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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: 1070489-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 two vulnerable adults (VA1 and VA2). Date of Incident(s): 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 from the facility and law enforcement records; and through five interviews conducted with two supervisory staff persons (P2 and the SP), VA1’s and VA2’s guardians (G1 and G2 respectively), and VA1’s case manager (CM). Attempts were made via telephone and email to contact and interview another staff person (P1), but P1 did not respond. VA1 and VA2 were each diagnosed with a mild developmental disability. According to VA1’s and VA2’s Individual Abuse Prevention Plans (IAPP), VA1 and VA2 were unable to budget or manage their financial resources safely and accurately; including managing savings accounts, paying bills, making necessary purchases, or paying bills timely. VA1 and VA2 did not recognize or understand mismanagement of finances. Staff persons maintained savings accounts in VA1’s and VA2’s name, paid all bills, deposited all checks, budgeted for expenses, and reported all disbursements to the legal representative. The SP made purchases based on VA1’s and VA2’s needs and P1 or P2 managed and balanced the accounts on a monthly basis. G1 provided the following information: · A few months prior to this investigation, VA1 received a large payment for COVID relief. On a previous occasion, the SP, who made payments from VA1’s bank account, told G1 to take money out so VA1 did not lose his/her state funding. · On October 7, 2022, at approximately 1 p.m., G1 called and told VA1 that s/he was going to take him/her shopping in order to spend down the COVID money. VA1 asked the SP if s/he could go with G1 shopping and out to dinner. The SP “immediately” asked VA1 how much money s/he needed for the outing and offered to get money from the bank. G1 was on speakerphone and told the SP that s/he did not need to help since G1 was bringing VA1 to the bank. The SP asked a second time how much money VA1 needed and G1 responded that s/he was going to be at the facility at approximately 3 p.m. to pick up VA1. The SP asked a third time in a “different way” saying s/he needed to go to the bank so G1 should tell the SP how much money VA1 needed. G1 was “blunt” and told the SP not to take out money for VA1. · When G1 arrived at the facility at 2:52 p.m., the SP was not there. The SP already left for the day even though s/he was scheduled until 3 p.m. · While driving to the bank, VA1 told G1 that there was approximately $3000 in VA1’s account. While at the bank, the teller told G1 and VA1 there was only approximately $500 in the account. G1 downloaded the online banking app and saw there were four cashed checks each written out to the SP and signed by the SP for: $1090, $500 (later determined to be $550), and $1000, and one for $200 which was written out that day and “pending. ” G1 cancelled the pending check so it did not go through. (The total amount written out to the SP was $2640.) · G1 asked VA1 if the SP brought blank checks to VA1 to sign and VA1 responded, “Yes,” and that the SP told VA1 that the checks were to pay VA1’s phone and rent. VA1 told G1 that the SP showed VA1 the checkbook where the SP wrote in the balances but refused to show VA1 the bank statements. G1 showed VA1 the online copy of the check written out for $1000 to the SP and asked VA1 if s/he knew what it was for and VA1 had “no idea.” · After dinner, G1 went to the facility and looked through VA1’s finances. In VA1’s financial book, the SP wrote that the check for $1000 was for something else (G1 could not recall what it was) but then crossed off and written as “voided.” · On October 8, 2022, G1 spoke to P1 and told him/her about the checks. P1 apologized “numerous” times because it was P1’s responsibility to balance VA1’s bank account monthly and P1 told G1 that s/he had not. P1 told G1 that s/he later went to the facility and found VA1’s bank statements that were hidden in the SP’s office. According to the law enforcement report: · On October 10, 2022, at approximately 9:30 a.m., P1 spoke to a law enforcement officer (LEO) and said that money was missing from VA1’s bank account and that there were five checks written out to the SP’s name totaling approximately $2400. · P1 told the LEO that the SP had been working for the facility for approximately five years and approximately six to seven months prior, was promoted to a supervisory staff person. In approximately July 2022, P1 realized that the SP had used the facility’s bankcard to withdraw approximately $1300 from the facility funds. The facility gave the SP two days to return the money, which the SP did, in full. · VA1’s checks totaled $2640 and provided the following: o A check dated June 28, 2022, for $1090, paid to the order of the SP’s name and signed by VA1. On the back, the check was endorsed with the SP’s name. o A check dated July 11, 2022, for $550, paid to the order of the SP’s name and signed by VA1. On the back, the check was endorsed with the SP’s name. o A check dated September 3, 2022, for $1000, paid to the order of the SP’s name and signed by VA1. On the back, the check was endorsed with the SP’s name. · P1 told the LEO that s/he reviewed VA2’s bank account and discovered money taken by the SP. VA2’s checks totaled $1250 and provided the following information: o A check dated July 24, 2022, for $400, paid to the order of the SP’s name and signed by VA2. On the back, the check was endorsed with the SP’s name. o A check dated August 11, 2022, for $300, paid to the order of the SP’s name and signed by VA2. On the back, the check was endorsed with the SP’s name. o A check dated September 8, 2022, for $150, paid to the order of the SP’s name and signed by VA2. On the back, the check was endorsed with the SP’s name. o A check dated September 23, 2022, for $150, paid to the order of the SP’s name and signed by VA2. On the back, the check was endorsed with the SP’s name. o A check dated October 4, 2022, for $250, paid to the order of the SP’s name and signed by VA2. On the back, the check was endorsed with the SP’s name. · On October 31, 2022, the LEO spoke to the SP who denied taking money from VA1 and VA2 and said that s/he did not know how his/her name ended up on the checks. The SP said that the signature on the checks was not his/her signature. The SP was a supervisory staff person and one of his/her responsibilities was to monitor VA1’s and VA2’s checkbooks. The SP was the only person who had access to VA1’s and VA2’s check books. When the LEO brought up the $1300 the SP used from the facility funds in July 2022, the SP stated it was a “misunderstanding” because the SP “accidently” used the facility bankcard that was inside the SP’s wallet. · The law enforcement report was submitted to the county attorney’s office for charges. P2 provided the following information: · VA1 and VA2 each had a checkbook that were kept inside a locked cabinet in the SP’s office along with each of their financial books. The SP balanced each clients’ finances and P1 reviewed the finances monthly. P1, P2, and the SP were the only staff persons with access to the SP’s office. · On October 8, 2022, P1 called P2 and said someone had taken VA1’s money out of his/her bank account. P1 said s/he asked VA1 about the checks and VA1 told P1 that the SP asked VA1 to sign a blank check for “cost of care.” · The following day, P1 also looked at VA2’s finances and saw checks written out to the SP. P1 told P2 that “for months” s/he had been asking the SP for VA1’s and VA2’s financial information so that P1 could balance the accounts, but the SP gave excuses to why s/he was not able to meet up or get P1 the information. · P2 asked VA2 about the checks and VA2 said s/he previously signed checks for the SP that were blank. VA2 was not able to read and was “frustrated and upset” about the checks. · P2 asked VA1 if the SP wrote out checks and VA1 responded, “Yeah.” P2 asked if the checks had been filled out and VA1 responded, “No.” P2 asked what the SP said the checks were for and VA1 responded, “Cost of care.” · P2 saw the copies of the checks and said the signature was the same as how the SP signs his/her name. Copies of VA1’s and VA2’s checks provided by the facility provided information that was consistent with the information in the law enforcement report. The SP’s signature on each check was similar to the SP’s signature on VA1’s and VA2’s annual plans. The SP provided the following information: · On October 7, 2022, G1’s spouse called the SP “screaming” saying that the SP stole money from VA1. On October 8, 2022, P1 texted the SP and said s/he needed to meet P1 at the main office on October 10, 2022. · On October 10, 2022, while at the main office, P1 told the SP that s/he knew that the SP had a check written out from VA1’s bank account to the SP. P1 showed the SP a copy of a check from VA1’s bank account and P1 told the SP s/he knew the SP wrote it because P1 said it matched the SP’s handwriting. The SP stated s/he “always” changed his/her handwriting. The SP denied writing checks to him/herself from VA1’s and/or VA2’s bank accounts. · The SP stated that if VA1 needed money to purchase something, VA1 signed the front and the back of a check and brought it to the bank and cashed it. When they returned to the house, staff persons documented any cash remaining on the cash tracker form and the cash was kept in a locked box in the SP’s office. The SP stated it was generally another staff person (P3) who brought VA1 to the bank. VA1’s checkbook was kept in a cabinet in the kitchen and all staff persons had access to it. If a staff person used a check, they documented in VA1’s financial binder. The SP was responsible for balancing VA1’s checkbook monthly but the SP worked “so many hours” of direct care that s/he was not able to balance the checkbooks. All staff persons also had access to the SP’s office. · On October 12, 2022, P1 contacted the SP and said that VA2 was also missing money in his/her bank account. The SP denied using VA2’s funds. The SP stated that previously s/he had used the facility credit card and it was a “complete mistake.” Once the SP realized s/he had made a few purchases with the company credit card, s/he called P1 and let him/her know about the charges and the SP repaid the charges. G2 was aware of the allegations and did not have any concerns. The CM was not aware of the allegations and generally received incident reports from the facility. The CM did not have any concerns.
According to the facility’s Safeguarding Individual Financial Resources and Property policy: · The facility ensured separation of funds of the vulnerable adults from the funds of the facility and staff persons. The facility obtained checking accounts for each vulnerable adult to minimize the use of cash. The vulnerable adults’ accounts had “as few signers as possible” which may have included the vulnerable adult, the guardian, the SP’s role, and P1’s role. · Each vulnerable adults’ bank account was maintained by the SP and monitored by P1. The facility “immediately” documented the receipt and disbursement of vulnerable adults’ funds at the time of receipt or disbursement. The SP reviewed the account, receipts, and expenses “at least weekly.” Receipts were kept in the checkbooks until removed by the SP when reviewing the account. · A copy of the statement, register, and receipts were given to P1 monthly for review. All extra checkbooks were locked in the staff office. The facility’s personnel files and training records documented that staff persons, including the SP, were each trained on VA1’s and VA2’s plans, the facility’s Safeguarding Individual Financial Resources and Property policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a), stated that a license holder must provide services based on persons’ identified needs. Conclusion: A. Maltreatment: Information showed that there were three checks, on three separate dates from VA1’s bank account, totaling $2640, written out to the SP, and endorsed with the SP’s name. There were also five checks, on five separate dates from VA2’s bank account, totaling $1250, written out to the SP and endorsed with the SP’s name. Given that only staff persons had access to VA1’s and VA2’s check books and banking information, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used VA1’s and VA2’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. P1 failed to review and/or reconcile VA1’s and VA2’s bank accounts, which were a violation of Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a). However, while a timelier review may have prevented some of the incidents, it likely would not have prevented all of the incidents. The SP was trained on the facility’s Safeguarding Individual Financial Resources and Property policy, the Reporting of Maltreatment of Vulnerable Adults Act, and VA1’s and VA2’s plans. The SP denied writing check to him/herself to this investigator and law enforcement and/or taking VA1’s and VA2’s money. However, VA1’s and VA2’s checks were made payable to the SP, the SP’s name was endorsed on the back, P2 said that the SP’s signatures on the checks matched the SP’s signature on VA1’s and VA2’s annual plans, and VA1 and VA2 provided information that the SP had each of them sign blank checks. Therefore, it was more likely that the SP took funds from VA1’s and VA2’s accounts. The SP was responsible for maltreatment of VA1 and VA2. 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 two vulnerable adults on multiple dates. 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. On January 13, 2023, the facility was issued a Correction Order for the violation outlined above, failing to report maltreatment as required, and failing to review a person’s individual abuse prevention plan and coordinated service and support plan as required.
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