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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: 1098083-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was alleged that a staff person (SP) took two vulnerable adults (VA1’s and VA2’s) funds for his/her personal use. Date of Incident(s): Multiple dated between February 3 and March 20, 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 three interviews conducted with a facility supervisory staff person (P1), a staff person (SP), and VA1’s guardian (G1). Attempts were made via phone, email, and U.S. mail to contact and interview VA2’s guardian’s (G2 and G3) but the attempts were not successful. VA1 was diagnosed with moderate intellectual disability, Down syndrome, early onset dementia, and major depressive disorder. VA1 enjoyed spending time with his/her family and shopping. VA1 wanted to save money to purchase a new iPad and take a trip to visit a family member. VA1’s Coordinated Service and Support Plan Addendum said that the facility was authorized in the “safekeeping” of VA1’s funds including VA1’s checking account. VA1’s Individual Abuse Prevention Plan said that VA1 was not able to manage his/her finances, including because VA1 did not understand money “fully” and would “give [money] away to anyone who asked.” If staff person’s suspected financial exploitation, they were to “report” it. VA2 was diagnosed with cerebral palsy and an intellectual disability. VA2 enjoyed dancing and playing with toy trucks. VA2’s Individual Abuse Prevention Plan said that VA2 had the inability to manage his/her own finances and was at risk for financial exploitation. Staff persons were to report any suspected financial exploitation. VA2’s Coordinated Service and Support Plan Addendum said that the facility was authorized in the “safekeeping” of VA2’s funds including VA2’s checking account. The facility stored clients’ money, including checkbooks, in a locked safe at the facility that all staff persons had access to. P1, the Hubbard County Sheriff’s Office Incident Report, the General Event Reports, and VA1’s and VA2’s bank account information including copies of checks and bank account statements, provided the following information: · On March 24, 2023, G1 notified P1 that upon review of VA1’s bank account, G1 saw that there were “several” of VA1’s checks written out to and cashed by the SP totaling $3000. This included: o Check #2005 written out to the SP on February 13, 2023, for $500; o Check #2006 written out to the SP on February 14, 2023, for $400; o Check #2007 written out to the SP on February 16, 2023, for $600; o Check #2008 written out to the SP on February 20, 2023, for $200; o Check #2009 written out to the SP on February 28, 2023, for $150; o Check #2010 written out to the SP on March 10, 2023, for $150; o Check #2011 written out to the SP on March 12, 2023, for $300; o Check #2012 written out to the SP on March 13, 2023, for $400; o Check #2013 written out to the SP on March 20, 2023, for $150; and o Check #2014 written out to the SP on March 20, 2023, for $150. · P1 then went to the facility to “suspend” the SP and when P1 arrived, the SP said, “Ya. I did it. I knew this was coming. I am sorry. I am [addicted to drugs].” · There were four clients at the facility, including VA1 and VA2. P1 then reviewed the other clients bank statements and saw that VA2 had “several cleared check transactions” which showed checks written out to the SP totaling $2731 (Note: There were no concerns with the other clients’ finances as staff persons did not handle those). P1 said that the SP “forged” VA2’s signature and then “cashed [the checks] for [his/her] personal gain.” This included: o Check #2077 written out to the SP on February 3, 2023, for $500; o Check #2078 written out to the SP on February 3, 2023, for $272; o Check #2079 written out to the SP on February 9, 2023, for $400; o Check #2080 written out to the SP on February 15, 2023, for $350; o Check #2081 written out to the SP on February 25, 2023, for $250; o Check #2082 written out to the SP on March 9, 2023, for $125; o Check #2083 written out to the SP on March 12, 2023, for $300; o Check #2084 written out to the SP on March 12, 2023, for $400; and o Check #2085 written out to the SP on March 12, 2023, for $134. · In addition, on March 15, 2023, there was a $300 withdrawal from VA2’s account. (Note: It was not VA2’s signature on the withdrawal slip and the SP denied withdrawing it so it was not determined if the SP withdrew this money.) · On March 30, 2023, law enforcement met the SP. The SP said that due to having a mental health disorder, s/he had made some “poor decisions.” The SP said that s/he took VA1’s and VA2’s checks and wrote them out to him/herself in February and March 2023. The SP said that s/he signed “all the checks.” The SP having “financial difficulty” and took the money as it was an “opportunistic thing.” The SP was “unsure” of the total amount of the checks s/he cashed. · Law enforcement sent the report to the country attorney for review of charges, which was still pending at the time of this report. · P1 “did not understand” why the SP wrote the checks to him/herself and said that the SP was “not very good at covering [his/her] track.” · VA1 and VA2 were not able to write their own checks due to their disabilities. The SP said that in February and March 2023, s/he made some “really bad decisions” and “stole some checks” from VA1 and VA2. The SP “was not quite sure” how many checks s/he took, or the total amount taken. The SP wrote the checks out to him/herself and signed the checks with VA1’s and VA2’s names. Staff persons were trained not to take the clients’ money. G1 said that VA1 had lived at the facility for 20 years and G1 “knew [VA1’s] pattern of spending.” At some point, G1 saw that there were “numerous” checks written out to the SP totaling $3000. G1 did not want to tell VA1 due to VA1’s “diminished” “mental capacity” and because it would “stress [VA1] out.” There were no times that VA1 did not have money to use because of this. G1 did not have any other concerns with the facility and said this was the “first issue” in the time that VA1 lived there. The Policy and Procedure Pertaining to Management of Individual Funds and Property said that all client’s checkbooks were “secured.” Staff persons were not to “borrow money” from a client or sign “on behalf of clients” in their checkbooks. The Policy and Procedure Pertaining to service Recipient Rights and Rights Restrictions said that the clients had the right to be free from financial exploitation, including by staff persons. Facility documentation showed that the SP and P1 each received training regarding the facility’s policies and procedures, including the Reporting of Maltreatment of Vulnerable Adults Act, client rights, and the Policy and Procedure Pertaining to Management of Individual Funds and Property, prior to the incident. Conclusion: A. Maltreatment: Information from the facility, law enforcement, G1, P1, and the SP showed that the SP wrote out checks to him/herself from VA1’s and VA2’s account. VA1 had a total of $3000 taken and VA2 had a total of $2731. The SP acknowledged to P1, law enforcement, and this investigator that s/he took VA1’s and VA2’s funds for his/her personal use. Therefore, there was a preponderance of the evidence that in the absence of legal authority, the SP willfully used, withheld, or disposed of funds of VA1 and VA2. 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 policies and procedures, including the Reporting of Maltreatment of Vulnerable Adults Act, client rights, and the Policy and Procedure Pertaining to Management of Individual Funds and Property, prior to the incident. The SP acknowledged writing and cashing checks from VA1’s and VA2’s checking accounts for his/her personal use. 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 maltreatment for which the SP was responsible was recurring maltreatment. The SP took money from VA1 and VA2 on multiple dates. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed, as the SP failed to properly “secure and utilize” VA1’s and VA2’s finances, which was in “violation” of the rights and financial policies. There were no prior similar concerns with the SP. The facility retrained staff persons regarding the “seriousness of financial exploitation” and a review of “pertinent policies and state statutes.” The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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