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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.”
Investigator(s): Lindsay Arth Suspected Maltreatment Reported: Allegation one: It was reported that between January and February 2021, a vulnerable adult (VA) gave two staff persons (SP1 and SP2) multiple checks totaling $12,179. These checks were in addition to what the VA paid for his/her monthly room and board and services. Allegation two: It was reported that SP1 and SP2 withdrew $800 from the VA’s bank account, despite being told by the VA’s team not to handle the VA’s finances. Initially there were concerns that the VA did not receive the $800 but the money was later was found in the VA’s bedroom. Date of Incident(s): Ongoing and prior to July 17, 2021 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), clauses (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 six interviews conducted with the VA, two facility supervisory staff persons (SP1 and SP2), the VA’s power of attorney (POA), and a community person (CP1) who worked for a program that provided in-home services to the VA. Additionally, the VA was a veteran and received supports from the Department of Veterans Affairs (DVA). This investigator also spoke to a community person (CP2) who was the VA’s medical foster home program coordinator from the DVA. CP2 and the VA’s Individual Resident Placement Agreement and Individual Abuse Prevention Plan both dated November 16, 2018, provided the following information: · The VA moved to the facility on November 16, 2018. Prior to the VA moving to the facility, the VA owned his/her own trailer home, which the VA continued to own and pay monthly payments on when s/he moved to the facility. The VA sold the trailer around January 1, 2021. · The VA was diagnosed with dementia, “cognitive impairment,” and diabetes. The VA also had a hearing impairment and used an IPad to communicate. The VA was not subject to guardianship. · The VA enjoyed baseball, video games, and fishing. · The VA required “total assistance” with his/her finances and the VA’s finances were to be “totally managed” by the VA and a “financial worker.” However, the VA could manage his/her “day to day money [him/herself].” · The VA privately paid the facility for his/her monthly room and board and services fees. The VA received income from the veteran’s administration and social security. · CP2 said that when the VA first moved to the facility, the VA had a “payee” (Note: The VA had three “payees” during the time that the VA resided at the facility, including the POA. However, there were also times when the VA did not have a payee when s/he lived at the facility and during those times, the VA managed his/her own finances). The VA hired and fired his/her payees. When the VA fired his/her payees, CP2 provided “education” to the VA on “payees” and how they could be “beneficial to supporting [the VA].” · Staff persons were to accompany the VA while in the community and staff persons were to arrange or provide transportation to the VA. · CP2 said when the DVA approves a home/facility for a veteran to live, the facility is given information on the DVA program requirements. Veteran Rights & Responsibilities is part of that programming that a facility agrees to follow. The Veteran’s Rights and Responsibilities from the DVA provided the following information: DVA clients “must be allowed” to manage their own personal financial affairs except when “restricted in this right by law.” Staff persons were to provide assistance with activities of daily living as needed, except for managing or handling a client’s money. Managing or having “control” of a DVA client’s money or assets created a “potential violation of interest.” If a DVA client “requests” assistance in managing personal financial affairs, the request must be documented. DVA clients were to be free from financial exploitation and staff persons were not to solicit, accept, or receive money from a DVA client other than the amount agreed upon for services. The Resident and Caregiver Agreement, the Resident Contract, and the Individual Resident Placement Agreement provided the following information: · SP1 and SP2 were to provide each client with assistance safeguarding cash resources as specified in the client’s plans. If a client “entrusts” cash resources to SP1 and SP2, the client and their guardian must be given a receipt by SP1 and SP2. SP1 and SP2 were not to be entrusted with cash resources in excess of $300 plus “resources sufficient to meet one month’s cost of care.” · A client’s rate could increase or decrease depending on the level of care required. However, no changes were to be made unless noted in an “addendum” and signed by “both parties.” · Clients were to pay for “room and board and care” on or before the 25th of the month prior to the month of service. If a client could not pay their monthly payment, the client was to apply for public assistance. Additionally, the client or their guardian was to inform the facility six months in advance if private pay funds were “running out.” Facility documentation showed that SP1 and SP2 received training on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. However, SP1 and SP2 did not have any additional training which was a violation of Minnesota Rules, part 9555.6185, subpart 2, which states that in addition to orientation training, caregivers must complete the training designed to meet the needs of the residents in care in any of the subject areas and in the amount specified in subpart 4. The operator must ensure that a record of training completed is maintained. Allegation one: It was reported that between January and February 2021, the VA gave SP1 and SP2 multiple checks totaling $12,179. These checks were in addition to what the VA paid for his/her monthly room and board and services. The VA’s Resident Contract signed by the VA on November 16, 2018, an undated Resident and Caregiver Agreement, and an Invoice dated February 25, 2021, provided the following information: · When the VA first moved to the facility on November 16, 2018, the VA paid SP1 and SP2 $897 per month for “room and board.” Additionally, the VA paid SP1 and SP2 $2042.55 for a “service rate” which was “based on an assessment completed at a home visit.” The VA’s total to SP1 and SP2 per month was $2939.55. · The undated Resident and Caregiver Agreement signed by the VA and SP2 showed that at some point, the VA’s total monthly payment increased to $3067. · In February 2021, the VA paid $934 for room and board and $2295 for “care and services.” The VA also paid $10 per month for cable. The total per month that the VA paid to SP1 and SP2 was $3239. The POA provided the following information: · The POA began working with the VA on April 2, 2021, (approximately two to three months after the incidents) and “managed” the VA’s personal funds. The POA’s responsibilities included that the POA wrote a check to SP1 and SP2 for the VA’s monthly room and board and services from the VA’s checking account and also paid ”all [the VA’s] other bills.”. · The POA was asked by the DVA to “step in” as the POA because in January and February 2021, prior to the POA working with the VA, there were “multiple” checks written from the VA to SP2 that were in addition to the VA’s monthly room and board and services fee. SP1 and SP2 had “overcharged [the VA] for services which resulted in an overpayment by [the VA] of $7529 (Note: The VA’s bank statements provided by the POA showed that the total amount was actually $12,179). There were no invoices for these checks. SP1 and SP2 should have had “records of every payment received from [the VA] and invoices to back up each check written, which was standard business practice.” · SP2 told the POA that at some point prior to January 2021, SP1 and SP2 had “not charged” the VA the “full amount” for the VA’s care because the VA could not afford it. However, the POA was not working with the VA at that time and did not know when this was. Then, in approximately January 2021, the VA sold a trailer that s/he owned. (Note: The VA’s bank statement showed that on January 8, 2021, the VA had a deposit of $18,899.21 to his/her account.) · SP2 told the POA that the “reason for all the checks” from the VA to SP2 in January and February 2021, was so that the VA could pay back the deficit. [Note: The VA’s bank statement showed that on January 2, 2021, there was a check for $2305 to SP2. There was nothing in the memo line but an Invoice dated January 1, 2021, said that the VA owed $2305 for “care and services back due.” Additionally, on January 16, 2021, there was a check for $934 to SP2 for “back rent.” It did not indicate what month(s) the “back” rent or services was for. These two checks were in addition to the $12,179]. · The POA thought that SP1 and SP2 wrote the checks and then had the VA sign them. This was “alarming” to the POA because the VA did not have the “capacity to understand what [s/he] was paying for or why.” SP1 and SP2 were also helping the VA with paying bills during this time and “knew how much [the VA] had in his/her checking account.” · The POA also said that at some point, because the VA was low on money, staff persons from the in-home company, including CP1, “pre-wrote” checks from the VA’s account for SP1 and SP2 to “hold.” SP1 and SP2 could then cash the checks for the VA’s room and board and services when the VA had money. However, SP1 and SP2 cashed “all” of those checks even after the VA’s “account” had been “brought up to date” when the VA sold his/her trailer. This resulted in “double payment for the services.” · Once SP1, SP2, the POA, and CP2 became aware that the VA had overpaid SP1 and SP2, a “repayment [see below]” plan was put in place for the VA. · SP1 and SP2 were “very disorganized” and it “would not surprise [the POA] if [SP1 and SP2] had billed [the VA] many times for the same thing.” · The POA also had concerns that SP1 and SP2 charged the VA a $1500 “move in fee” which the POA had not seen before at other similar programs. (Note: The Resident Contract said that there was a “non-refundable move in and hold fee” which was used to ensure that “all hygiene items, bedding, doctor appointments, paperwork, move in assistance, and any extra items or services offered by [SP1 and SP2] to help with the transition to [the] home.” This is a violation of Minnesota Statutes, section 245A.04, subdivision 13, paragraph (d), clauses (4) and (5) which states the license holders and program staff must not require a person served by the program to purchase items for which the license holder is eligible for reimbursement; or use funds of persons served by the program to purchase items for which the facility is already receiving public or private payment.) · The POA had additional concerns that the VA had a bank account that was “shut down shortly after the sale of the trailer home” and then the VA’s current account was opened. SP2 told the POA that this was done because the “old account was a mess and they wanted to start fresh.” The POA said that there would have been checks written to SP1 and SP2 out of the prior account but that the POA could not “access” that account because it had been “closed.” CP1 provided the following information: · CP1 worked with the VA “every couple of weeks” for three to four months in approximately the spring or summer of 2021 [Note: All other information showed that CP1 worked with the VA in approximately the winter of 2020/2021.] One of CP1’s responsibilities was to assist the VA with his/her finances. The VA often “ordered” things and would spend a lot of money, including on electronics. As a result, the VA often did not have enough money to pay his/her bills. Because of this, CP1 wrote out checks to SP2 ahead of time for room and board and services. CP1 did not specifically recall who asked CP1 to do this but thought it could have been the company CP1 was employed through or SP2. CP1 did not recall if s/he dated these checks. CP1 did “not remember” if s/he wrote anything in the memo line of the checks regarding what each check was for but said that s/he typically had a “tendency to do [so].” · Around January 2021, the VA sold a trailer s/he owned. The VA owed “back rent” to SP1 and SP2 and had other bills so after the VA sold his/her trailer, CP1 assisted the VA with writing checks and getting “up to date” with the payments s/he owed. CP1 said that SP2 showed CP1 “bills” or “invoices” for what the VA owed, including for the VA’s rent and the VA’s credit card company. CP1 then wrote out checks to those places for the amount owed. · After CP1 wrote out any check, CP1 showed the VA and told the VA what each check was for. The VA “approved” the checks before s/he signed them and the VA “signed every check.” · At some point, CP1 had concerns because the VA’s money was not “adding up.” This included that when CP1 was “balancing” the VA’s account, CP1 saw that there were checks on the VA’s bank statement written to SP1 or SP2 that CP1 did not write. CP1 did not know who wrote them. CP1 also thought that a “whole book of checks” was missing because there was a “huge gap” in the check numbers CP1 wrote compared to the checks on the VA’s bank statements that CP1 did not write. CP1 did “not know if there was malfeasance” but s/he felt “uncomfortable.” Because of this, in approximately February 2021, CP1 told the in-home company that s/he was employed with that s/he was “done” assisting the VA with his/her finances and “did not want any part of it.” The VA’s bank statements and checks for January and February 2021, showed that 14 checks, totaling $19,307, were written out to SP2 and cashed from the VA’s account. The 14 checks provided the following information: · Check number 2339 dated January 2, 2021, for $2305, and cashed on January 5, 2021. There was nothing in the memo line (Note: An Invoice dated January 1, 2021, said that the VA owed $2305 for “care and services back due.”) · Check number 2348 dated January 8, 2021, for $650, and cashed on January 11, 2021. There was nothing in the memo line. · Check number 2349 dated January 13, 2021, for $500, and cashed on January 14, 2021. There was nothing in the memo line. · Check number 2350 dated January 14, 2021, for $1500, and cashed on January 15, 2021. There was nothing in the memo line. · Check number 2340 dated January 16, 2021, for $934, and cashed on January 19, 2021. Memo line stated “back rent.” · Check number 2341 dated January 16, 2021, for $3239, and cashed on January 26, 2021. Memo line stated “Feb[ruary] Rent.” · Check number 2342 dated January 16, 2021, for $650, and cashed on January 19, 2021. Memo line stated “trailer cleaning.” [Note: CP2 said that the VA did not have anyone in his/her personal life to help the VA with cleaning his/her trailer. CP2 said that the VA paid SP2 less than had the VA hired a cleaning service.] · Check number 2351 dated January 20, 2021, $500 to SP2 and cashed on January 22, 2021. There was nothing in the memo line. · Check number 2352 dated January 22, 2021, for $650, and cashed on January 25, 2021. There was nothing in the memo line. · Check number 2354 dated January 27, 2021, for $3229, and cashed on January 28, 2021. There was nothing in the memo line. · Check number 2355 dated February 1, 2021, for $1500, and cashed on February 2, 2021. There was nothing in the memo line. · Check number 2356 dated February 7, 2021, for $1500, and cashed on February 17, 2021. There was nothing in the memo line. · Check number 2357 dated February 7, 2021, for $1500, and cashed on February 8, 2021. There was nothing in the memo line. · Check number 2358 dated February 12, 2021, for $650, and cashed on February 16, 2021. There was nothing in the memo line. The VA said that at some point, SP1 and SP2 were “cashing checks that [the VA] did not authorize.” SP1 and SP2 took money out of the VA’s account to pay for a vacation to Florida (around February 2021). When this investigator asked the VA why s/he thought this, the VA said that around the time of the vacation, the VA signed checks which SP1 and SP2 said were for “rent.” However, the checks were “more” than the VA’s usual rent. The VA normally paid $2000 for rent but the checks were for $3000 or $4000 (Note: This investigator did not see any checks for $4000). Additionally, around this time, SP1 also told the VA that s/he was “kind of stressed.” However, the VA did not know further details about this. The VA said that s/he did not “authorize” “no one” to take money out of his/her account. CP2 provided the following information: · The VA had a history of “debt struggles” and concerns with “money management.” When the VA first moved to the facility, s/he was not able to pay the “full [monthly] rate” to SP1 and SP2 due to the VA owning the trailer and paying a “lot fee” for that. For two years, SP1 and SP2 were “kind” and took a “reduced amount” and did not make the VA pay this money back. CP2 did not know the reduced rate but “recommended” to SP1 and SP2 that they “utilize good processes and book keeping.” CP2 said that SP1 and SP2 “undersold themselves as far as what they charged [the VA].” However, when the VA’s trailer sold around January 1, 2021, the VA began paying the “full rate” to SP1 and SP2. · At some point around January 2021, the VA did not have a “payee” and did “not have the skill set” to write checks on his/her own. Because of this, SP1 and SP2 had staff persons from an in-home company, including CP1, assist the VA with writing checks. This included writing checks to SP1 and SP2 for the “monthly” rent and service payment. At some point, the checks were “double written” to SP2 and “deposited” but CP2 did not recall the amount. CP2 said this was because “two different people” wrote out the same checks. Once it was discovered that the checks were “double written” and “deposited,” it was CP2’s “understanding” that SP1 and SP2 paid the VA back. · At some point, the VA had two bank accounts but then they got “folded into one account.” CP2 was not aware if the VA’s family member was on this account. · CP2 described SP1 and SP2 as “a little disorganized.” Additionally, their home life was “chaotic” given three clients and SP1 and SP2 having their own children. The Refund Plan for (the VA) from (SP1 and SP2) signed by SP1, SP2, and the VA; and dated March 9, 2021, provided the following information: · SP1 and SP2 said that prior to CP1 working with the VA, the VA was not able to pay SP1 and SP2 “on time” due to the VA having limited funds. Because of this, other staff persons from the in-home company wrote checks for SP1 and SP2 to “hang onto” so that SP1 and SP2 could cash them when the VA had money. The staff persons wrote “partial checks” and a “full” check “in case” SP1 and SP2 “could not find someone to write them.” · Later, CP1 “took over” writing the checks. When CP1 began working with the VA in approximately the winter of 2020/2021, s/he wrote “new checks” for VA1 and VA2. · At some point, SP1 found some of these checks in a drawer where SP1 and SP2 kept uncashed checks. SP1 “assumed” that SP1 and SP2 had not deposited them yet because SP1 and SP2 had “so much going on.” SP1 then deposited the checks into his/her and SP2’s bank account, using a mobile app on SP1’s phone. SP1 did not “double check” the checks before s/he deposited them and s/he was “not really paying attention” so did not realize that the checks were duplicative to the amounts that SP1 had previously deposited when other staff persons wrote the checks. · Later, when SP1 saw a “balance difference” in his/her account, SP1 thought that s/he and SP2 had received a COVID stimulus check and did not think anything further. · At some point, CP1 notified SP1 of the discrepancies in the VA’s account. When SP1 became aware of the error, s/he created a refund plan and said that s/he would “obviously return the amount.” The refund plan included that SP1 and SP2 would take off $1000 each month from the VA’s monthly rate until the VA was fully refunded and when they received their “actual stimulus,” it would go to the VA (Note: The POA said that SP1 and SP2 never gave the VA their stimulus check “as far as [the POA] knew”). SP1 said that $7529 was the total to be refunded. · The checks identified by SP1 as incorrect on the repayment plan totaled $7529 and were as follows: o Check number 2352 dated January 22, 2021, $650 o Check number 2354 dated January 27, 2021, $3229 o Check number 2355 dated February 1, 2021, $1500 o Check number 2357 dated February 7, 2021, $1500 o Check number 2358 dated February 12, 2021, $650 (Note: SP1 told this investigator and law enforcement that there were additional checks that should have also been on the repayment plan but that s/he was not aware of them until this investigator and law enforcement asked him/her about it. This included check number 2348, 2349, 2350, 2351, and 2356 totaling an additional $4650) · The VA’s new monthly rate from March through September 2021 was $2229 per month and October 2021 was $2800. (Note: During this timeframe, the VA would have been repaid $7529, still short the $4650. In addition, the VA moved out of the facility in July/August 2021, prior to the completion of the payment plan.) SP2 provided the following information: · The VA lived at the facility for approximately three years. When the VA moved to the facility, the VA was unable to pay his/her room and board fees due to the VA also paying for his/her trailer. Because of this, SP1 and SP2 ”took the bare minimum” from the VA and “waived” the room and board fee for two years until the VA sold his/her trailer. The VA only paid for “services.” SP1 and SP2 did not require that the VA pay them back. · At times, the VA had a “fiduciary” who would send SP1 and SP2 a check for services. When the VA did not have a “fiduciary,” the VA wrote the check or a staff person from the in-home company wrote the check and the VA signed the check. SP2 denied writing any checks from the VA’s account. SP2 “did not think” that SP1 wrote a check and s/he never saw SP1 do so. · SP2 did not recall the year but said that in the “winter,” the VA did not have a fiduciary and the VA was “behind” with payments to SP1 and SP2. Additionally, around this time, the VA “almost ran out of money.” This was partly due to the VA paying for his/her trailer (prior to it selling) and the VA’s history of “wildly” spending money on things, including a vacuum, metal detector, and drums. Because of this, the VA wrote smaller checks to SP1 and SP2 when the VA had money and SP2 said that this occurred multiple times a month. SP2 said that if the VA did not do this, SP1 and SP would not get paid.
· SP2 also said that around December 2021, SP1 and SP2 were having “financial struggles and trying to keep [their] house.” [Note: SP1 denied this and said that while SP1 and SP2 did not have a lot in “savings,” SP1 and SP2 had enough to take their “first” vacation and said that SP1 paid for the vacation in full in December 2021.] SP2 denied taking the VA’s money for his/her personal use. SP2 said that if s/he wanted to take the VA’s money, s/he would have done it a “different” way. · When this investigator asked SP2 why there were so many checks written from the VA to SP2 in January and February 2021, that was in addition to the VA’s monthly payments, SP2 said to talk to SP1 as it was SP1’s “scope.” However, SP2 said that s/he signed those checks. · SP2 said that at some point, s/he and the VA “pulled money” from the VA’s bank account and moved it to another account. This was because the VA had concerns that his/her family member, who was also on the account, was” taking” the VA’s money. However, the VA could not close the account because the VA’s family member’s name was also on it and that person needed to sign it to close it. SP1 provided the following information: · The VA moved to the facility in 2018. For the first two years the VA lived at the facility, the VA also owned a trailer. The VA was unable to pay both the room and board fee and the fees “associated” with the trailer and also have “money left over” for things the VA “wanted to do.” Because of this, SP1 and SP2 “waived” the VA’s room and board fee for two years. · The VA had a “rep[resentative] payee” when s/he first moved to the facility. However, around January 2019, the VA “let [him/her] go” because the payee was not “paying on time” and charging the VA “late fees.” Around January 2019, the VA had a new “rep[resentative] payee.” This person also did not pay things for the VA on time and was “charging [the VA] crazy rates,” approximately $100, “every time” SP1, SP2, or the VA called to “ask a question.” Partly due to these fees, the VA was “running out of money” to pay for things which made “no sense” because the VA “had a lot of money.” [Note: CP2 said that s/he was not aware of this.] Due to these concerns, at some point between September and November 2020, the VA “stopped working” with this “rep[resentative] payee.” · In November 2020, the VA was “out of money” so SP1 and SP2 “reduced” their rate to ensure the VA would not “overdraw” his/her account. This included the VA not paying SP1 and SP2 “for a while” and the VA paying SP1 and SP2 in “smaller increments” that SP1 and SP2 “knew [the VA] could afford.” · After the VA no longer had a representative payee, staff persons from the in-home company, including CP1, assisted the VA with writing checks. In October or November 2020, the staff persons from the in-home company began writing checks for the VA to SP2 “ahead of time” and in smaller increments so that the VA did not “overdraw” his/her account. These amounts would add up to the VA’s monthly “room and board rate.” The pre-written checks were kept “in a drawer” where SP1 kept other checks that s/he needed to deposit. The staff persons from the in-home company would check the VA’s bank account and let SP1 know when the VA had money (from the DVA or from social security) so that SP1 could cash the checks. These pre-written checks were not dated and SP1 wrote in the date when s/he was ready to deposit them. · In January 2021, the VA sold his/her trailer so the VA was able to get “caught up” on his/her payments to SP1 and SP2. The VA told SP1 to “cash the checks for rent” and SP1 did. After the VA’s trailer sold, SP1 thought that any extra pre-written checks were “destroyed.” However, at some point, SP1 saw checks written out to SP2 in the drawer and thought that s/he had “forgotten to deposit them.” SP1 “did not remember” who signed them but SP1 deposited these checks. SP1 initially said this occurred on one or two occasions. However, this investigator told SP1 that there were multiple dates that the checks were deposited on the VA’s bank statement. SP1 said that s/he was also cashing checks for other clients so did it on multiple dates and s/he “did not know where [his/her] brain was.” · In February 2021, CP1 notified SP1 that the VA’s bank statement was off. SP1 looked into it and realized that s/he deposited checks that “should not have been deposited.” This included that SP1 deposited checks for $650 “on accident” three times. However, one of the checks was “correct” and supposed to be deposited. During this time, SP1 was “not paying attention” and was “incredibly stressed” because s/he and SP2 were getting ready to leave for their “first vacation.” SP1 said it was “pure stupidity” and that s/he should have “kept better track” of the VA’s payments and been more “organized.” · When this investigator and the LEO told SP1 that there was a difference of $4650 between what was on the Refund Plan compared to additional withdrawals that were on the VA’s bank statements for January and February 2021, SP1 said that s/he was not aware of this money when s/he created the refund plan. However, SP1 said that this money also should have been included on the refund plan and refunded to the VA. · SP1 denied taking the VA’s funds for his/her or SP2’s personal use. SP1 also said that SP2 was the “most honest person you will meet in your life.” At times, the VA asked SP1 and SP2 to “hold onto” his/her checkbook, which SP1 and SP2 kept in a locked file cabinet. However, SP1 denied writing out any of the VA’s checks. SP1 “did not remember” if SP2 helped the VA write checks. Law enforcement also investigated this report but closed out their case without charges. Conclusion for Allegation One: A. Maltreatment: The VA’s plans said that the VA required “total assistance” with his/her finances and that his/her finances were to be “totally managed” by the VA and a “financial worker.” SP1, SP2, the POA, CP2, and CP1 each said that around January 2021, the VA did not have a “financial worker” helping him/her, including to write checks for monthly payments to SP1 and SP2. Because of this, staff persons, including CP1, from an in-home company assisted the VA with doing this. Additionally, around this time, the VA did not have enough funds to pay SP1 and SP2 the full monthly payment so the in-home staff wrote checks in smaller amounts, which SP2 signed, and then SP1 or SP2 then cashed when the VA had money. CP1 stated that at some point (after the VA sold his/her trailer), CP1 had concerns because the VA’s money was not “adding up.” In addition, there were checks written to SP1 and SP2 that CP1 did not write and a “whole book of checks” was missing because there was a “huge gap” in the check numbers CP1 wrote compared to the checks on the VA’s bank statements that CP1 did not write. The POA, CP2, SP1, and the Refund Plan each said that at some point, the checks were “double written” to SP2 and “deposited.” The VA’s bank statements showed that between January and February 2021, there were 14 checks written to SP2 and cashed by SP1 totaling $19,207. Ten checks totaled $12,179, did not have an invoice or anything written in the memo line, and were in excess of the monthly amount the VA owed SP1 and SP2. Information was consistent that once SP1, SP2, the POA, and CP2 became aware of these payments, there was a “repayment” plan made for SP1 and SP2 to pay the VA back $7529. However, this investigator and law enforcement discovered $4650 that was not accounted for and was not on the repayment plan. SP1 said that this should have been included on the repayment plan but that s/he was not aware of it because s/he did not have access to the VA’s bank statements. In addition, the VA moved out of the facility prior to the completion of the repayment plan. The VA said that at some point, SP1 and SP2 took money out of the VA’s account to pay for a vacation to Florida. When this investigator asked the VA why s/he thought this, the VA said that around the time of the vacation, the VA signed checks, which SP1 and SP2 said were for “rent.” However, the checks were “more” than the VA’s usual rent. The VA normally paid $2000 for rent but the checks were for $3000 or $4000 (Note: This investigator did not see any checks for $4000). The POA and CP2 said that SP1 and SP2 were “very disorganized” and it “would not surprise [the POA] if [SP1 and SP2] had billed [the VA] many times for the same thing.” The POA also had concerns that the VA had a bank account that was shut down shortly after the sale of the VA’s trailer home and then the VA’s current account was opened. SP2 told the POA that this was done because the old account was a “mess” and they wanted to “start fresh.” The POA said that there would have been checks written to SP1 and SP2 out of that old account also, but the POA could not “access that account because it has been closed.” SP2 said that the account was not closed but that money was moved from that account to a different account because the VA had concerns that his/her family member, who was also on the account, was” taking” the VA’s money. However, the VA could not close the account because the VA’s family member’s name was also on it and that person needed to sign it to close it. Given these things and that there was no documentation from this account, it was not known if any funds were taken from this account without the VA’s approval. Although the VA was his/her own guardian and at times handled his/her own financial matters, information was consistent from the VA’s plans, the POA, and CP2 that the VA did not have the “capacity to understand what [s/he] was paying for or why.” CP2 said that the VA did “not have the skill set” to write checks on his/her own. SP1 and SP2 denied taking the VA’s money for their own personal use and SP1 said that cashing the multiple checks was an “accident.” However, given that the VA said s/he did not authorize anyone to take money from his/her account; that the Resident and Caregiver Agreement, the Resident Contract, and the Individual Resident Placement Agreement stated that SP1 and SP2 were not to be entrusted with cash resources in excess of $300 plus “resources sufficient to meet one month’s cost of care;” and that SP1 cashed 10 checks (that did not have anything in the memo line and which SP2 said s/he signed), on ten dates between January 11 and February 16, 2021, totaling $12,179; there was a preponderance of the evidence that in the absence of legal authority SP1 and SP2 willfully used the VA’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 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1 and SP2 were trained on the Reporting of Maltreatment of Vulnerable Adults Acts prior to the incident. Given SP1’s and SP2’s role, each had significant administrative authority over the operation of the facility and ensuring that the facility maintain compliance with Minnesota Rules and Statutes. There were ten checks written out to SP2 that SP2 signed and SP1 deposited, on ten dates in a one month period of time. The ten checks were in addition to the VA’s monthly room and board and services, which the VA said that s/he did not “authorize.” Therefore, SP1 and SP2 were responsible for the financial exploitation of the VA. When substantiated maltreatment is determined to have been committed by an individual who is also the facility license holder, both the individual and the facility must be determined responsible for the maltreatment, and both the background study disqualification standards under section 245C.15, subdivision 4, and the licensing actions under sections 245A.06 or 245A.07 apply. Therefore, the facility was also responsible for the financial exploitation of the VA. 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. In addition, the Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 financial exploitation for which SP1, SP2, and the facility were responsible did not meet the definition of serious. However, SP1 and SP2 were responsible was recurring maltreatment because there were ten checks cashed on ten dates. SP1 and SP2 were disqualified from providing direct contact services. Allegation two: It was reported that SP1 and SP2 withdrew $800 from the VA’s bank account, despite being told by the VA’s team not to handle the VA’s finances. Initially there were concerns that the VA did not receive the $800 but the money was later was found in the VA’s bedroom. The POA and the VA’s bank statement for July 2021 provided the following information: · On July 20, 2021, the POA reviewed the VA’s bank statements and saw that on July 17, 2021, the VA’s debit card was used to withdraw $800 (total) from two ATM machines. The POA then called SP2 and the VA to ask if they knew anything about the funds being withdrawn. The VA and SP2 “both denied knowledge.” · The VA, the POA, and SP2 then called the VA’s bank to cancel the debit card and report “fraud” on the account. The POA asked the bank to provide photos of who had made the withdrawals and the “exact times” and amounts withdrawn. The VA’s bank said that they would “work” on getting that information. · On July 22, 2021, the POA received a phone call from SP2. SP2 said that earlier that day, SP1 told SP2 that on July 17, 2021, the VA had given SP1 his/her debit card and “requested” that SP1 withdraw $1000 in cash for the VA’s “personal use.” However, SP1 was only able to withdraw $800. SP2 “denied” that s/he knew about the withdrawal until s/he spoke to SP1 on the morning of July 22, 2021. SP2 “acknowledged” to the POA that SP1 “should not have done that” but was in a “hurry” and wanted to “comply” with the VA’s “demands for cash.” SP2 told the POA that SP1 had “only done what was requested” by the VA. · The POA said that it seemed “very odd” that SP1 would “withdraw such a large amount of cash” on the VA’s behalf, because there had been an “effort to reduce [the VA’s] spending and reduce the cash [that the VA] had on hand for many months.” Prior, SP1 and SP2 had “consistently refused” the VA’s “efforts to get cash and had limited withdrawals to small amounts.” The $800 withdrawal was “inconsistent” with “normal activity” on the VA’s account and the VA “did not regularly withdraw large sums of funds from [his/her] checking account.” · On July 30, 2021, SP2 called the POA to “search for the funds” in the VA’s bedroom so that the POA could be a “witness” to verify the whereabouts of the $800. While on the phone, SP2 asked the VA how much money the VA had in his/her possession. The POA heard the VA ask SP2, “What is this about?” SP2 then stated to the POA that s/he searched the VA’s desk drawer and “found” an envelope which contained the $800. The VA asked SP2, “Where did that come from?” and “How did that get there?” The POA could tell that the VA was “shocked” that the cash was in his/her drawer and the POA “did not believe” that the VA knew about the money in his/her drawer.
· SP2 then told the POA that the VA had been “lying to everyone about the missing funds and that the [$800] had been in [the VA’s] possession all along.” However, the POA said that the VA seemed “confused about what was happening.” The VA seemed “truly unaware” of the $800 withdrawal from his/her account. · The POA had concerns that s/he been “complaining [to SP1 and SP2] about the funds being missing” since July 20, 2021. It did not seem “feasible” that the $800 “suddenly appeared” on July 30, 2021, and the POA thought that SP1 and SP2 got “funds” from another source and then “replaced” the money. The POA had concerns that SP1 and SP2 “did not immediately” look for the funds to ensure they were “secure” when the POA initially told them the money was “missing.” Instead, SP1 and SP2 “waited another 10 days or so to discover that the money was in [the VA’s] desk.” · The POA had “no way of knowing” if the $800 had been in the VA’s drawer all along or if SP1 and SP2 had taken the funds for their personal use but returned the funds once the POA had “reported” the withdrawal as a “theft” to the VA’s bank. Additionally, the POA had been at the facility on July 19, 2021, for an unrelated matter and prior to knowing about the withdrawal. At that time, the POA looked in the VA’s desk drawer where the VA normally kept his/her paperwork and money. The POA did not see an envelope with cash at that time and did not find a bank statement from the bank for the withdrawal, which should have been in the drawer. Additionally, on this date, the VA told the POA that s/he was “upset” that s/he could not have more cash and said that SP1 and SP2 would not “allow” him/her to withdraw funds from his/her bank account. The VA told the POA that the only money s/he had in a “long time” was $50 cash plus additional cash s/he received from the DVA for “reimbursement of travel expenses.” · Prior to July 17, 2021, SP1 and SP2 had “overcharged” the VA for services. (See allegation one) Because of this, the POA and CP2 told SP1 and SP2 that going forward, they were not to handle cash or checks for the VA and that “doing so would not be tolerated.” SP1’s use of the VA’s debit card to get $800 cash out of the VA’s account on July 17, 2021, was in “violation of this agreement.” The VA provided the following information: · The VA said that SP1 and SP2 “did not really give [him/her] cash.” The VA was “supposed” to get an allowance of $100 per month but the VA did not get that money. When this investigator asked the VA how s/he got things s/he needed, the VA said that SP1 and SP2 “did not really take me out if I asked them to.” · The VA stored cash in a locked box in his/her bedroom and the VA had the key. The VA had a debit card which the VA kept on his/her person. However, on an unknown date, SP1 and SP2 told the VA that they needed the VA’s debit card to get cash for the VA. The VA “did not know why” SP1 and SP2 needed his/her debit card and the VA did not ask SP1 or SP2 to withdraw money for him/her. Additionally, SP1 and SP2 did not give the VA cash when SP1 and SP2 returned the debit card to the VA. · At some point, $800 “showed up” in the VA’s desk drawer. The VA did not “authorize” SP1 or SP2 to withdraw $800 from his/her account. The VA denied asking SP1 and SP2 to withdraw money for the VA, including to go to the state fair. CP2 provided the following information: · CP2 said that on “many” occasions prior to July 17, 2021, CP2 told SP1 and SP2 to stay “far away” from the VA’s finances. This was because the VA’s finances were “complicated” and it was a “boundary” that the DVA set for the “safety of everyone.” Additionally, there were prior concerns with how SP1 and SP2 handled the VA’s finances. (See allegation one) · Around July 17, 2021, the POA told CP2 that there was $800 withdrawn from the VA’s account. The POA told CP2 that s/he spoke to SP2 who had “no idea” about the withdrawal. · CP2 then spoke to SP1 who said that s/he withdrew the money for the VA and was “really sorry.” SP1 told CP2 that the VA “really wanted” to go to the state fair and that s/he needed money. When this investigator asked CP2 if the VA would have needed or wanted $800 for the state fair, CP2 said that it was “very possible” as the VA liked to “buy stuff.” The VA was “very complicated” and it would “not surprise” CP2 if the VA asked for $1000 to go to the fair as the VA had a history of buying or wanting to buy “really expensive” things. The VA had a history of purchasing larger items such as a “Shark vacuum cleaner on QVC,” purchasing “remote control car [parts]” off the internet, a big screen TV, and things from the Home Shopping Channel on TV. SP1 “agreed” to get the money but could not get it all from one ATM so SP1 went to “multiple” ATM’s. SP1 said that SP2 had not been aware that s/he had done this. · At some point, the $800 was located in the VA’s bedroom. · The VA’s reporting of events in general was not “consistent” so it was “difficult to track facts.” Additionally, the VA was “not a good historian” or a “reliable” reporter and had some “cognitive issues.” · After the incident on July 17, 2021, CP2 told SP1 and SP2 that they “may have meant well” but SP1 should have told the VA that s/he was “sorry” but that s/he could not help the VA with withdrawing money. SP1 then should have notified the POA or CP2, who were helping the VA with “money management.” SP1 should not have withdrawn money for the VA. · CP2 did not know if SP1 and SP2 were “innocently” helping the VA or if they took the money for their own use. SP1 and SP2 may have been “well intended people who made bad decisions.” CP2 did not know if SP1 made a “really stupid call” when s/he decided to withdraw money for the VA or if there was a “greater trend.” CP2 had another former client who lived at the facility and there were no financial concerns with that client. SP2 provided the following information: · At some point, the POA and CP2 told SP1 and SP2 that they should not withdraw money for the VA because of the VA’s “mental stability.” This included that the VA “wildly” bought new things, including a vacuum, metal detector, and drums. The VA also spent “umpteen” amounts of money on junk food, which the VA was not supposed to have because the VA was diabetic. However, the VA handled his/her own money and was his/her own guardian, so the VA could “do what [s/he] wants.” Additionally, the VA “had the ability to [access his/her] own money.” Therefore, the VA could ask SP1 or SP2 to withdraw money from his/her account. · When the VA asked SP1 and SP2 for money, SP1 and SP2 “advised” the VA not to withdraw money. SP2 also worked with the VA to help the VA understand money using Monopoly game money. When the VA asked SP1 and SP2 for money, SP1 and SP2 told the VA, “No,” “multiple times” but SP1 and SP2 also “felt bad” and sometimes “honored” the VA’s request to withdraw money. The VA also did not have any family members to help him/her when the VA needed money or other things. SP2 and SP1 were “stuck between a rock and a hard place.” · At some point, the VA asked SP1 to withdraw $800 from his/her bank account and SP1 did so. However, SP2 was not aware that SP1 withdrew the money until after s/he did so. SP2 did not know what the VA wanted the money for but said that the VA had talked about getting new clothes around this time. · The VA “typically” asked for larger amounts of cash. Additionally, SP1 and SP2 did not get to the bank as often as the VA liked and it was sometimes “easier” to get larger amounts of cash for the VA. · Although the POA had concerns that the VA did not receive the $800, SP2 said that the $800 was in the spot the VA always kept money, which was “behind a box” in the VA’s drawer. The $800 was “never” missing and the VA had it. SP2 denied that s/he or SP1 took the $800 for their personal use. · SP2 said that SP1 could have called the POA or CP2 to see if it was okay to withdraw the money. However, if SP1 would have told the VA, “No,” the VA would have continued asking for money. SP1 provided the following information: · In approximately June or July 2021, SP1 was getting ready to leave the facility when the VA asked SP1 if SP1 could “grab” cash for the VA. SP1 had done this before because the VA had no family members to help him/her. SP1 asked the VA how much money s/he wanted. The VA said that s/he had not had cash “for a while” and that s/he wanted $1000 that s/he could use for the “whole summer,” including for fireworks, festivals, and a fishing trip. The VA was “in charge” of his/her own finances, including how much s/he spent, so SP1 said that s/he would get the VA money while s/he was out. · SP1 then drove to an ATM machine but the ATM only “allowed” SP1 to withdraw $300. SP1 then went to another ATM and withdrew $500. SP1 did not want to “run around” all day so SP1 got the VA $800 total, instead of the $1000 the VA requested. · When SP1 returned to the facility, SP1 put the $800 in an envelope with the VA’s name written on it and then showed the VA the envelope. SP1 then put the envelope on the VA’s desk in the VA’s bedroom, which is where SP1 typically put the VA’s money. · Approximately one or two weeks later, SP2 told SP1 that the VA was missing money but it “did not occur” to SP1 that it was the $800 SP1 withdrew. Later, SP2 told SP1 the amount that was missing and SP1 realized it was the $800 SP1 withdrew for the VA. SP1 then found the money which the VA had “tossed” in his/her drawer and SP1 showed SP2. SP2 then called the POA and CP2 and said that the money was located. At some point after, CP2 called and told SP1 that the VA told CP2 that s/he did not have the money so SP1 took a photo of the money and sent it to the POA. · The VA had a representative payee but the VA was “ultimately in charge of [his/her] of finances.” · The VA usually withdrew small amounts of cash such as a “couple hundred” dollars at a time.” However, the VA may also request large amounts of cash and at times, the VA had around $1200 in his/her bedroom. · SP1 was told by the VA’s team multiple times not to handle the VA’s money but there was “literally no one else to do it.” Additionally, the POA lived in another city one hour away so it was difficult for the POA to get the VA money. SP1 and SP2 “tried to keep their distance” regarding handling the VA’s finances but the VA would not leave SP1 or SP2 “alone” until SP1 and SP2 got the VA money. SP1 and SP2 were “between a rock and a hard place” when the VA was “begging” SP1 and SP2 to withdraw money. SP1 did not recall why the VA’s team told SP1 and SP2 not to handle the VA’s money but SP1 thought it was due to a “banking error” SP1 made and other “issues.” Additionally, because the VA was a veteran, SP1 and SP2 were not supposed to help the VA with his/her finances but the VA did not have anyone else to assist him. · SP1 denied that s/he or SP2 took the VA’s money for their own use and said that would not be appropriate to do and the incident was a “stupid mistake.” · The VA had a history of providing inaccurate information. The VA did not want to live at the facility and the VA “knew this would move the process along” if the VA “told people that [SP1 and SP2] took money from [the VA].” Conclusion allegation two: Information was consistent from the POA, CP2, SP1, and SP2 that SP1 and SP2 were not supposed to handle the VA’s finances, including withdrawing money. However, SP1 and SP2 said this was difficult as the VA often asked for money and was his/her own guardian. On July 20, 2021, the POA reviewed the VA’s bank statements and s/he saw that the VA’s debit card was used to withdraw $800. SP2 initially denied knowledge of this but later said that SP1 told him/her that SP1 withdrew the money. SP1 said that s/he withdrew the money for the VA per the VA’s request and then gave the VA the money. The VA told the POA and this investigator that s/he was not aware of this withdrawal and did not ask SP1 or SP2 to make the withdrawal. The POA said that s/he was at the facility on July 19, 2021, but did not see the $800 and did not see documentation from the VA’s bank for the withdrawal. However, on July 30, 2021, SP2 found the $800 in the VA’s drawer. Although there were concerns that SP1 and SP2 took the VA’s money for their personal use, given that the $800 was found in the VA’s bedroom and that SP1 and SP2 each denied using the VA’s money for their personal use, there was not a preponderance of evidence whether SP1 or SP2 took the funds for their own personal use. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were not adequate because the facility had a “pretty open policy” to help the clients as they “requested.” Following the incident, the facility no longer assisted the clients to get cash or items unless the client’s family or representatives took them or bought what they requested. The facility also determined that policies and procedures were followed because the facility policies and procedures said that if a client was able to make their own financial decisions, then staff persons could assist with what they requested. The VA was able to make “requests” and manage his/her personal funds so SP1 and SP2 did what was requested by the VA when s/he asked SP1 to withdraw money. The event was similar to prior events as the VA had requested “many times” that SP1 or SP2 pick up cash or items but there had not been any prior issues with this. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were 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 SP1 and SP2 were responsible for maltreatment and the disqualification of SP1 and SP2 are each subject to appeal. Additionally, based on determinations of substantiated maltreatment and the disqualification of controlling individuals, the facility’s license was revoked. The maltreatment determination, SP1’s and SP2’s disqualification, and the revocation are each subject to appeal.
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