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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: 1068926-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady Suspected Maltreatment Reported: It was reported that a staff person (SP) took funds belonging to four vulnerable adults (VA1-VA4). Date of Incident(s): Ongoing, prior to August 2, 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): 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 interviews conducted with two facility staff persons, VA2, VA3, VA4, VA1’s guardian, VA2’s guardian, VA3’s guardian, and a family member of VA3. VA1 used gestures and short answers to communicate so VA1 was not able to provide information pertinent to the investigation VA1’s, VA2’s, VA3’s and VA4’s support plans each stated that they had disabilities related to their physical and/or mental health. Each of the VAs were at risk for financial abuse and staff persons were to assist the VAs in all aspects of managing their money. VA1, VA2, VA3, and VA4, each required to be supervised by staff persons both at home and in the community. An administrative staff person (P1) and the SP, who was a supervisor, each stated that all of the VAs kept petty cash at the facility. Each of the VAs had a petty cash ledger. Staff persons were to document and initial all cash transactions. Each line in the ledger was numbered. Receipts for purchases were to be kept and staff persons were to indicate the line number from the ledger on the receipt. If staff persons forgot a store receipt, they were asked to go back and get one. For expenditures that might not have receipts such as going to a fair, staff persons were to complete handwritten receipts. The SP’s Position Description stated that the SP was responsible for managing and overseeing the VAs’ finances including checking, and savings, and petty cash accounts. The SP was to complete monthly and quarterly financial reports and maintain receipts for purchases. Regarding VA1 VA1 enjoyed spending time with family. VA1’s guardian (G1) stated that when VA1 needed money, staff persons would call G1 and G1 would typically drop off $200 for VA1. G1 dropped off money about every two weeks and had been doing that for several years without incident. G1 stated that sometimes no staff persons were at the facility when s/he dropped off the money and on those occasions, s/he left the money with a note on the kitchen table. Documentation provided by the facility, a law enforcement Incident Report, and in an interview with P1 showed the following: · VA1’s bank statement dated June 2022, showed that $200 withdrawals were made on June 10, 18, and 25, 2022. On June 19, 2022, there was a $60 withdrawal (withdrawals were made by G1). G1 gave $200 to the facility for VA1 on June 10, 18, and 25, 2022. G1 told P1 that s/he was not sure who s/he gave the money to at the facility. · VA1’s pretty cash ledger dated June 2022, showed deposits of $200 on June 9 and June 17, 2022 (although these dates are a day off from the bank statement, withdrawals might have posted the following day). There were no other deposits documented. There were handwritten receipts for $200 deposits received on June 9 and 17, 2022. On July 1, 2022, the SP documented that VA1’s petty cash ledger balanced. There were receipts, some handwritten, for small purchases (candy, fast food). · On July 28, 2022, a staff person told P1 that at one point, s/he saw an envelope with $60 in it in VA1’s closet and later the money was gone. P1 asked the SP about the $60 and the SP said that s/he deposited the $60 and documented it in the ledger, but there was not a deposit written in the ledger for $60. The SP stated that s/he was not aware of the $60 being in an envelope, but since the SP was responsible for monitoring VA1’s funds and was the last person to see the $60, s/he reimbursed VA1 $60. The SP told P1 that s/he did not spend the $60. · VA1’s progress notes dated between June 17 and 26, 2022, did not have any information regarding what might have happened to $60 or $200 cash. The SP told P1 that s/he did not know anything about the missing $200. · After the facility was not able to account for the money, the facility limited the amount of cash at the facility for VA1 to $20. VA1 obtained a debit card for expenditures and G1 was going to monitor the debit card usage. VA1’s petty cash was to be counted by an administrator three times a week. · All of the deposits in July 2022 were accounted for. VA1’s petty cash ledger dated July 2022, showed three $200 deposits and on August 1, 2022, the SP documented that the ledger balanced. After the facility provided the initial information, an administrative staff person (P2) sent additional information regarding dates in 2021, where bank statements from the FM showed $200 withdrawals with no record of $200 deposits in the VA’s petty cash ledger. Attempts to reach P2 for additional information via telephone and email were unsuccessful. The SP provided the following information: · The SP placed the $60 that was found at the facility in VA1’s petty cash, but forgot to document it. The SP stated that staff persons spent the money but did not get receipts. The SP stated that since s/he forgot to document it, s/he reimbursed VA1 $60. · The SP did not know anything about $200 that was dropped off for VA1 on June 25, 2022. · The SP stated that s/he did not take any of VA1’s money and did not spend any of VA1’s money on anything that was not for VA1. G1 stated that after VA1’s money was not accounted for, G1 no longer dropped cash off at the facility. Instead, G1 obtained a debit card for VA1. Regarding VA2 VA2’s guardian (G2) stated that s/he did not have any concerns about the care that VA2 received at the facility. VA2 stated that staff persons handled VA2’s money. VA2’s money was kept in the staff person office. If VA2 needed to spend money, s/he asked staff persons for it. VA2 stated that receipts were kept of his/her expenditures. VA2 enjoyed crafts. The facility indicated concerns with the following transactions in VA2’s petty cash ledger: · On July 2, 2022, the SP documented that VA2 spend $25.50 at Wal-Mart on personal needs (the transaction was documented out of sequence). There was only a handwritten receipt stating personal needs. · On July 3, 2022, the SP documented that VA2 spent $34.50 for lunch (the transaction was documented out of sequence). There was only a handwritten receipt that said, “Lunch with staff [persons].” It was initialed by the SP. · In July 2022, VA2 attended a musical festival. On July 22, 2022, $400 was deposited into VA2’s petty cash. The expenditures for the music festival were $140 for shirts, $60 for a bus shuttle, and $45 for food. It was documented that another person (not a staff person or consumer at the facility) who went to the musical festival reimbursed VA2 for $20 for that person’s cost of the shuttle. On July 27, 2022, the SP reimbursed him/herself $80 out of VA2’s petty cash with an entry stating lunch, bag, and two shirts. There were handwritten receipts for all the transactions completed by the SP. There was no documentation in VA2’s progress notes pertaining to the music festival. P1 stated that s/he asked the SP about the Wal-Mart expenditure and getting a receipt and the SP made up a receipt in an online shopping cart from Wal-Mart that showed what s/he believed s/he bought VA2. The SP provided the following information: · The SP did not remember what items s/he purchased for VA2 on July 2, 2022. The SP took his/her own vehicle to Wal-Mart and the receipts might have been in his/her vehicle, but s/he threw them away when s/he cleaned out his/her vehicle. · The SP believed that on July 3, 2022, VA2 paid for a staff person’s lunch because there was no money in household petty cash. The receipt got lost at the facility. The SP did not remember who took VA2 out to eat. · The SP reimbursed him/herself $80 out of VA2’s petty cash because the SP bought VA2 some shirts and personal need items for VA2. The SP bought the items when s/he was shopping for him/herself and put the receipts in his/her vehicle. The SP threw receipts away cleaning out his/her vehicle without looking at the receipts. · The SP stated that s/he did not take any of VA2’s money and did not spend any of VA2’s money on anything that was not for VA2. Regarding VA3 VA3 stated that staff persons kept a checkbook and cash for VA3 in the staff person office. If VA3 needed money, s/he would ask staff persons and they would give it to him/her. When VA3 spent money, staff persons kept the receipts. VA3 stated that s/he kept a list of things s/he needed such as personal needs items and when s/he went shopping, staff persons would take VA3 shopping for the items. VA3 enjoyed ice cream and visiting with family. VA3’s support plan included an objective where VA3 would make a written list of any items VA3 needed to purchase. VA3 would then arrange a day to go shopping for the items. VA3 would choose the store that s/he wanted to go to. Staff persons were to accompany VA3 to the store. After VA3 returned from shopping, VA3 would put the items away. The facility internal review report stated that on July 28, 2022, it was discovered that $80 of VA3’s petty cash was not accounted for at the facility. Original receipts were not kept for purchases. As a result of the investigation, VA3’s petty cash was to be counted on a daily basis. The facility indicated concerns with the following transactions in VA3’s petty cash ledger: · On July 22, 2022, the SP documented that VA3 took $30 to a family outing. · On July 23, 2022, the SP documented that VA3 went shopping for personal needs at Wal-Mart and spent $25.50. There was a handwritten receipt stating personal needs completed by the SP. · On July 25, 2022, the SP documented that VA3 went shopping at Wal-Mart and bought pads/briefs for $24.50. There was a handwritten receipt stating briefs and pads completed by the SP. VA3’s progress notes dated July 22 to 25, 2022, did not mention shopping. P1 provided the following information: · P1 asked the SP about the Wal-Mart expenditure and getting a receipt and the SP made up a receipt in an online shopping cart that showed what s/he believed s/he bought the VA3. The SP told P1 that s/he sent the $30 with VA3 when s/he went on a family outing. The SP told P1 that s/he took his/her own vehicle to Wal-Mart when shopping for VA3 and that the receipts might have been in his/her vehicle but s/he threw them away when s/he cleaned out his/her vehicle. The SP stated that some staff persons did not know how to fill out receipts so that was why generic receipts were filled out. · P1 stated that typically briefs for VA3 were delivered to the facility. VA3 had an objective to go to the store shopping for needed items and VA3 did not go to the store. A family member (FM) of VA3 and a family member/guardian (G3) provided the following information: · The FM and G3 did not recall staff persons sending $30 with VA3 for a family activity. Typically when VA3 did activities with family, VA3 did not bring money as the family paid for activities. · If VA3 went shopping with family members, receipts were kept for purchases and the receipts were returned to the facility. The SP provided the following information: · The SP sent $30 with VA3 when VA3 went on an activity with his/her family. VA3 did not bring any of the money back. If VA3 had money and did not spend the money, VA3 would bring it back to the facility.
· The SP made purchases for VA3 at Wal-Mart on July 23 and 25, 2022. The SP stated that s/he “misplaced” the receipts. The SP did not take VA3 with him/her shopping because those dates were before VA3’s regular shopping and at the time the SP went shopping, VA3 was at his/her day program. · The SP stated that s/he did not take any of VA3’s money and did not spend any of VA3’s money on anything that was not for VA3. Regarding VA4 VA4 stated that staff persons managed VA4’s money. VA4 stated that s/he did not have concerns about staff persons. VA4 stated that s/he enjoyed walking, riding bike, and reading. The facility’s internal review report stated that on July 28, 2022, it was discovered that original receipts were not kept for purchases ($32.50). The SP stated that some staff persons did not know how to fill out receipts so that was why generic receipts were filled out. As a result of the investigation, VA4’s petty cash was to be counted on a daily basis. The facility indicated concerns with the following transactions in VA4’s petty cash ledger: · On July 2, 2022, the SP documented that VA4 spent $16.25 for lunch at Subway. There was a handwritten receipt initialed by the SP. · On July 3, 2022, the SP documented that VA4 spent $16.25 on clothes at Goodwill. There was a handwritten receipt initialed by the SP. VA4’s progress notes dated July 2 and 3, 2022, did not have any information regarding going to Subway or Goodwill. P1 stated that on July 2 and 3, 2022, the SP was not scheduled to work. P1 talked to two staff persons who worked on July 2 and 3, 2022, and they each said VA4 did not go to Goodwill or Subway. The SP provided the following information: · On July 2, 2022, VA4 paid for the staff person’s lunch because there was not household petty cash. The SP did not know which staff person went out to eat with VA4. · On July 3, 2022, a staff person took VA4 shopping, but forgot to bring back receipts. The SP did not know which staff person took VA4 shopping. · When asked why the SP initialed the above purchases in the ledger if s/he did not make the purchases, the SP said s/he was not sure which staff person took VA4 out and with all the staff persons working, it was hard to keep tracking of who was working at which time. · The SP stated that s/he did not take any of VA4’s money and did not spend any of VA4’s money on anything that was not for VA4. A law enforcement Incident Report stated that a law enforcement officer (LEO) talked to the SP and the SP told the LEO that s/he did not take any money and it was a just a mix up with receipts. Law enforcement did not take any additional action. Conclusion: A. Maltreatment: Regarding VA1 In June 2022, two staff persons, including the SP, were aware that VA1 had an envelope containing $60 cash. The SP stated that $60 was placed in VA1’s petty cash, but s/he forgot to document it. The SP stated that staff persons spent the money but did not get receipts. The SP stated that since s/he forgot to document it, s/he reimbursed VA1 $60. Given the above, it was not determined whether VA1’s funds were spent on items not for VA1 or whether it was poor record keeping on the part of the facility. G1 stated that s/he gave $200 to the facility for VA1 on June 10, 18, and 25, 2022. G1 told P1 that s/he was not sure who s/he gave the money to at the facility. G1 also stated that on occasions when s/he dropped off money, no staff persons were at the house and in those instances, s/he left the money on the kitchen table. There was documentation at the facility that on June 9 and 17, 2022, $200 was deposited into the VA1’s petty cash (it was unclear why the dates were one day off but could be a documentation error or how the funds posted at the bank and showed on the statement). There was no documentation at the facility regarding the $200 that G1 said that s/he dropped off on June 25, 2022. The SP stated that s/he did not know anything about that $200. In addition, the facility provided bank statements and petty ledgers from 2021 where the statements showed some $200 withdrawals made by the FM with no corresponding deposits in petty cash ledgers. However, there was no additional information obtained about those withdrawals. Because G1 said that s/he dropped off $200 at the facility or just left it at the facility, that there were no identified staff persons who accepted any of VA1’s funds, and there was no record of the $200 being at the facility, there was not a preponderance of the evidence whether a staff person took or withheld money from VA1. 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). Regarding VA2, VA3, and VA4 In July 2022, there were concerns about purchases made with VA2’s, VA3’s and VA4’s funds. The SP, who was responsible for monitoring the funds, made purchases for VA2, VA3, and VA4 without bringing the original receipts back to the facility and/or created handwritten receipts and then completed ledger documentation which was signed by the SP. The SP provided explanations as to how the money was spent and denied using of the VAs’ funds for purchases not for the VAs. Regarding items purchased for VA2, VA3, and VA4, it was not determined whether funds were spent on items not for the VAs or whether it was poor record keeping on the part of the facility. However, on July 2, 2022, the SP documented that VA4 spent $16.25 at Subway for lunch. The SP initialed the receipt and initialed the entry in the ledger. In addition, on July 3, 2022, the SP documented that VA2 spent $34.50 for lunch (the transaction was documented out of sequence) and there was only a handwritten receipt that said, “Lunch with staff [persons].” It was initialed by the SP. The SP stated that on both occasions s/he thought the staff person who took each VA to lunch bought themselves lunch with the VAs’ money because there was no facility petty cash for the staff persons to use. The SP did not know who took VA2 and VA4 out to eat. Neither VA2 nor VA4 were able to go into the community without supervision so a staff person would be with them if they ate lunch out. VA4 could have spent $16.25 on Subway for him/herself but the SP documented that a staff person used VA2’s money to buy themselves lunch as well. In addition, it was unlikely that VA2 would spend $34.50 on lunch for him/herself (plus the SP documented that a staff person ate lunch with VA2). Therefore, there was a preponderance that a staff person(s) willfully used the funds of VA2 and VA4. 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 documented the lunch transactions in the petty cash ledger and hand wrote receipts for VA2’s and VA4’s lunch. However, the SP stated that s/he did not know who took VA2 out to eat and the SP believed that the original receipt got lost at the facility. In addition, the SP said that s/he did not know who took VA4 out to eat and P1 said that the SP was not scheduled to work that day and that the two staff persons working that day told P1 that they did not take VA4 out to eat. The SP denied using VA2’s or VA4’s money for anything other than for VA2 and VA4. Because it was not determined which staff person or persons took VA2 or VA4 out to eat or which staff person used VA2’s or VA4’s money for their own food and all staff persons had access to VA2’s and VA4’s money, the responsibility for the maltreatment of VA2 and VA4 was inconclusive. Action Taken by Facility: The facility completed an internal review report and determined that the policies and procedures were adequate, but not followed. Staff persons were retrained on petty cash procedures for the VAs. The SP no longer worked at the facility. The facility reimbursed VA1 $200. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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