Item R3 R3
BOARD OF COUNTY COMMISSIONERS
COUNTY of MONROE �� i Mayor Holly Merrill Raschein,District 5
The Florida Keys Mayor Pro Tern James K.Scholl,District 3
Craig Cates,District 1
Michelle Lincoln,District 2
' David Rice,District 4
Board of County Commissioners Meeting
November 19, 2024
Agenda Item Number: R3
2023-3279
BULK ITEM: No DEPARTMENT: Administration
TIME APPROXIMATE: STAFF CONTACT: Bob Shillinger
Yes
AGENDA ITEM WORDING: Discussion of the Grand Jury's report into the Investigation into the
2022 Trauma Star Diversion of Controlled Substances and direction to staff on the recommendations
contained therein. TIME APPROXIMATE 10:30 A.M.
ITEM BACKGROUND:
On August 29, 2024, the Grand Jury's report regarding the Investigation into the 2022 Trauma Star
Diversion of Controlled Substances was made public. The report summarizes the Grand Jury's findings
and conclusions as well as makes 14 recommendations to the County Commission and staff.
County staff has attached a chart summarizing the recommendations and outlining the steps the County
has taken and will be taking to respond to each recommendation.
PREVIOUS RELEVANT BOCC ACTION:
The Board held a preliminary discussion prior to the public release of the Grand Jury Report on August
21, 2024 and a more detailed discussion on September 11, 2024, after the Grand Jury report was
published.
INSURANCE REQUIRED:
No
CONTRACT/AGREEMENT CHANGES:
n/a
STAFF RECOMMENDATION: Discussion and direction.
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DOCUMENTATION:
Final Report of the Monroe County Grand Jury Spring term 2024-Trama Star published on Clerk-pdf
GJReport and comments on 10-28-24 for 11-19-24.docx
FINANCIAL IMPACT:
n/a
4386
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
DENNIS W. WARD
w ac = ► State Attorney
� s, COLLEEN M. DUNNE
Assistant State Attorney
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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
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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, 8, 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.
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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
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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
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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
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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.
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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
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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.
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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
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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
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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
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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
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4399
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