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4. Final Report of the Monroe County Grand Jury Spring term 2024-Trama Star IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT IN AND FOR MONROE COUNTY, FLORIDA FINAL REPORT OF THE MONROE COUNTY GRAND JURY SPRING TERM 2024 THE INVESTIGATION INTO 2022 TRAUMA STAR DIVERSION OF CONTROLLED SUBSTANCES, THE INDIVIDUALS INVOLVED AND THE ACTIONS/INACTIONS OF MONROE COUNTY PUBLIC OFFICIALS AND SERVANTS MEMBERS OF THE SPRING TERM 2024 GRAND JURY RANDALL PETERS, Foreperson r— : DENNIS W. WARD w ac = ► State Attorney � s, COLLEEN M. DUNNE Assistant State Attorney I. INTRODUCTION It is the province and the duty of the Grand Jury to investigate possible unlawful actions by all the persons, private citizens and public officials alike, and to return indictments when warranted; it is also the Grand Jury's lawful and proper function to consider the actions of public bodies and officials in the use of public funds, and to report or present findings and recommendations as to practices, procedures, incompetency, inefficiency, mistakes, and misconduct involving public offices and public monies. On July 26, 2022, the Monroe County Sheriffs Office (MCSO) was notified by Monroe Country Fire Rescue (MCFR) that it was discovered from their controlled substance logs that numerous vials of narcotics were unaccounted for and Trauma Star Chief Flight Nurse, Lynda Rusinowski had admitted to being responsible. At the time MCFR reported the crime to MCSO, it was still undetermined how many total controlled substance vials had been diverted and how far back the diversions had started. The Monroe County Sheriffs Office commenced a criminal investigation into the facts surrounding not only the actual thefts of the controlled substances but also how it was discovered, how the thefts occurred, what information members of MCFR had of the thefts or any suspicions they may have had, whether any other individuals may have been involved in the thefts directly or indirectly as well as whether there had been any prior similar incidents. Simultaneous to the investigation being conducted by MCSO, the then Fire Chief, Steven Hudson, requested the Monroe County Clerk of Courts conduct an audit of MCFR's Emergency Medical Services system performance and controlled substance inventory records for the period of June 2021 through July 2022. The Clerk's Office was requested to evaluate MCFR's methods of ordering controlled substances, the internal controls and processes over storage and security of the controlled substances, the efficiency and effectiveness of the receipt and storage of the controlled substances, review MCFR's compliance with the controlled substance 2 policy and procedures as well as applicable laws and regulations, review and evaluate the inspection and reporting requirements of controlled substance containers tampered or degraded, the disposal activities of unused and expired controlled substances and the documentation, records, reviews and management for storage policies. On May 11, 2023, the Monroe County Clerk's Office issued a 79-page Internal Audit Report and provided copies to the Board of County Commissioners, Roman Gastesi the County Administrator, Bob Schillinger the County Attorney, Fire Chief James Callahan and Deputy Fire Chief R. L. Colina. The Internal Audit was also made public by the Clerk of Court. The report contained numerous findings of inefficiencies and inadequacies in the management of controlled substances by MCFR, lack of and deficient performance on the part of Dr. Sandra Schwemmer, the Medical Director contracted by the Board of County Commissioners and also reported a total of over 600 missing controlled substances likely to have been diverted in just a 13-month review. Along with the findings, the audit report made many detailed recommendations to MCFR management for the purpose of correcting the inadequacies and safety issues identified. Although MCFR did provide written responses to the clerk's recommendations, it is unclear to what extent any of the recommendations or alternative processes were put into place by MCFR management. The State Attorneys Office initiated an investigation into MCFR's response to the 2022 criminal investigation by MCSO and thereafter the Clerk of Court's internal audit report. On August 2, S, and 15th, 2024, the Grand Jury heard testimony from 20 witnesses involved in or having knowledge of the 2022 Trauma Star investigation and actions by MCFR and other public servants. It should be noted that Roman Gastesi was afforded an invitation on two separate dates to appear in person or via ZOOM but did not appear. 3 On August 2, 2024, the Grand Jury returned a thirty-six-count indictment charging Lynda Rusinowski with Official Misconduct and Grand Theft of Controlled Substances. On August 8, 2024, the Grand Jury returned a nine-count indictment against Division Chief of Trauma Star/EMS Andrea Thompson charging Official Misconduct, Tampering with a Witness, Tampering with Evidence, False Statement to Law Enforcement and Alteration of Patient Records. On the same day a third indictment was also returned against Dr. Sandra Schwemmer charging Official Misconduct, False Statement to Law Enforcement and Alteration of Patient Records. Thereafter on August 15, 2024, the Grand Jury returned a one-count indictment against the former County Administrator Roman Gastesti charging Official misconduct and a superseding indictment against Andrea Thomson adding two additional charges of False Statement to Law Enforcement. This report is the culmination of the Grand Jury's inquiry and contains not only findings but recommendations based upon the testimony and evidence presented over three full days. II. THE FACTS AND OUR ASSESSMENT Integrity and accountability are important in public service to ensure that the public's best interests are served. What we the Grand Jury have discovered is that those two core principles are seriously lacking in current (and former) MCFR high ranking administrators and county employees and allowed for a caustic and cronyistic environment and culture to exist for many years within the agency. This culture seriously affects the morale of its employees and the delivery of services affecting the life and safety of Monroe County citizens and visitors and must come to a stop. This culture has been one of long duration where certain employees have received preferential treatment to the detriment of other employees, often leading to the termination or resignation of such employees who have refused to allow such dysfunctional behavior to exist. Sadly, such threats of retaliation and harassment have resulted in various employees caving into the demands or turning a blind eye 4 because of fear of being terminated or retaliation otherwise being imposed. Unfortunately, this environment has existed for many years and can be documented back to 2010. Over the years, many recommendations have been made to the Board of County Commissioners (BOCC). Grand Jury Reports, Clerk of Court Audits, Sheriff Reports, and other official documents have been issued seeking to address various problems, criminal conduct, and other misdeeds that have occurred in Monroe County Government and its Departments. While some processes and procedures have been taken and/or implemented, many have not. Individuals identified as being responsible for various misdeeds have been allowed to remain in their governmental positions, often being promoted to newly created positions. The Board of County Commissioners (BOCC) is ultimately responsible for the effective and efficient operation of Monroe County Government. This responsibility is accomplished through the County Administrator, who serves at the pleasure of the BOCC, and directly answers to the BOCC. The County Administrator oversees the daily operation of County government through various Department heads, who report directly to the County Administrator. Each Department then has its own hierarchy of supervision or chain of command. When the hierarchy of supervision/chain of command is compromised through favoritism, special treatment, misappropriation, intimidation, harassment, criminal activity, or otherwise turning a blind eye to the professional responsibilities that enure to and are expected of Public Officials, a toxic work environment is created and allowed to exist. All Public Officials are expected to uphold a standard of professionalism that is beyond reproach. Thomas Jefferson once said that the basic principle of public service is when a person assumes a public trust, that person should consider themselves as public property. Public service is a public trust. To ensure public confidence in the integrity of Monroe County Government and its employees, ethical behavior is required and expected of all County officials and employees, both exempt and non-exempt. County employees are expected to place loyalty to Federal and State laws, and ethical principles above their own personal and/or private 5 gains. Unfortunately, this has not occurred in Monroe County and MCFR. Roman Gastesi has served as Monroe County Administrator since May 2008. He retired on February 23, 2024, but has continued to serve as a "volunteer" to the BOCC during the six-month period of time he cannot be employed by Monroe County under the terms of Florida's Deferred Retirement Option Program (DROP). Based upon public information in various news articles, the BOCC is planning to rehire Roman Gastesi as County Administrator. This is unacceptable to the Grand Jury. Based on the witness testimony, Mr. Gastesi has been directly involved in many of the events that transpired involving certain employees of the MCFR and are part of this investigation. The Grand Jury returned its indictment against Roman Gastesi on August 15, 2024, charging him with official misconduct as a public official.. This is not the first time Mr. Gastesi has been a part of a Grand Jury investigation. In 2012, the Grand Jury issued its Official Report calling for the termination of Roman Gastesi as County Administrator for his participation in the theft of County owned cell phones and 1-pads by another county employee. Obviously the BOCC chose to ignore the recommendations of that Grand Jury. The question is posed as to whether Mr. Gastesi actually serves at the pleasure of the BOCC, or does Mr. Gastesi control the actions of the BOCC? The proverbial "tail wagging the dog." What is certain, through the testimony of the various witnesses, is that Mr. Gastesti has used what appears to be boundless power and authority in manners not consistent with the best interests of Monroe County as a whole, but rather for select individuals that align themselves with him, or otherwise not against his agenda. From the investigation undertaken by the State Attorney's office and presented to this Grand Jury through witness testimony and documentation, it is clear that the incident in July 2022, in which Lynda Rusinowski was initially charged with theft of morphine and alteration of drug logs, was merely the tip of the iceberg. Multiple incidents involving controlled substances and drugs utilized by 6 the Trauma Star/EMS program have occurred since at least 2010. Many of these incidents (2010, 2013, 2019, and 2022) have involved the same employees of Monroe County, Roman Gasesti, James Callahan, Andrea Thompson, and Sandra Schwemmer. Mrs. Thompson has been directly involved in several of the incidents and instead of being terminated or disciplined as recommended by MCFR officials, she has consistently been promoted throughout the years until she was most recently serving as MCFR Division Chief of the EMS and Trauma Star Division at the time of her arrest on August 9, 2024. Information provided to the Grand Jury has shown that both Roman Gastesi and Fire Chief James Callahan have consistently intervened on behalf of Mrs. Thompson throughout her career with MCFR to prevent disciplinary action being taken. Of concern to the Grand Jury is the personal relationship between Andrea Thompson, James Callahan, and Roman Gastesi, together with the involvement of Sandra Schwemmer. These relationships have resulted in minimal, if any, discipline imposed on Mrs. Thompson since the first misconduct we heard about back in 2010 wherein, Andrea Thompson, while off-duty removed medical supplies from the supply room to allegedly treat a volunteer firefighter at their residence. For a reason still unclear to the Grand Jury, Andrea Thompson was not disciplined, and more disturbing was learning that the only mention of this behavior in her personnel file is in an unrelated complaint she fled against another employee. The Grand Jury learned of various accounts where Andrea Thompson exhibited very poor leadership and judgment while acting in a position of authority at MCFR. She placed her personal friendship with the Chief Flight Nurse Rusinowski ahead of public safety, improperly inserted herself in the investigation into the narcotics theft by Rusinowski and thwarted law enforcernents attempts to discover all the facts and evidence surrounding the crime committed by her friend. Andrea Thompson failed miserably in her commitment to serving the citizens of Monroe County with honor and integrity. Aside from the above, Andrea Thompson was a main architect of the toxic workplace that existed at MCFR, actively participating in intimidation, threats and coercion to keep those she managed under her control. Yet, Thompson was rewarded for her "loyalty and service" by being promoted multiple times even after she was suspended with pay in connection with her acts as reported by MCSQ's investigation into the theft of the controlled substances by Rusinowski. Fire Chief Callahan and Mr. Gastesi have been able to directly influence many of the incidents and outcomes to this day. Most recently, Roman Gasesti intervened and stopped HR and Employee Services from conducting an internal investigation by an outside third-party independent firm of the July 2022 incident and more specifically Andrea Thompson. The popular adage, "it's who you know, not what you know," could not be more fitting to describe Andrea Thompson and the obvious cronyism. Fire Chief James Callahan served as Fire Chief of MCFR for 15 years before retiring in May 2021. Thereafter, Deputy Chief Steven Hudson served as Fire Chief of MCFR until his retirement December 17, 2022. Information presented to the Grand Jury indicates that Chief Hudson was harassed and received multiple threats of retaliation resulting in his decision to retire instead of being terminated when Chief Hudson attempted to implement changes and impose discipline for the July 2022 Rusinowski incident. To Chief Hudson's credit, he requested that the Monroe County CIerk of Court conduct a full and complete audit of the EMS and Trauma Star program. Not surprisingly, Chief Hudson received much pushback from the County Administrator Gastesi and certain BQCC commissioners. Despite the pushback, the Monroe County Clerk of Court completed the Audit releasing its findings in May 2023. With Fire Chief Hudson's December 2022 retirement, County Administrator Gastesi rehired former Fire Chief Callahan to serve as interim Fire Chief beginning January 3, 2023 until the present day. Fire Chief Callahan was to serve temporarily as fire chief during which time the MCFR was to seek a new fire chief. Deputy Chief R. L. Colina served as interim Fire Chief from December 2022 until January 2023 8 when Fire Chief Callahan came onboard. At this time Fire Chief Callahan has been retained as fire chief for MCFR. Information presented to the Grand Jury indicates that former Fire Chief Hudson was not afforded the tradition of selecting his successor. Information also presented to the Grand Jury indicates that County Administrator Gastesi authorized Fire Chief Callahan to work remotely resulting in his being out of Monroe County more often than he is in Monroe County, typically only appearing for the monthly BGCC meetings. While Fire Chief Callahan is out of county, Deputy Chief R. L. Colina continues to serve as acting Fire Chief. Sandra Schwemmer has served as the Medical Director for Monroe County since 1987. Her contract with the BGCC has continually been renewed since then and she was currently serving as the Monroe County Medical Director at the time of her arrest. The Grand Jury received a significant amount of information indicating that Dr. Schwemmer was not complying with the terms of her contract with the BGCC. She was not readily available to MCFR EMS/Trauma Star personnel when needed. She rarely appeared in County and would delegate her various responsibilities to other EMS/Trauma Star personnel including but not limited to Andrea Thompson, Linda Rusinowski, and others. Actions required to be taken by Dr. Schwemmer under the terms of her contract were not completed, such as required monthly meetings. Reference is made to the Clerk of Court's May 2023 Audit for additional examples of contractual noncompliance. Testimony and information presented to the Grand Jury indicated that inventory controls for controlled substances such as morphine, fentanyl, dilaudid, ketamine, and versed regularly went missing without remedial action being taken. However, she did not institute any real changes to the inventory process during her tenure that would ensure such drugs did not go missing or unaccounted for. In fact, Dr. Schwemmer did not enforce at least one of her directives that incorrect entries in the drug logs must be struck through and reentered. The Clerk's Audit and MCFR internal review of the paper drug logs showed that this procedure was not being followed and the logs were being altered. 9 The Grand Jury is extremely concerned about the BOCC's willingness to continually renew contracts, such as the Medical Director contract, without ensuring that the terms of the contract have been complied with. Given the multiple incidents involving controlled substances during Dr. Schwernmer's tenure, the Grand Jury is deeply concerned about the willingness of the BOCC to continually renew Dr. Schwemmer's contracts that regularly increased the amount of compensation she received without any oversight that the terms of the contracts were being complied with. We believe that MCFR EMS services and the Trauma Star program are exceptional services which are vital for Monroe County. There are many highly trained, dedicated, ethical and committed individuals within those programs who take pride in serving Monroe County. The long standing, underlying problem has been the various individuals placed in leadership roles who have abused the power given to them and created an unhealthy almost tyrannical environment. We acknowledge and support the steps thus taken since the Clerk's Internal Audit Report to ensure best practices are followed. It is evident additional actions are critically necessary. We encourage the BOCC to provide the necessary resources needed to bring about more accountability, integrity and transparency. We must highly commend the fire-fighter/paramedics, the auditors for the Clerk of Court, and former MCFR employees who provided critical and impactful testimony and enlightened the Grand Jury to the existing work environment and culture. The currently employed fire-fighter/paramedics who testified exposed themselves to potential retribution and ostracism, were especially courageous despite being at risk of severe personal and professional consequences. Without their courage to speak out, many issues might have remained hidden, allowing harmful practices to persist unchecked. The Grand Jury was in full consensus that MCFR EMS and the Trauma Star program provides outstanding critical patient care and services. Many lives depend 10 on these services on a daily basis. We commend their efforts and encourage public trust and confidence in these services. John Stuart Mill stated, "A person may cause evil to others not only by his actions but by his inaction, and in either case he is justly accountable to them for the injury." Although the Grand Jury has only indicted four (4) individuals whose actions and inactions were criminal and affected the public's trust and safety, there may be others whose actions are questionable. III. RECOMMENDATIONS We make the following recommendations and strongly encourage they be immediately adopted and implemented. if such recommendations are not adopted, the BOCC and MCFR should provide a written explanation to the Grand Jury and provide an explanation at a public BOCC meeting before the end of 2024. 1. Roman Gastesi be immediately terminated from any and all Monroe County positions, including volunteer positions. This recommendation was previously made by the 2012 Grand Jury in its Official Report and ignored. Mr. Gastesti must never hold any position with Monroe County. 2. Andrea Thompson be immediately terminated from her position with MCFR and not be allowed to return or hold any position with MCFR or hold any position of trust with Monroe County. 3. Chief Callahan be asked to resign as Fire Chief before the end of 2024 and the BOCC begin immediately the necessary steps to appoint a new Fire Chief who possesses the requisite education, technological knowledge and professional skills to perform the Fire Chiefs job responsibilities and oversees the daily operations in county and be on site. 4. We strongly recommend that MCSO allow Firefighter/Paramedics Damian Suarez and Harold Perez to return to Trauma Star as flight medics if they so 11 choose. Additionally, Monroe County should reinstate with backpay Damian Suarez and Harold Perez Trauma Star flight pay from the day they were allowed to return to work, but denied flight status pay. S. An internal affairs division should be created to handle MCFR personnel discipline, similar to what is afforded for law enforcement officers under Chapter 112, Florida Statute. 6. Monroe County Employee Services to implement random drug testing for all county employees in special-risk positions as was previously recommended in the Clerk's Internal Audit Report. 7. Employee Services and MCFR request the Medical Director to issue a Medical Directive requiring all MCFR EMS and Trauma Star employees to be subject to random drug testing. 8. All MCFR employees to receive diversion training to identify signs of substance abuse, and steps to prevent the theft of narcotics. 9. Monroe County's Human Resources/Employee Services department to develop a new and uniform policy and procedures for the handling of any complaint received from a Monroe County employee. More specifically, the policy and procedures to require in every complaint that a written finding, resolution or conclusion be provided to the complainant or the subject of the complaint no later than 45 days from receipt of the complaint. That the subject of the complaint be allowed to review the complaint and all statements, names of witnesses and evidence before any investigative interview is conducted of the subject of the complaint. The complainant to also be allowed to review any evidence, statements or names of witnesses by the subject of the complaint and allowed to respond prior to any investigative interview of the complainant. 10. Monroe County's Human Resources/Employee Services departments should review and update its whistleblower/anonymous reporting process to require a response be sent confirming receipt of the report. There also needs to be a written report or response documented internally indicating what was done 12 to investigate the report as well as a response being provided to the individual who made the report. 11. All Monroe County elected officials, BOCC, department heads, executives and any person in a management/supervisory level be required to complete an ethics and compliance in the workplace training with a focus on intimidation, bullying, harassment, retaliation, discrimination and working in a regulated environment. The training should be required on an annual basis. 12. All Monroe County elected officials, BOCC, department heads, executives and any person in a management/supervisory level be required to complete a Leadership training course with continuing education on an annual basis. 13. The BOCC immediately hire an independent third-party firm to conduct a review of all contracts of services and determine compliance with the required contract terms before any contact is renewed. 14. The BOCC implement more checks and balances as it pertains to the County Administrator position. There should be written monthly reports detailing a thorough review by the County Administrator of the County's departments' work environment, work product and efficiency along with any pending complaints or incidents related to public trust or accountability A reminder from Thomas Paine, "A body of men holding themselves accountable to nobody ought not to be trusted by anybody." We ought not trust those who are unwilling to be accountable. SO SAY WE ALL, RANDALL PE �- —,........__. w TERS Foreperson 13