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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: 1071729-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison Suspected Maltreatment Reported: It was reported that on June 4, 2021, a check was written out for $1000 cash from a vulnerable adult’s (VA’s) bank account. It was alleged that this cash was used to purchase two VISA gift cards totaling $746.90 (including activation fees). Of the $746.90 in gift cards, there were only two receipts totaling $467.56 to show purchases made for the VA. The cards were no longer in the VA’s possession and the balance of the cash was also not found. Date of Incident(s): Unknown date between August 4 and October 28, 2021; the Department of Human Services was notified on September 20, 2022. Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 9, paragraph (b), clause (1)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 was obtained during a site visit conducted on September 29, 2022; from documentation at the facility and law enforcement records; and through four interviews conducted with two supervisory staff persons (the SP and P1), one facility staff person (P2), and the VA’s guardian (G). The VA’s diagnosis was a moderate intellectual disability. The VA enjoyed coloring, playing games on his/her tablet, and listening to music. This investigator met the VA, but due to his/her diagnoses and the length of time that had passed, s/he was not able to provide pertinent information. The VA had a wallet with his/her cash and checkbook in a lockbox located inside a locked cabinet at the facility. The VA’s monthly bank statement showed a check was cashed for $1000 on June 4, 2021, and receipt from the financial institution dated June 4, 2021, showed “cash paid to customer” of $1000. Facility records showed that on June 4, 2021, there was an entry in the VA’s financial ledger for $1000 with the description “cash.” The ledger entry had the SP’s initials by it. Law Enforcement Records showed: · Two gift cards were purchased and activated on June 4, 2021, one for $490 plus a $5.95 activation fee and the second for $245 plus a $5.95 activation fee. · There were two purchases on August 3, 2021, at Walmart.com using the two gift cards for $210.63 and $256.93 (totaling $467.56). (Facility records showed two email receipts dated August 3, 2021, totaling $467.56 in the VA’s financial book from Walmart.com sent to the SP’s email address. The first receipt for $210.63 was for clothes (tank top, pants, and jeggings) and a lounge chair. The second receipt for $256.93 was for sneakers and a television.) A law enforcement officer and this investigator saw the chair, television, and sneakers at the facility on September 29, 2022. · After that there was not another purchase made with the gift cards until October 28, 2021. Between October 28-November 27, 2021, there were the below transactions totaling $211.18 that were not made for the VA. o Eight transactions at various gas stations totaling $83.26. o One transaction at a fast-food restaurant for $15.39. o One transaction at a liquor store for $59.41. o One transaction at a hardware store for $53.12. P1 provided the following information: · In December 2021, P1 received an email from a lawyer who was assisting the G in regard to the VA’s finances. The email requested P1 to reach out as there were some discrepancies in the VA’s finances. P1 missed seeing this email. · In September 2022, the lawyer called P1. P1 was not a supervisor of the facility until October 2021, four months after the check was cashed. · P1 stated that the VA’s financial book was “pretty much non-existent.” P1 and current staff persons “[tore] the house apart trying to find the finances.” P2 told P1 that s/he did not remember seeing VISA gift cards for the VA or additional cash in the VA’s wallet. P1 was able to find two receipts (one for a lounge chair and clothing totaling $210.63 and another for shoes, clothing, and a television totaling $256.93), along with the VA’s financial journal from June 2021. P2 provided the following information: · P2 said that when s/he first started, staff persons all “did” the financial book for clients, including the VA. Staff persons took clients shopping, wrote down if a check or cash was used, and put the receipt in the book. On the day of the interview P2 stated that now P2 “just hand[s] over [his/her] receipts.” · P2 said s/he “probably” took the VA to the bank when s/he first started working at the facility, but now the supervisors took care of that. P2 thought that the method changed how the finances were handled because it was easier for just one person to do it. · P2 said the SP liked to order items online for the clients. The SP bought three pair of the same type of tennis shoe. If they fit, the clients kept them, if not the items sat in the corner “forever.” P2 did not know if the items were ever returned. · P2 saw “maybe” $80 at most in the VA’s wallet at one time. It was unusual for the VA to have that much cash and P2 did not remember seeing more than that. The SP provided the following information: · When the SP started at the facility as a supervisor, s/he was told by his/her supervisors that the VA’s financial books were “all messed up.” The SP worked with his/her supervisors to get bank records and got the discrepancy amount down from between $100-200 to around $30. From there the SP thought the VA opened a new bank account and everything was balanced out. · The SP was responsible for auditing the clients’ financial records at the facility, including the VA. The SP stated that any staff person was able to take the VA shopping. Any staff person who took the VA shopping was supposed to write in the ledger and put receipts in the VA’s financial book. If a receipt was lost or not provided, staff persons were to write out on a slip of paper how much was spent and the check number. · The SP remembered going to a store to purchase the gift cards for the VA. The SP said the store was only able to activate two cards, so the remaining cash from the $1,000 was put in the VA’s wallet in a lockbox at the facility. The SP used the gift cards to buy items online for the VA and then put the gift cards back in the VA’s wallet in the lockbox. · Initially the SP denied taking the cash and gift cards. When the SP was shown, by law enforcement, a transaction ledger detailing where the gift cards were used, the SP admitted to using the VA’s gift cards. The SP took the cash (the SP did not specify the amount) and the gift cards after making the online purchases for the VA. The SP said s/he “forgot” about the gift cards and found them in his/her bag on a later date. · The SP said s/he took the cash and gift cards from the facility all at once in a “moment of dumbness” and did not think s/he would get caught. The SP felt “bad” for what s/he did to the VA. The G had a law firm that assisted with reconciling the VA’s finances. The G was aware there was a discrepancy and that the law firm was working with the facility to determine what had happened. The G said that staff persons were supposed to notify the G when a “spend down” was needed if the amount was more than $100. The G remembered the VA needed a new television, a chair, and that the VA was looking at a bed during this time period. The SP, P1, and P2 provided consistent information about the term “spend down.” This occurred when a client had over the allotted amount of money s/he was available to have saved. When the spend down occurred, staff persons made a list of what items the VA needed such as new clothes or new bedding. The SP and P1 stated that they needed approval from the guardian before purchases were made for a “spend down.” P2 stated that s/he needed to get permission from a supervisor before s/he took the VA shopping. Facility records showed that the SP and P2 were trained on the Reporting of Vulnerable Adults Act and the VA’s plans. At the time of this report the law enforcement investigation was still pending. Conclusion: A. Maltreatment: Sometime after August 3, 2021, the VA’s cash and two gift cards were taken from the facility and used for various items not for the VA. Given that the SP stated s/he took the VA’s cash and gift cards from the facility and stated that s/he used the cash and gift cards for personal purchases not for the VA, there was a preponderance of the evidence that in the absence of legal authority, the VA’s funds were willfully used, withheld, or otherwise disposed of. 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 responsible for the VA’s finances and took the VA’s cash and gift cards using them for purchases not for the VA. 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 not serious maltreatment because it did not meet the definition of serious maltreatment and not recurring maltreatment because the SP took the cash and gift cards during a single occurrence. Action Taken by Facility: The facility completed an Interval Review and found their policies and procedures adequate, but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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