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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: 1067651-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Huettl Anderson 651-431-6553 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA1) borrowed a “bunch” of quarters to a staff person (SP) who did not repay VA1, that the SP took left over pizza from another vulnerable adult (VA2), and that the SP took used pillows from a third vulnerable adult (VA3). Date of Incident(s): unknown prior to March 3, 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 through seven interviews conducted with VA1, VA1’s case manager, VA3’s guardian, and facility staff persons. Attempts to were made to contact and interview the SP via telephone and US mail, but the SP did not respond to the requests. Attempts to contact VA2’s guardian (G1) were made via telephone. A voicemail message was left for G1 notifying him/her of the investigation but this investigator and G1 did not connect to discuss the incident. VA2 and VA3 were not interviewed by this investigator due to limited communication and recollection of the incident. VA1’s Coordinated Services and Supports Plan stated that VA1 enjoyed participating in community outings, spending time with family and friends, and shopping. VA1’s Personal Data Sheet stated that VA1 was diagnosed with mild intellectual disability and that VA1 was not subject to guardianship. VA1’s Individual Abuse Prevention Plan stated that VA1’s family members assisted VA1 with all financial matters. VA1 had a safe in his/her bedroom where s/he stored his/her debit card, extra money, electronics, and other valuables. Staff persons did not have access to VA1’s safe. VA1’s Funds and Property Authorization dated December 17, 2021, stated that the facility did not assist VA1 with safekeeping of his/her money. VA2’s Coordinated Services and Supports Plan stated that VA2 enjoyed watching sporting events, traveling, talking on the telephone, and going out to eat. VA2’s Personal Data Sheet stated that VA2 was diagnosed with mild developmental disability and a seizure disorder. VA2’s Individual Abuse Prevention Plan stated that VA2 was unable to handle his/her own financial matters. Staff persons were to verbally and physically assist VA2 with “all” financial transactions and to keep an accurate record of all financial transactions. VA2’s Funds and Property Authorization stated that the facility was responsible for assisting VA2 with safekeeping of his/her cash, checking account, savings account, paychecks, and property. Staff persons were restricted from borrowing money from VA2, purchasing personal items from VA2, and using VA2’s funds to purchase items for which the program received payments for. VA3’s Support Plan Addendum (SPA) – Intensive Supports Services stated that VA3 enjoyed coloring, playing video games, and swinging. VA3’s Personal Data Sheet stated that VA3 was diagnosed with moderate intellectual disability. VA3’s Individual Abuse Prevention Plan stated that VA3 was not able to handle his/her own financial matters and that staff persons assisted VA3 with making “all” of his/her purchases. Staff persons were to accompany VA3 in the community and carry VA3’s money. VA3’s financials were documented according to the facility’s policies and procedures. The facility’s General Event Reports stated that on March 1, 2023, VA1 told a facility staff person (P1) that “a while ago” the SP borrowed a “bunch” of quarters from VA1 and never repaid VA1. VA1 did not know when the SP borrowed the quarters and did not know the total amount of money the SP borrowed. VA1 estimated that the total was between $30 and $35. A second General Event Reports stated that on March 2, 2023, the SP believed that sometime in August 2022, s/he took home leftover pizza that was purchased by VA2 for VA2’s birthday party. A third General Event Reports stated that on March 2, 2023, P1 stated that on an unknown date, the SP took VA3 to purchase new bed pillows and that the SP took VA3’s old pillows home for the SP’s puppy. VA1 told this investigator that sometime “last” summer, the SP asked VA1 if s/he could borrow quarters so the SP could do his/her laundry. VA1 opened his/her safe and thought that the SP wanted four or five quarters, but that the SP took all of VA1’s quarters and never repaid VA1. VA1 did not know how many quarters the SP took, but guessed that there was approximately $30 to $35 in quarters. VA1 was upset that the SP never repaid him/her. VA1’s case manager (CM) stated that s/he was made aware of the incident, but did not have concerns regarding VA1’s care at the facility. VA3’s guardian (G2) stated that s/he was made aware of the incident, but told that the incident occurred approximately four or five years prior. G2 was not aware of a time when VA3 purchased new pillows for him/herself or giving old pillows to the SP. G2 did not have any concerns regarding VA3’s care. Facility documentation and interviews with P1, a facility staff person (P2), and two facility management persons (P3 and P4) provided the following information: · On March 1, 2023, VA1 told P1 that VA1 did not trust the staff persons and did not want anyone entering his/her bedroom. P1 asked VA1 why s/he did not trust the staff persons and VA1 stated that sometime last summer the SP took a “bunch” of quarters from VA1 and never repaid VA1. VA1 told P1 that the SP needed quarters for laundry and asked VA1 if s/he could borrow some quarters. VA1 remembered opening his/her safe to get the quarters for the SP and the SP taking “all” of VA1’s quarters. VA1 did not know the total of quarters that the SP took, but stated that the SP never gave VA1 paper money (cash) to pay for the quarters. · After P1 talked to VA1 about his/her missing quarters, P1 remembered a time in August 2022 when VA2 had a birthday party and the SP ordered pizza from Dominos for VA2. P1 stated that s/he thought the SP ordered too many pizzas but did not say anything at that time. When the party was over, there was “a lot” of left over pizza. However, when P1 arrived at work the following day there was no pizza in the facility. At that time, VA1 and VA3 told P1 that VA2 let the SP take the pizza home to his/her family. P2 stated that s/he was at VA2’s birthday party and noticed that there were two extra pizzas that were ordered but not served to the guests. · P1 did not know the details and said that it “might” just be a “rumor,” but that many years ago the SP took VA3’s pillows home for the SP’s puppy. · P2 did not know anything about VA1’s missing quarters or VA3’s pillows, but had concerns regarding other things that went “missing” at the facility. P2 did not have details about the missing items, but whenever s/he noticed something missing s/he spoke to P3 and P4. · P3 and P4 each stated that they did not have concerns about the SP’s interactions with the individuals living at the facility, but that they were each “suspicious” of the SP because there had been a history of household food and household petty cash missing. The SP was responsible for purchasing the household food and keeping track of the household petty cash. P4 stated that there was never any proof as to who was taking the household food or the petty cash, but that the facility recently implemented a new tracking system to monitor it closer. · VA2’s financial documents included a receipt for Domino’s Pizza dated August 27, 2022, for seven pizzas totaling $100.39. P3 stated that s/he was not able to locate any evidence that VA3 purchased pillows within the last three years but P3 was told that the SP took VA3’s pillows for the SP’s puppy. P3 stated that the SP’s puppy was at least five years old at the time of the incident. · According to P3 and P4 the SP was trained on the facility’s financial policies which stated that staff persons were not to borrow money or take property from an individual living at the facility. When P3 spoke to the SP about VA1’s missing quarters, the SP acknowledged taking the quarters from VA1, but stated that s/he s/he “bought” the quarters from VA1 in exchange for cash. The SP told P3 that s/he bought between $30 and $35 worth of quarters, but could not remember the exact amount. The SP told P3 that s/he did not take any pizza from VA2 and denied taking VA3’s pillows. · The facility’s Policy on Management of Persons Receiving Services Funds stated that staff persons were prohibited from borrowing money or purchasing personal items from a person receiving services. Staff persons were required to know and follow the facility’s policies and procedures to protect the individual from financial exploitation. The facility’s personnel files showed that P1, P2, P3, P4, and the SP were each trained on the facility’s Policy of Management of Persons Receiving Services Funds and the Reporting of Maltreatment of Vulnerable Adults Act prior to the investigation. Conclusion: A. Maltreatment: VA1 stated that the SP borrowed $30 to $35 of quarters from VA1 and did not repay VA1. Additional information from P1 and P2 stated that the SP took left over pizza from VA2 and used pillows from VA3. VA2 had a receipt for expenditures from Domino’s pizza showing that s/he purchased seven pizzas and P1 and P2 each stated that there was left over pizza but were informed by VA1 and VA3 that VA2 told the SP that s/he could take the pizza home to his/her family. There was no information regarding VA3’s pillows, and given the time between when the incident likely occurred and the Department being made aware of the allegation, it was not able to be determined whether the SP took VA3’s pillows. There was no information provided to discredit VA1’s account of his/her incident, and there was a receipt showing that VA2 had ordered multiple pizzas that reasonably would be expected to result in left over pizza. Although the SP told P3 that s/he repaid VA1 with cash, VA1 stated that the SP never gave him/her cash or repaid VA1. In addition, the SP was the person responsible for ordering the pizza for VA2’s party and at that time P1 thought that it was too many pizzas, and VA1 and VA3 provided consistent information regarding the leftovers. Therefore, there was a preponderance of the evidence that the SP took VA1’s quarters and VA2’s property 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 trained on the facility’s Policy of Management of Persons Receiving Services Funds and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. 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” because the SP willfully borrowed and/or used property of VA1 and VA2 on different occasions. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility conducted an internal review and determined that their policies and procedures were adequate but not followed at the time of the incidents. 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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