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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: 1109436-HCBS (Home and Community-Based Services) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) gave a staff person (SP) $4,000 cash to order furniture for him/her; $500 cash to order a new computer; $350 cash to order a virtual reality headset; and $1,000 cash for safe keeping. These orders were not fulfilled and most of the money was not returned to the VA. It was reported that the VA discovered $7,000 cash missing from his/her home safe, of which, s/he and the SP were the sole ones with access. Date of Incident(s): Unknown dates between October 2022 and January 2023
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 an interview conducted with a facility supervisory staff person (P). This investigator also contacted the VA, who already provided a statement to a law enforcement officer (LEO); the VA did not have anything to add to his/her statement. Attempts by telephone and mail to contact the SP were unanswered by the completion of this investigation. The VA’s support plan and support plan addendum provided the following information: · The VA lived in his/her own home and contracted in-home supports and services through the facility. The facility employed staff persons who assisted the VA during certain hours of the day with preparing meals, creating daily routines, keeping his/her home accessible, and transporting for errands. · The VA was susceptible to financial exploitation by others. The VA “didn’t trust banks,” and so, instead, kept “large amounts of cash” in a home safe. Staff persons were instructed to have the VA present with them anytime they accessed the safe. · The VA’s diagnoses included Parkinson’s disease. A Rochester Police Department Incident Report provided the following information: · In April 2022, the SP was employed by the facility to provide in-home supports and services to the VA. · The VA developed a “trusting relationship” with the SP and allowed the SP to access the VA’s home safe without the VA present. Each time, after the SP had left for the day, the VA checked the safe and ensured no cash was missing. Initially, the VA did not have any concerns with the SP’s conduct and had never discovered any cash missing from the safe. · The VA and the SP were the sole people with access to the safe. · Around the end of October 2022, the VA noticed that s/he was spending his/her cash “too fast.” The VA asked the SP to hold $2,000 of the VA’s cash, so that the VA would not spend it. The SP agreed and said that the VA could have it back anytime s/he wanted. A short time later, the VA asked for $1,000 cash back, and the SP gave this amount to him/her without incident. (This left $1,000 with the SP for safekeeping.) · On an unknown date, the VA gave the SP $500 cash to buy the VA a computer. The SP told the VA that s/he attempted to purchase a computer but the sale “fell though.” The VA told the SP to hang onto the cash and look to buy the VA a different computer. · On an unknown date, the VA gave the SP $350 cash to buy the VA a virtual reality headset. The SP told the VA that s/he ordered the headset using the VA’s money. However, the headset never arrived, and the SP told the VA that s/he was “checking into it.” The VA told the SP to cancel the order and to, instead, combine the $350 cash with the $500 cash for an even better computer. · On an unknown date, the VA asked the SP to help purchase furniture for the VA’s house. The VA gave the SP $4,000 cash for this purpose. The SP told the VA that s/he ordered furniture using the VA’s money, and that the furniture was “on its way.” The furniture never arrived, and the $4,000 cash was never returned to the VA. · On an unknown date, the VA asked the SP to put an undisclosed amount of cash back into his/her safe. The SP agreed and accessed the safe without the VA present. After the SP’s shift ended, the VA went to the safe and counted the money to ensure it was all there. The VA discovered $7,000 cash missing. · The VA asked the SP about the $7,000 cash. The SP suggested that the VA miscounted the cash in the safe, or previously spent that amount of cash and forgot to record it. The VA did not believe these scenarios to be true but decided to “let it go” and not pursue the missing cash any further. The $7,000 cash was never returned to the VA. · On an unknown date, the VA asked the SP to return $1850 cash; this included $500 cash to order a new computer; $350 cash to order a virtual reality headset; and $1,000 cash for safe keeping. The VA asked the SP about this cash return more than once; each time, the SP did not return the cash and “had an excuse” as to why. · On January 9, 2023, the VA took a shower and mistakenly left his/her cash bag on the couch with the SP. When the VA exited the shower, the SP was gone and $100 was missing for the VA’s cash bag. · On January 10, 2023, the SP’s employment at the facility ended. · On/or around January 17, 2023, the SP’s significant other (SO) came to the VA’s house. The SO had $1,800 cash to give to the VA on behalf of the SP. However, the SO wanted the VA to sign a document, which indicated that this exchange of money was due to a “conflict of interest” or home repair work that the SO was hired to complete but did not. The VA told the SO that the document was not accurate. The SO declined to give the cash to the VA unless s/he signed the document, and so, the VA signed the document. The SO gave the VA the $1,800 cash and then left with the document. · The VA said that the SP has $11,150 cash of the VA’s money. · The LEO attempted to contact the SP about the allegations; the SP did not respond to the LEO. · The LEO’s case was referred to a county attorney for review of criminal charges. The P provided the following information: · The VA handled his/her own finances. The facility did not provide the VA with money management services, and the facility did not train staff, who worked with the VA, on handling funds or money management. However, the VA might ask staff to help with shopping or swiping his/her credit card; and this was acceptable for staff to do, but the VA needed to be present, and all transactions needed to go through the VA. · The VA did not trust banks and kept most of his/her cash in a home safe. Staff were instructed to never access the safe without the VA present. The VA was in control of his/her own money, and staff should not be borrowing or using the VA’s money for personal use. · As part of the facility’s internal review for this incident, the P asked the SP about the allegations. The SP reiterated that s/he placed the orders, but the items were never delivered. Regarding the purchase of the VA’s furniture, the SP provided the P with an emailed receipt as evidence that the furniture was ordered. However, the email was a “gmail” account, not a company account as the P would have expected. When the P tried to respond to the gmail account, s/he discovered there was no actual account for this email address. The P next contacted the furniture company and discovered the receipt was not valid as the company was unable to locate a furniture order associated with the receipt. Facility documentation stated that the SP received training on the VA’s support plan and support plan addendum. However, the facility did not have documentation that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act. However, the facility was confident that the SP received this training as part of an online module, which all new employees were required to complete. The failure to maintain training documentation was in violation of Minnesota Statutes section 245D.09, subdivision 5, paragraph (a), clause (2), which states that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Conclusion: A. Maltreatment: The VA provided information that s/he gave $5,850 cash to the SP for various purchases and/or safe keeping. The SO returned $1,800 cash to the VA on behalf of the SP. The remaining $4,050 was not returned and the VA never received merchandise for the intended purchases. When the facility asked the SP about a $4,000 purchase of furniture, the SP provided a receipt for the purchase. However, upon contacting the furniture company, the receipt was not valid as the company was unable to locate a furniture order associated with the receipt. The VA also provided information that s/he discovered $7,000 cash missing from the VA’s safe after the SP had accessed the safe upon the VA’s request, but without the VA present. The VA and the SP were the sole people with access to the safe. The $7,000 cash was never returned to the VA. Given that the SP did not respond to this investigator and provided an invalid receipt to the facility, and that there was no information provided to discredit the VA’s account,, the VA was considered more credible. Therefore, there was a preponderance of the evidence that the SP used the VA’s money without the legal authority to do so. 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. The SP was employed by the facility as an in-home caregiver for the VA. The SP received training on the VA’s support plan and support plan addendum; and it is a community standard that a person should not take another person’s money without the person’s permission. The SP was responsible for maltreatment 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. 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. The SP was responsible for more than one instance of using or withholding the VA’s cash. 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 by the SP. The facility provided additional training to all staff persons. The SP was no longer employed, and the facility was “encouraging safer alternatives for [the VA’s] money.” 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 April 12, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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