|
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: 1107690-HCBS (Home and Community-Based Services) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: A vulnerable adult (VA) was found deceased in his/her apartment. The VA recently received services from the facility. Prior to the VA’s death, a temporary payment withhold was issued to the facility due to allegations of fraud and the provider suspended services to the VA. It was unknown if a service suspension was issued and if the program coordinated with the VA’s team to ensure continuation of services. Date of Incident(s): December 15, 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, law enforcement records, and medical records; and through two interviews conducted with a facility staff person (P) and the VA’s case manager (CM). The VA was not subject to guardianship. The VA’s diagnoses included bipolar disorder, unspecified pain, and mobility issues. The VA enjoyed spending time out in the community, watching television and movies, doing puzzles, and playing card games, chess, and dominos. The VA rented an apartment from the facility. The VA received in-home Integrated Community Supports (ICS) services from the facility that included household management, health interventions, eating and meal preparation, meaningful activities, modifications, movement, personal cares, psychosocial health, and self-preservation. The facility provided the VA with a lease, signed by the VA on September 24, 2025; however, the lease was not signed by the facility authorized agent, nor did the lease include the beginning and ending date of occupancy. The VA’s Individual Abuse Prevention Plan (IAPP) dated July 7, 2024, showed the VA was not at risk for abuse. The VA had some pain and mobility issues and used a cane to get around. The VA needed assistance with transportation, navigating spaces safely, and reminders for appointments. The facility was to provide safe and stable housing for the VA as well as staff persons during the day to “help [the VA] manage [his/her] health, access [his/her] community, and complete activities of daily living.” The VA’s Support Plan dated March 1, 2025, stated the VA was to receive 14 hours of in-person services and supports from the facility. The VA lived by him/herself in an apartment, also referred to as the facility throughout the report, that shared a building with 22 other apartments. A property management company owned the building and the facility leased four apartments in the building and provided services to residents in those four apartments. [Note: The license holder was to provide the VA with integrated community supports (ICS). The VA’s apartment and the other three apartments in the building were “provider-controlled” ICS settings. An ICS setting was a setting in which a provider had an approved setting capacity report and had direct/indirect control over a person’s living unit (e.g., apartment), which meant that the provider either owned, operated, or leased the living unit, or had direct or indirect financial interest in the property or housing, including a financial relationship with the property owner. A person who lived in an ICS setting was not required to receive ICS. However, when a person lived in an ICS setting, ICS could only be delivered by the provider who controlled the setting.] On November 13, 2025, the license holder was issued an ICS temporary payment withhold from the Department of Human Services, with an effective date of December 2, 2025, due to concerns related to possible fraud. The facility was no longer receiving payments for services provided to clients. On November 28, 2025, the facility issued a Notice of Temporary Service Suspension to the VA. It was noted that the program “was put on unexpected payment suspension [and] therefore [is] unable to take preventative actions.” A law enforcement (LE) report stated that on December 15, 2025, at 8:08 p.m., officers responded to a “foul smell” at the VA’s residence. The VA changed the locks and no key was available for the apartment. Forced entry was made into the residence, and the VA was located deceased. A representative from the facility told LE that s/he took the VA to an appointment on December 9, 2025, and attempted to contact the VA on December 11 and 12, 2025, without success. An autopsy was conducted and the cause of the VA’s cause of death was listed as methamphetamine and cocaine toxicity and the manner of death was listed as an accident. Documentation from facility records from November 1-14, 2025, showed there were six days in which the VA only received five to eight hours of services, and not the full 14 hours of services outlined in the VA’s Support Plan. (Note: the facility did not provide additional documentation for the last two weeks of November, and the facility Internal Review stated the VA “refused services for almost two weeks prior to the service suspension.”) The P provided the following information: · The P stated that facility staff persons went to the VA’s residence every day and provided 14 hours of services per day, which included assistance with everyday life tasks. · On November 13, 2025, the facility was notified of a “payment withhold” effective December 2, 2025. On November 21, 2025, the facility reached out to the VA’s CM and requested assistance with finding the VA a new provider. The CM did not respond. · On November 28, 2025, the VA’s services were “paused” and the facility “fired” all staff persons except for “managers.” The facility continued to work with the VA to find a new provider and supervisory and/or management staff persons took the VA to tour other facilities. · On December 9, 2025, the facility took the VA on a tour of another ICS provider. On December 11 and 12, 2025, a staff person from the facility attempted to contact the VA to do a virtual tour of another provider, but the VA did not answer the door. · After the facility received the Notice of Payment Withheld, the facility “worked to secure alternative care” for the VA. The facility contacted “nearly every known” provider but encountered a “lack of capacity or willingness to accept new clients.” The facility assisted the VA with completing applications and provided transportation to facility tours, with the last noted tour from text communications being on December 9, 2025. · On December 15, 2025, at 10 p.m., the facility authorized a forced entry by law enforcement into the VA’s apartment. The VA was found deceased. The CM provided the following information: · The VA was supposed to receive 14 hours of services per day for vulnerability and mobility issues. The VA did not need services for medical needs. · On September 18, 2025, the facility notified the CM that there was evidence of drug use in the VA’s residence but there was no proof that the VA was the one who used the drugs (Note: The VA’s plan did not reference any current or previous drug use/abuse). · On November 20, 2025, the facility’s administration sent the CM an email and provided the CM with the Notice of Temporary Service Suspension. On November 21, 2025, the facility emailed the CM and notified him/her that the suspension started on November 28, 2025, and the VA’s lease was up on December 31, 2025. The facility said they were assisting the VA with finding new placement and would make sure s/he was “taken care of during the transition.” The facility asked the CM to share any placement efforts that the CM had initiated. · The CM helped clients find new providers but historically, has “not helped with relocating clients.” The CM stated it was a “tertiary duty” and “not explicitly part of [the CM’s] job role.” Housing stabilization previously handled helping clients move. The CM said it was part of his/her role to assist a client in finding a new provider and help with communication between the provider and individual. The CM stated s/he had “plenty of email referrals” from providers and databases that were checked to find provider openings. · At some point, the facility reached out the CM and tried to coordinate moving the VA. The facility left the CM voice mails and when the CM called the facility back, no one answered. The CM did not think the facility wanted his/her assistance with finding the VA a new provider and was not actively searching for a new provider for the VA. · The CM was not sure what the status was of the VA finding a new provider at the time of the VA’s passing. The CM was unable to get in contact with the VA, as the VA frequently changed phone numbers and the CM was not sure how to contact the VA. The CM had two email addresses for the VA. · On December 9, 2025, the VA left a voice mail message for the CM about getting a new personal care attendant. On December 11, 2025, the VA left another voice mail message for the CM asking for assistance finding a new place to live, as the VA’s lease was done on December 31, 2025. The CM called the VA back on December 11, 2025, and did not receive an answer. · The CM stated s/he was unaware his/her assistance was needed until the VA contacted him/her on December 11, 2025. The P was trained on the Reporting of Maltreatment of the Vulnerable Adults Act. Conclusion: Information showed that on November 28, 2025, the facility suspended services to the VA received and the VA’s lease was set to expire on December 31, 2025. On December 15, 2025, the VA was found deceased, with a cause of death listed as accidental, not related to services provided by the facility. The VA lived on his/her own in an apartment and was supposed to receive 14 hours per day of in-person supports and services from the facility. The VA had pain and mobility issues and used a cane. The VA needed assistance with transportation, navigating spaces safely due to mobility issues, and reminders for appointments. On November 21, 2025, the facility reached out to the CM via email and asked the CM to share any placement efforts the CM had initiated while the facility also assisted the VA with looking for a new placement/services. The CM stated return phone calls to the facility went unanswered and the facility stated the CM did not respond to emails. The CM believed that the facility was facilitating finding the VA a new provider. Although the facility suspended services after November 28, 2025, they continued to assist the VA in searching for a new provider, including taking the VA to tour several potential placements. The last contact the facility had with the VA was on December 9, 2025, when a staff person took the VA to tour a potential facility. On December 11, 2025, the VA called the CM and asked for help in finding a placement. On December 11 and 12, 2025, a staff person from the facility attempted to contact the VA to tour a provider, but the VA did not answer the door. Although transfer of the VA’s ICS services to another provider was not completed by the date the facility’s services were suspended, resulting in the VA having no services from November 28, 2025, until the time of the VA’s passing sometime on/after December 11, 2025, given that the facility continued to contact other providers to find services for the VA, including taking the VA on tours of other facilities, that the facility contacted the VA’s CM for assistance in coordinating efforts, and that the VA’s death was related to an accidental overdose that may have occurred regardless of the level of services that were provided at the time of death, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and 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’s Internal Review stated policies and procedures were adequate and were followed, there was not a need for additional staff training, the event was not similar to past events, and there was not a need for corrective action to be taken. Action Taken by Department of Human Services, Office of Inspector General: The scope of this investigation was limited to the VA’s death. Concerns regarding the facility’s documentation and number of hours of ICS they provided to the VA were referred to the DHS, Office of Inspector General, Program Integrity and Oversight Division.
|
