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POLICY AND PROCEDURE ON Reporting and Review of Maltreatment of Vulnerable Adults


This sets forth Bethel’s Policy and Procedure for safeguarding vulnerable adults (generally students) while on campus or engaged in Bethel related programs and activities. Included are specific directions concerning when and how reporting of maltreatment or abuse of vulnerable adults should be accomplished. The Policy also commits the University to review all such incidents. The content of this policy document and related procedures is informed by and modeled upon various Minnesota Statutes that safeguard the welfare of vulnerable adults in our State. Relevant portions of those Statutes are attached in Appendix A for your information. Portions of these Minnesota Statutes may apply to Bethel employees that are statutorily defined “mandatory reporters”. Bethel University’s policies and procedures, however, apply to all employees, whether or not they are considered mandatory reporters under state law. Finally, even where the Minnesota Statutes concerning the protection and welfare of vulnerable adults do not technically apply to Bethel and Bethel employees, the University nevertheless will enforce this Policy consistent with the spirit and intent of those Statutes as determined by University leadership. In all cases the ultimate goal is the protection of vulnerable adults in the Bethel community. For avoidance of doubt, employees should assume that conduct that is prohibited under Minnesota Statutes set forth in Appendix A is also prohibited by this Policy and Procedure document. Any questions or request for clarification may be directed to Katie Bonawitz, Ed.D., Assistant Dean, Center for Access and Integration, Bethel University, (651) 638-6724,


The purpose of this policy is to establish guidelines for the external and internal reporting and the internal review of maltreatment of vulnerable adults.


All Bethel employees, including but not limited to those who may be mandatory reporters under Minnesota Statutes, must report all of the information they know regarding an incident of known or suspected maltreatment of vulnerable adults, either externally or internally. All employees of Bethel University who encounter maltreatment of a vulnerable adult must take immediate action to ensure the safety of all vulnerable adults in the Bethel community. This policy defines maltreatment of vulnerable adults as abuse, neglect, or financial exploitation and utilizes the definitions from Minnesota Statutes, section 626.5572 set forth in Appendix A to this policy.


A. Employees of Bethel University who encounter maltreatment of a vulnerable adult must take immediate action to ensure the safety of the person or persons. If an employee knows or suspects that a vulnerable adult is in immediate danger, they will call “911and then contact campus security.

B. If an employee knows or suspects that maltreatment of a vulnerable adult has occurred, they must make a verbal report immediately (within 24 hours) either to the Minnesota Adult Abuse Reporting Center (MAARC)/Common Entry Point (CEP) or internally to Student Life and BUILD (if the victim is a student in BUILD). Should the employee choose to make a report directly to an external agency, they must make the verbal report by calling the MAARC/CEP.

C. Where to report –You can make an external or an internal report.

1. You may make an external report to the MAARC/CEP by calling 844-880-1574 or mandated reporters can file a report online at reporting is for mandated reporters onlyand not other employees, or family members, friends, guardians etc.).

2. You may make an internal report to the appropriate Resident Director or Residential Supervisor

3. If a Residence Director or Supervisor is the alleged abuser or is otherwise involved in the alleged or suspected maltreatment, you must report to either the Assistant Dean of Residence Life or the Assistant Dean of the Center for Access and Integration.

D. When verbally reporting the alleged or suspected maltreatment, either externally or internally, employees will include as much information as known and will cooperate with any subsequent investigation.

E. For internal reports of suspected or alleged maltreatment, the person who receives the report will:

1. Contact the MAARC/CEP if the report is determined to be suspected or alleged maltreatment.

2. Inform the parent(s) and/or guardian(s) within 24 hours of reporting maltreatment, unless there is reason to believe that the parent/guardian is involved in the suspected maltreatment. The person who received the report will disclose to the parent(s) and/or guardian(s) the:

a. Nature of the reported incident, and

b. The agency that received the report.

3. Complete and mail the Notification to an Internal Reporter to the home address of the employee who reported the maltreatment within two working days in a manner that protects the reporter’s confidentiality. The notification must indicate whether or not Bethel University reported externally to the MAARC/CEP. The notice must also inform the employee that if Bethel University did not report externally and the employee is not satisfied with that determination, they may still make an external report to the MAARC/CEP. It will also inform the employee that they are protected against any retaliation if the employee decides to make a good faith report to the MAARC/CEP

F. When Bethel University has knowledge that an external or internal report of alleged or suspected maltreatment has been made, an internal review will be performed. The Resident Director/Residential Supervisor is the primary individual responsible for ensuring that internal reviews are completed for reports of maltreatment. If there are reasons to believe that the Resident Director/Residential Supervisor is involved in the alleged or suspected maltreatment, then the Assistant Dean of Residence Life or the Assistant Dean of the Center for Access and Integration shall be responsible for ensuring that an internal review is performed.

G. The Internal Review will be completed within 30 calendar days. The person completing it will:

1. Ensure an Incident and Emergency Report has been completed.

2. Contact the lead investigative agency if additional information has been gathered.

3. Coordinate any investigative efforts with the lead investigative agency by serving as the Bethel University contact, ensuring that staff cooperate, and that all records are available.

4. Complete an Internal Review which will include the following evaluations of whether:

a. Related policies and procedures were followed;

b. The policies and procedures were adequate;

c. There is a need for additional staff training;

d. The reported event is similar to past events with the vulnerable adults or the services involved; and

e. There is a need for Bethel to take corrective action, including employee discipline, in order to protect the health and safety of the vulnerable adult(s)

H. Based upon the results of the internal review, Bethel University will develop, document, and implement a corrective action plan designed to remedyany current lapses and prevent future lapses in performance by Bethel Universityand its employees.

I. Internal reviews shallbe made accessible to lawful authorities upon request for internal reviews regarding maltreatment, with due regard for the privacy of the vulnerable adults involved and other applicable law.

J. Bethel University will provide an orientation to the internal and external reporting procedures to all enrolled vulnerable adultsand/or legal representatives. This orientation will include the centralized telephone number forthe MAARC/CEP. This orientation for each newenrolleewill occur within 24 hours of moving onto campus, or for persons who would benefit more from a later orientation, the orientation may take place within 72 hours.

K. If an employeemakes a maltreatment report in good faith, they are protected from any retaliation. If an employeemakes a false report or fails to report an incident appropriately, they maybe liable for disciplinary sanctions up to termination, and/or face criminal charges or fines.

L. Residence Life and BUILD Program employeeswill receive training on this policy, MN Statutes, section 245A.65 and sections 626.557 and 626.5572 and their responsibilities related to protecting vulnerable adultsfrom maltreatment and reporting maltreatment. This training shallbe provided within 72 hours ofan employee being assigned to duties involving vulnerable adultsand annually thereafter.

Appendix A –Relevant Minnesota Statutes

Legal Authority:Minn. Stat. §§§§§ 626.557; 626.5572; 245A.65; 245A.04, subd. 14; 245D.09, subd. 4 (5)





Subdivision 1. Scope. For the purpose of section 626.557, the following terms have the meanings given them, unless otherwise specified.

Subd. 15. Maltreatment.

"Maltreatment" means abuse as defined in subdivision 2, neglect as defined in subdivision 17, or financial exploitation as defined in subdivision 9.

Subd. 2. Abuse.

"Abuse" means:

(a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of:

(1) assault in the first through fifth degrees as defined in sections 609.221to 609.224;

(2) the use of drugs to injure or facilitate crime as defined in section 609.235;

(3 )the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and

(4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342to 609.3451.

(a) violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction.

(b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following:

(1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult;

(2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening;

(3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and

(4) use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825.

Subd. 9. Financial exploitation.

"Financial exploitation" means:

(a) In breach of a fiduciary obligation recognized elsewhere in law, including pertinent regulations, contractual obligations, documented consent by a competent person, or the obligations of a responsible party under section 144.6501, a person:

(1) engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult which results or is likely to result in detriment to the vulnerable adult; or

(b) In the absence of legal authority a person:

(1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult;

(2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult;

(3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or

(4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another.

(c) Nothing in this definition requires a facility or caregiver to provide financial management or supervise financial management for a vulnerable adult except as otherwise required by law

Subd. 17. Neglect.

"Neglect" means:

(a) The failure or omission by a caregiver to supply a vulnerable adult withcare or services, including but not limited to, food, clothing, shelter, health care, or supervision which is:

(1) 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

(2) which is not the result of an accident or therapeutic conduct.

(b) The absence or likelihood of absence of care or services, including but not limited to, food, clothing, shelter, health care, orsupervision necessary to maintain the physical and mental health of the vulnerable adult which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult.

(c) For purposes of this section, a vulnerable adult is not neglected for the sole reason that:

(1) the vulnerable adult or a person with authority to make health care decisions for the vulnerable adult under sections 144.651, 144A.44, chapter 145B, 145C, or 252A, or sections 253B.03or 524.5-101to 524.5-502, refuses consent or withdraws consent, consistent with that authority and within the boundary of reasonable medical practice, to any therapeutic conduct, including any care, service, or procedure to diagnose, maintain, or treat the physical or mental condition of the vulnerable adult, or, where permitted under law, to provide nutrition and hydration parenterally or through intubation; this paragraph does not enlarge or diminish rights otherwise held under law by:

(i) a vulnerable adult or a personacting on behalf of a vulnerable adult, including an involved family member, to consent to or refuse consent for therapeutic conduct; or

(ii) a caregiver to offer or provide or refuse to offer or provide therapeutic conduct; or

(2) the vulnerable adult, aperson with authority to make health care decisions for the vulnerable adult, or a caregiver in good faith selects and depends upon spiritual means or prayer for treatment or care of disease or remedial care of the vulnerable adult in lieu of medical care, provided that this is consistent with the prior practice or belief of the vulnerable adult or with the expressed intentions of the vulnerable adult;

(3) the vulnerable adult, who is not impaired in judgment or capacity by mental or emotional dysfunction or undue influence, engages in consensual sexual contact with:

(i) a person including a facility staff person when a consensual sexual personal relationship existed prior to the caregiving relationship; or

(ii) a personal care attendant, regardless of whether the consensual sexual personal relationship existed prior to the caregiving relationship; or

(4 )an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care; or

(5) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician, and:

(i) the necessary care is provided ina timely fashion as dictated by the condition of the vulnerable adult;

(ii) if after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition;

(iii) the error is not part of a pattern of errors by the individual;

(iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility;

(v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and

(vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency.

(d) Nothing in this definition requires a caregiver, if regulated, to provide services in excess of those required by the caregiver's license, certification, registration, or other regulation.

(e) If the findings of an investigation by a lead agency result in a determination of substantiated maltreatment for the sole reason that the actions required of a facility under paragraph (c), clause (5), item (iv), (v), or (vi), were not taken, then the facility is subject to a correction order. An individual will not be found to have neglected or maltreated the vulnerable adult based solely on the facility's not having taken the actions required under paragraph (c), clause (5), item (iv), (v), or (vi). This must not alter the lead agency's determination of mitigating factors under section 626.557, subdivision 9c, paragraph (c).

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