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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: 1108615-SUD (Substance Use Disorder) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) talked about sexual topics with a vulnerable adult (VA), touched the VA sexually, and provided tetrahydrocannabinol (THC) vape pens to the VA while the VA was receiving services from the facility. It was also reported that the day that the VA was discharged from the facility, the SP and the VA had sex in a hotel room, paid for by the SP, and that the SP paid for the VA’s hotel room for three weeks. Date of Incident(s): Multiple dates in June 2024 and July 2024. 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 2, paragraph (b), clause (1); and subdivision 2, paragraph (c): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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' includes the primary genital area, groin, inner thigh, buttocks, and breast. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility; and through four interviews conducted with two facility supervisors (P1 and P2), a community person (CP), and the VA. The SP declined to be interviewed for the investigation. The VA was diagnosed with an anxiety disorder and major depressive disorder. The VA received services from the facility for a mild alcohol-use disorder and substance-use disorder. The VA chose the facility because the VA wanted a higher level of care. The VA liked riding motorcycles and snowmobiles and working on cars. The VA had goals of establishing and maintaining abstinence from substances, maintaining optimal health, and developing coping skills when experiencing cravings. According to facility documentation, the VA began receiving services at the facility on June 6, 2024, and was discharged from the facility on July 5, 2024, at 1:30 a.m. The VA told the facility that s/he was returning to live with a family remember after being discharged. The SP was employed at the facility from March 11 to October 29, 2024. The facility provided residential services that focused on providing “comprehensive, multifaceted [substance use] treatment services.” The VA and CP provided the following consistent information: · The CP stated that the VA said that the VA and SP began having a “relationship” within the first week of the VA residing at the facility. · The VA stated that s/he did not do much when s/he first arrived at the facility because s/he was still “using” for three days, and then “detoxing,” so the VA did not want to leave his/her room. After the three days, the VA “complained” about not having access to marijuana, so the SP bought THC “vapes” for the VA and brought them to the facility. The SP rarely had a day off and began taking three-hour walks with the VA around a track at the facility during the SP’s shifts. The VA and SP talked about “anything and everything,” including sex. The SP told the VA that s/he wanted to have sex with the VA, but that they had to wait until the VA “got out” of the facility or the SP would “get in a lot of trouble.” At that time, the VA said that s/he did not know what to say because s/he was “detoxing.” One time, the SP said that s/he had to walk with other residents because the SP was “spending too much time” with the VA. · The VA stated that one evening, on an unknown date, the SP asked the VA to ride with him/her to pick up another resident at a nearby hospital. It was in the evening after supervisory staff persons left the facility. The SP drove the facility vehicle and pulled over at a boat launch in a park on the way to the hospital. When the SP parked, the VA and SP began kissing one another and touching one another’s genitals over their clothing for about 15-20 minutes. After, they got out of the van to smoke cigarettes, then continued to the hospital. (Investigator’s Note: Facility documentation showed that residents were picked up from the hospital mentioned by the VA on June 6, 7, 20, and 24, 2024. The SP worked each of those dates.) · The VA and SP communicated using social media and personal cell phones while the VA was receiving services at the facility. The VA stated that other residents at the facility possibly knew that the VA and SP were spending time together but that the VA could not recall the names of residents because it had been several years. · According to the VA, on July 5, 2024, the VA “graduated” from the program but did not have to leave the facility right away. The SP reserved and paid for a hotel room for the VA to stay in for several nights. The SP contacted the VA to tell him/her s/he had a hotel room reserved. The VA left the facility on July 5, 2024, at around 1 a.m. and went directly to the hotel room where the SP and VA had sex “instantly.” · The SP and VA stayed together in a second hotel for about three weeks. The VA said that s/he felt like s/he “had” to stay at the hotel because the SP was paying for it. The SP continued to go to work and went back to the hotel, as if the SP and VA were living there together. After about three weeks, the VA told the SP that s/he could not stay at the hotel anymore because the VA was “going nuts.” The VA felt like law enforcement was “watching” them come and go from the hotel. The VA realized, after the fact, that it was not a “good situation.” · The SP paid for a portion of the VA’s motorcycle down payment using his/her credit card within a week of the VA’s discharge from the facility. · The CP stated that the VA said s/he felt “exploited,” and felt that the relationship with the SP impacted the VA’s recovery because it caused the VA “distress.” The VA felt “embarrassed to be taken advantage [of].” The VA stated that s/he had not been able to keep a full-time job consistently and has been in and out of treatment multiple times in the past several years, which caused additional loss of wages. · The CP stated that the VA was “high functioning” and “intact” regarding providing information. The CP also described the VA as “reliable and transparent.” The VA’s Discharge Summary, dated July 5, 2024, showed that the VA’s urinalysis results during his/her time at the facility showed that the VA’s THC level went down after arrival to the facility, and then back up, prompting staff persons to ask the VA if s/he had been using marijuana. The VA stated that s/he had marijuana in his/her vehicle and that it was confiscated by staff persons on June 18, 2024. The VA’s July 2, 2024, urinalysis results for tetrahydrocannabinol acid (THCA) stated, “[Urinalysis] shows levels significantly higher from prior [urinalysis]. [The VA] was discharged prior to [his/her] test results.” P2 stated that it was within the SP’s scope to drive residents to appointments. P2 named the hospital that the VA named as a location that staff persons did resident pick-ups, but stated that residents should not ride along with the SP. P2 denied noticing the VA and SP spending time together or communicating outside of the scope of treatment, however P2 worked different hours than the SP. P2 denied knowledge of the VA and SP kissing and was not notified by any staff persons or residents that anything was going on with the VA and SP outside the scope of treatment. P2 denied knowledge of the SP bringing the VA THC vapes at the facility and did not ever observe the SP have “inappropriate” relationships with the VA or other residents. P2 stated that the SP was caring and “really good” with residents. P2 stated that the VA had a hard time at the beginning of treatment but remembered how much “better” the VA was when it was closer to graduation. P1 and P2 stated that relationships between residents and staff persons were “prohibited,” and that this included exchange of personal phone numbers or social media accounts. Prohibited behaviors also included any type of touching, flirting, giving money, or buying residents things. Relationships between residents and staff were to be only within the scope of the services being provided by the staff person to the residents. P2 stated that the residents typically left at around 5 or 6 a.m. in the morning when discharged but did not know what time the VA left the facility. Facility documentation showed that the SP worked 19 dates from June 6, through July 5, 2024, and was primarily scheduled evening shifts. The facility’s Patient Fraternization & Personal Relationships Policy stated it “prohibited personal involvement (sexual contact) with patients or former patients within two years of the patient having contact with the staff with or without being formally discharged.” All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information from the VA and the CP showed that the VA began receiving services from the facility on June 6, 2024, and was discharged from the facility on July 5, 2024. The VA left the facility around 1 or 1:30 a.m. Facility documentation showed that the SP was employed during those dates. According to the VA, the SP and VA began taking three-hour walks within the first week the VA resided at the facility and talked about sex. The VA said that the SP said s/he wanted to have sex with the VA, but that s/he had to wait until the VA “got out.” The VA stated that s/he complained about not having access to marijuana and the SP purchased and provided THC vapes to the VA while at the facility. The VA stated that on an unknown date, the SP told the VA to ride with the SP to pick up a resident from a hospital. The SP pulled over and the SP and VA kissed for about 15 to 20 minutes and touched each other’s genitals over the clothing. The VA stated that when the VA left the facility at about 1 a.m. on July 5, 2024, s/he went straight to a hotel, reserved and paid for by the SP, and that the SP and VA “immediately” had sex. The SP continued to pay for a hotel for the VA and stayed with the VA at the hotel for about three more weeks. The SP also paid for part of the VA’s motorcycle with his/her own credit card. The VA stayed at the hotel for three weeks because s/he felt like s/he “had” to and VA eventually told the SP s/he had to leave. The VA stated that as a result of this, s/he had been in treatment multiple times, felt “exploited,” and was “embarrassed” about the relationship with the SP. The VA stated that the relationship with the SP impacted the VA’s recovery because it caused the VA “distress.” The CP provided consistent information with what the VA stated and said that the VA was “intact” when it came to providing information and also described the VA as “reliable and transparent.” Although no other person said they witnessed the SP and the VA in a relationship, given the sexual nature of the allegations it was reasonable that the SP and VA had interactions at times and in places that others would not be present. The VA provided consistent information to this investigator and the CP, and the CP stated that the VA was “reliable and transparent.” Therefore, it was more likely than not that the VA’s information regarding the allegations was credible. The SP declined an interview so did not provide information to this investigator. Regarding neglect: The VA stated that the SP provided the VA with THC and the VA and the SP began a relationship while the VA was receiving services at the facility and while the SP was a staff person. The relationship continued after the VA was discharged from the facility. Given the VA’s history of substance use disorder, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA, both now and in the future. Therefore, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health. 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: Although the VA and the SP had sexual contact after the VA was discharged from the facility which would not be considered sexual abuse because the VA was no longer receiving services, given that while the VA was receiving services, the SP and the VA touched each other’s genitals over the clothes, there was a preponderance of the evidence that the SP had sexual contact with the VA. It was determined that sexual abuse occurred (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' includes the primary genital area, groin, inner thigh, buttocks, and breast). 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 the Reporting of Maltreatment of Vulnerable Adults Act therefore, 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, abuse resulting in serious injury, or financial exploitation of a vulnerable adult if the value of the funds or property is $1,000 or greater. 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 that the SP was responsible for was not recurring or serious maltreatment because it was a single pattern of neglect and did not meet the definition of serious maltreatment. It was determined that the substantiated sexual abuse that the SP was responsible for was not recurring maltreatment because it was determined the SP had sexual contact with the VA on one occasion while the VA received services from the facility but was serious maltreatment because it was sexual abuse. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility’s Internal Review stated that the facility’s policies and procedures were adequate and followed. The facility added boundary training as part of the annual training review for staff persons. The SP no longer worked for 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. On August 20, 2026, the facility was issued a Correction Order for a background study violation for not completing an updated background study when a staff person had a legal name change.
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