicated that s/he saw the VA on “Saturday” but was too busy to chat. In a subsequent email, the SP said that s/he hoped to hear the VA play his/her guitar someday. [Note: The SP worked one Saturday a month at the facility. At this point in time, the SP was not licensed by a health-related licensing board. However, on May 21, 2026, the SP became licensed by a health-related licensing board.] · March 13, 2026 – The SP emailed the VA from an email address which was not captured in the screenshot. The SP said, “Considering I was using my work email to talk to you about non-clinical subjects, I felt like I should maybe switch emails. Which isn’t allowed in any capacity for either job, but I want to continue the conversation. If you’re okay with an email thread that is technically not allowed.” The SP signed the email with his/her first name. [Note: In a subsequent email on March 14, 2026, the SP’s and the VA’s email addresses were visible in the screenshot, and they were consistent with the email addresses used by this investigator to contact the SP and the VA for this investigation.] · March 14, 2026 – The SP emailed the VA and said, “I don’t wanna be like ‘keep a secret’ but in this situation that we have a dual relationship (from two different places that forbid this personal reconnection) I do have to protect myself as well as you.” · Also, on March 14, 2026 – The SP texted the VA’s cellphone; however, neither phone number was captured in the screenshot. The text message said, “Hello from the world’s worst rule breaker ever. Ethically speaking. It’s [the SP’s first name] btw (by the way) & now that I can text you. I can send you my Spotify links. (heart emoji).” The VA had this phone number saved in his/her cellphone as, “[The SP’s first name].” · In an undated text, the SP sent the VA a picture of the SP’s face. The SP was fully clothed, but tattoos were visible on his/her neck, arms, and hands. [Note: The picture was consistent with a known picture of the SP obtained for this investigation. There were other pictures, described below, which also showed the SP’s face and were also consistent with the known picture of the SP.] · March 17, 2026 – The SP texted the VA and said, “Not to distract from your dinner/meeting.” The SP then texted a picture of the SP’s exposed buttocks and the SP making a kissing face. · In an undated text, the VA said to the SP, “I truly am interested. But im also worried. Lying and sneaking around is what precedes relapse for me … Not to mention that if anyone ever found out, it would ruin your career completely and you’d never be allowed to practice in the field again. My opportunity at [the facility] is my last chance before prison … But the risk is too great that there’s only one right direction … Id like to be friends and who knows what the future holds…but my recovery needs to be my only focus right now. (heart emoji).” · In an undated text, the SP texted the VA and “apologized” for “pursuing” the VA. · March 19, 2026 – The SP texted the VA and said, “Is it respecting boundaries to say that I kind of missed our chats today?” The VA did not respond, and two hours later the SP texted, “OMG I’m embarrassing. I’m sorry [the VA’s first name]. I won’t text anymore ….” · In an undated text, the SP texted that s/he “appreciated” the VA’s honesty and “adored” the VA “to the fullest extent” but that the SP would “slow down” his/her messages to the VA. · [Note: The last dated text message the VA provided for this investigation was from March 20, 2026. However, the VA told this investigator that the texts continued through June 7, 2026, but s/he had limited time to screenshot the texts while incarcerated. The VA also provided more than one undated picture of the SP with some showing the SP’s tattoos and/or face. The pictures included more than one of the SP’s exposed buttocks, more than one of the SP’s exposed chest, and one of the SP’s exposed genitalia. Of the exposed buttocks pictures, one included a pair of red velvet handcuffs, two included the SP bent over, and another included the SP lying on his/her stomach with his/her exposed buttocks raised in the air. Of the exposed chest pictures, one included the SP kneeling in front of and above the camera while holding his/her chest and another included the SP lying on his/her back with his/her knees bent up.] C1 and C2 were each, at one point, the VA’s roommate at the facility. C1 and C2 each said that during the time they were roommates with the VA, the VA told each of them that s/he was texting with the SP and had received pictures from the SP. C1 and C2 did not see or know the content of the text messages; however, C1 said that the VA showed him/her “nude” pictures of the SP on the VA’s cellphone and that C1 knew it was the SP because of the SP’s tattoos in the pictures. C2 did not see the pictures or know the content of the pictures. C1 and C2 each also said that the VA was “upset” and “angry” when s/he learned the SP was married. [Facility documentation showed that C2 was the VA’s roommate in April and May 2026 and C1 was the VA’s roommate in June 2026.] P1-P3 provided the following information: · P1 and P3 each said that after the VA discharged from the facility, C1 told each of them that s/he saw “nude” pictures of the SP on the VA’s cellphone. · P3 said that the VA did not have history of making allegations against staff. When P3 asked the VA about the allegations, the VA did not want to answer and said, “I don’t want to ruin anyone’s life.” The VA told P3 that the Department (this investigator) had called him/her asking about the allegations and P3 told the VA to be “honest” with the Department about what happened. · P1-P3 each said that the facility trained staff on “boundaries” with clients. Staff were not allowed to have a personal relationship with a client while the client was receiving services at the facility. Staff needed to wait at least two years after the client last received services at the facility to have a personal relationship. If staff had an established relationship with a client (e.g., a relative), they needed to tell a supervisor and then they needed to have nothing to do with the client’s care (e.g., charting) while the client was receiving services at the facility. If the client was someone whom the staff person had previously exchanged text messages, they should stop texting the client while the client was receiving services at the facility. The SP never told P1 or P2 that s/he knew the VA prior to the facility. · P3 said that s/he was aware the SP also worked at the SUD program and that the VA was formerly a client at the SUD program. P3 assumed the SP and the VA were acquainted in a professional capacity. The SP never disclosed having a personal relationship with the VA. · P1-P3 each said that they were not previously aware of concerns with the SP’s interactions with clients and the SP never said anything to them about the VA. The SP provided the following information: · The SP initially told this investigator that s/he did not know the VA well enough to describe his/her personality. The SP said that s/he knew the VA in a “professional capacity” but that the VA was not a “personal acquaintance” of the SP. The SP said that s/he never emailed or texted or sent pictures to the VA. · However, when this investigator described the screenshots which included the SP’s emails and texts and pictures of the SP, the SP’s statements changed. The SP said that s/he knew the VA and had exchanged emails and texts with the VA. The SP did not recall how either of them obtained the other’s email or phone number and did not recall the content of the emails or texts. Regarding the pictures, the SP said, “I don’t recall what pictures were sent (to the VA). What they were or any of that content.” The SP said that s/he did not recall there being “nude” pictures. The SP said, “I guess I can’t explain what pictures were sent.” The SP said that s/he never had physical or sexual contact with the VA. · The facility trained that staff should not associate with clients on social media until at least two years after the client last received services at the facility. The SP did not believe the training covered exchanging phone numbers or texting with a client, but added, “It’s kind of implied.” The facility’s policies and procedures on “boundaries” stated that it was the staff person’s responsibility to adhere to ethical and professional standards of conduct and maintain appropriate therapeutic boundaries with clients. Staff were to not have a personal relationship with any client who was currently receiving services or within two years after the client last received services. If a prior personal relationship existed, staff were to tell a supervisor. Examples of “boundary violations,” included making sexual advances to a client, sharing personal information with a client, and entering a sexual or social relationship with a client. Facility documentation stated that the SP and P1-P3 received training on “boundaries” and on the Reporting of Maltreatment of Vulnerable Adults Act. On May 21, 2026, the SP became licensed by the Minnesota Board of Behavioral Health and Therapy. Conclusion: A. Maltreatment: The VA, C1, and C2 provided consistent information that the SP emailed, texted, and/or sent pictures, including the SP unclothed, to the VA’s cellphone. The VA’s screenshots included at least one showing the SP’s personal email address and two others containing pictures showing the SP’s face, which were consistent with a known picture of the SP obtained for this investigation. In one of the screenshots, the SP texted the VA a picture of the SP’s unclothed buttocks and in more than one screenshot, the SP commented about how emailing and texting the VA was “unethical.” The VA said that the SP also sent about 10 to 15 “nude” pictures of him/herself to the VA, which were identifiable as being the SP because they showed the SP’s tattoos and/or face. C1 said that s/he saw “nude” pictures of the SP on the VA’s cellphone. The VA said that due to his/her incarceration, s/he had limited time to take screenshots of the SP’s emails and texts for this investigation, and so the screenshots provided did not include the entirety of their communications which occurred from mid-March to June 7, 2026. The SP provided conflicting information. Initially the SP stated that s/he did not know the VA on a personal level, and did not email, text, or send pictures to the VA. However, when asked about the screenshots, the SP’s statements changed, and s/he acknowledged emailing and texting with the VA but stated that s/he did not recall the content of the emails or texts and said, “I don’t recall what pictures were sent (to the VA). What they were or any of that content.” Regarding neglect: Given that the VA had a history of a 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 likely hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship and were inconsistent with the standards of a professional caregiver in a facility licensed by the Department and with the facility’s policies and procedures on “boundaries.” The VA said that more than once s/he tried to end his/her relationship with the SP. In a screenshot, the VA told the SP, “Lying and sneaking around is what precedes relapse for me … Not to mention that if anyone ever found out, it would ruin your career completely and you’d never be allowed to practice in the field again. My opportunity at [the facility] is my last chance before prison.” However, despite this, the SP continued to text and/or send pictures to the VA which then resumed the relationship. The contact continued throughout the VA’s stay at the facility until June 7, 2026, when the VA said s/he learned the SP was married. On June 8, 2026, the VA relapsed and on June 9, 2026, the VA was arrested for not remaining in treatment. The VA remained incarcerated during this investigation. Given that the SP was aware of the VA’s history and needs and the VA’s desire to be sober, yet the SP continued to engage in conduct which was detrimental to the VA’s ongoing sobriety and recovery ultimately resulting in the VA’s relapse when the VA learned the SP was married and subsequent rearrest resulting in the VA’s incarceration, there was a preponderance of the evidence that there was a failure to provide the VA with care and services, which were reasonable and necessary for the VA’s health and safety. 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). Regarding sexual abuse: Given that the VA and the SP each denied having any physical or sexual contact, there was a preponderance of the evidence that there was not any conduct, prior to May 15, 2026, which met the definition of sexual abuse. It was determined that sexual abuse did not occur prior to May 15, 2026 (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' include the primary genital area, groin, inner thigh, buttocks, and breast). On May 15, 2026, Minnesota Statutes, section 626.5572, subdivision 2, the definition of “sexual abuse,” was changed. The VA provided information that the SP sent the VA 10 to 15 “nude” pictures of the SP over the course of the VA’s stay at the facility between mid-March and June 7, 2026. C2 said that while s/he was roommates with the VA in April and May 2026, the VA told C2 that the SP sent him/her pictures. C1 said that the VA showed him/her “nude” pictures of the SP on the VA’s cellphone, while s/he was roommates with the VA, which would have been in June 2026. The VA provided limited screenshots of texts and emails including pictures that were dated between March 10 and 20, 2026. The photos were sent to the VA by the SP and included more than one of the SP’s exposed buttocks, more than one of the SP’s exposed chest, and one of the SP’s exposed genitalia. Of the exposed buttocks pictures, one included a pair of red velvet handcuffs, two included the SP bent over, and another included the SP lying on his/her stomach with his/her exposed buttocks raised in the air. Of the exposed chest pictures, one included the SP kneeling in front of and above the camera while holding his/her chest and another included the SP lying on his/her back with his/her knees bent up. Although the pictures were undated and the VA had limited access to his/her cellphone to take screenshots of his/her communications with the SP, based on the VA’s, C1’s, and C2’s accounts of the timeline and the SP’s continued texts and emails even after the VA told the SP s/he wanted to focus on treatment, it was most likely that the SP continued to text and email and send pictures of sexual images from May 15 to June 7, 2026. Therefore, there was a preponderance of the evidence that the SP’s actions were not therapeutic and that s/he shared sexual images via electronic communication with the VA. It was determined that sexual abuse occurred on or after May 15, 2026, (any contact with the vulnerable adult that is not therapeutic conduct, and a reasonable person would consider a sexual act or any nonconsensual sexual interaction with the vulnerable adult, including but not limited to: making, viewing, or sharing sexual images or videos with or of the vulnerable adult; and using oral, written, gestured, or electronic communication that is sexually harassing, including but not limited to unwelcome sexual advances or requests for sexual favors). 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 on “boundaries” and on the Reporting of Maltreatment of Vulnerable Adults Act. The screenshots of emails and text messages between the SP and the VA showed that the SP stated his/her communication with the VA was “technically not allowed,” that the SP asked the VA to keep their communication and relationship a “secret” to “protect [him/herself and the VA],” and that the SP “apologized” to the VA for “pursuing” the VA. 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 and sexual abuse for which the SP was responsible was “recurring” because the SP was responsible for the neglect and sexual abuse of the VA, and the maltreatment was “serious” because the SP was responsible for sexual abuse. D. Person Regulated by Health-Related Licensing Boards Pursuant to Minnesota Statutes, section 245C.31, subdivision 1, when individuals regulated by a health-related licensing board are determined to be responsible for substantiated maltreatment under Minnesota Statutes, section 260E or 626.557, instead of the Commissioner of the Department of Human Services making a decision regarding disqualification, the licensing board makes a determination whether to impose disciplinary or corrective action under Minnesota Statutes, chapter 214. The SP is regulated by a health-related licensing board. The health-related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for serious maltreatment and would be disqualified from direct contact if s/he were not regulated by the board. 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 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified by the Office of Inspector General that s/he was responsible for recurring and serious maltreatment and would be disqualified if not licensed by a health-related board. The maltreatment determination is subject to appeal. The health-related board that the SP was regulated by was notified that the SP was responsible for recurring and serious maltreatment and would be 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, if not licensed by the health-related board.
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