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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: 1068726-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a staff person (SP) took money from three vulnerable adults (VA1-VA3). Date of Incident(s): October 23, 2022 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 9, paragraph (b), clause (1): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation and video surveillance from the facility and law enforcement records; and through eight interviews conducted with a supervisory staff person (P1), VA1’s-VA3’s case managers (CM1-CM3 respectively), VA1’s-VA3’s guardians (G1 and G3-G5). Attempts were made by phone and mail to contact a guardian (G2) but G2 did not respond. Attempts were made via telephone and certified mail to contact and interview the SP, but the SP did not respond to the requests. The SP’s interview with law enforcement was included below. VA1 was diagnosed with autism. According to VA1’s Individual Abuse Prevention Plan/Self-Management Assessment, VA1 required “minimal assistance” with money. When VA1 needed money at work or for an activity, staff persons verbally and manually “guided” VA1 with payments. VA1 had “pocket money” and spent it as s/he chose to. Prior to payment at a store, staff persons verbally discussed how much an item costs and how much change VA1 should receive. According to VA1’s petty cash ledger, on October 24, 2022, cash in the amount of $50 was taken out and VA1 had a balance of $100. VA2 was diagnosed with a severe developmental disability. According to VA2’s Individual Abuse Prevention Plan/Self-Management Assessment, VA2 did not understand finances so VA2 was not able to manage his/her own money. Staff persons managed VA2’s finances and receipts monthly. According to VA2’s petty cash ledger, on October 19, 2022, VA2 had a balance of $43.72. VA3 was diagnosed with a moderate developmental disability. According to VA3’s Individual Abuse Prevention Plan/Self-Management Assessment, VA3 was dependent of others for assistance with finances. VA3 was aware s/he needed money to purchase items but did not know how to count money. Staff persons assisted VA3 with purchases and receipts. VA3 had petty cash available at the facility and staff persons managed VA3’s petty cash. According to VA3’s petty cash ledger, on October 21, 2022, VA3 had a balance of $120.02. According to the facility’s Recipient Fiscal Policies, each vulnerable adult had a petty cash envelope and a ledger that were stored in a locked cabinet. All staff persons had access to the envelopes and were instructed on the correct procedure for all money transactions. As transactions were made, the transaction was recorded in the corresponding ledger, including the date, item purchased, amount of purchase, and amount remaining in the account. Receipts were obtained whenever possible. A supervisory staff person counted and verified the finances weekly. Staff persons did not borrow money from a vulnerable adult, purchase personal items from a vulnerable adult, or have a vulnerable adult purchase items for staff persons. The law enforcement report provided the following information: · On October 24, 2022, a supervisory staff person (P2) conducted routine petty cash balances for VA1-VA3 and noticed that VA1’s-VA3’s petty cash amounts were off. P2 reviewed the video surveillance from the facility office and saw the SP open the drawer where VA1’s-VA3’s petty cash was stored. P2 then called P1, who went to the facility and they both balanced VA1’s-VA3’s petty cash accounts and realized that VA1 was missing $50, and VA2 and VA3 were each missing $40, all totaling $130. Later that afternoon, P1 and P2 met with the SP who admitted to taking the money. · The SP admitted to the LEO that on October 23, 2022, s/he took $130 from VA1’s-VA3’s petty cash. The SP confirmed the location of VA1’s-VA3’s petty cash envelopes. The SP was the only staff person working at the time and took the money because s/he did not have enough money to pay for gas for his/her personal vehicle. · The LEO issued a citation to the SP for three charges of financial exploitation of a vulnerable adult. P1 stated that during a conversation on October 24, 2022, between P1, P2, and the SP, P1 asked the SP to reimburse the $130. A few days later, the SP brought $130 to P1. P1 identified the SP in the video also viewed by P1 and P2. Video surveillance from the facility showed on October 23, 2022, at 9:42 and 10:14 p.m., the SP opened the filing cabinet drawer where the petty cash envelopes were stored. The SP’s back was toward the camera and his/her body blocked the majority of the view. G1, G3-G5, and CM1-CM3 were all aware of the allegations and did not have any concerns with the facility. The facility’s personnel files and training records documented that staff persons, including the SP, were each trained on VA1’s-VA3’s plans, the facility’s Recipient Fiscal Policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Video surveillance from the facility showed that on October 23, 2022, the SP was in the staff office going into the cabinet where VA1’s-VA3’s petty cash was stored. P1 and P2 provided consistent information to this investigator and/or law enforcement that on October 24, 2022, a total of $130 was missing from VA1’s-VA3’s petty cash envelopes. Although the SP did not respond to interview requests from this investigator, the SP told P1, P2, and the LEO that s/he had taken the $130 for his/her personal use for gas money and later repaid $130. Therefore, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used $130 of VA1-VA3’s funds. It was determined that financial exploitation occurred (In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult).
B. Responsibility pursuant to Minnesota Statutes, section 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the facility’s Recipient Fiscal Policies, the Reporting of Maltreatment of Vulnerable Adults Act, and VA1’s-VA3’s plans. The SP told law enforcement that s/he took $130 out of VA1’s-VA3’s petty cash for his/her own use. The SP was responsible for maltreatment of VA1-VA3. 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, or abuse resulting in serious injury. 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 financial exploitation for which the SP was responsible was recurring maltreatment because s/he took funds from three different vulnerable adults. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at 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.
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