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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: 1071853-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Scout Peterson Scott.Broady@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) used funds from two vulnerable adults (VA1 and VA2) to make purchases that were not for VA1 or VA2. Date of Incident(s): Multiple Prior to June 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 three interviews conducted with two facility staff persons (SP and P1) and a facility supervisory staff person (P2). Facility documentation showed that VA1 and VA2 were each vulnerable to financial exploitation. The facility was responsible for the management of all VA1’s funds. The facility was responsible for managing VA2’s funds, though s/he was “involved in all aspects of [his/her] finances.” VA1 enjoyed people watching and music. VA2 enjoyed doing art and dressing up. The facility completed a review of the facility’s residents’ finances between July 1, 2022, and June 30, 2023, and found the following: · Eight expenditures to VA1’s account for which no receipts were found totaling $293.76; o December 13, 2022: Amazon $41.19 o May 3, 2023: Amazon Music $5.38 o May 18, 2023: Amazon Prime $7.54 o May 21, 2023: Amazon $195.59 o May 27, 2023: Amazon Audible $16.05 o June 3, 2023: Amazon Music $5.38 o June 8, 2023: Amazon Prime Video $9.70 o June 15, 2023: Amazon $12.93 · Nine charges to VA2’s account for which no receipts were found totaling $98.81; o October 19, 2022: Sam’s Club $18.23 o January 4, 2023: Amazon $6.46 o January 18, 2023: Amazon Prime $7.54 o March 18, 2023: Amazon Prime $7.54 o March 27, 2023: Amazon Audible $16.05 o March 27, 2023: Amazon Prime Video $9.70 o April 18, 2023: Amazon Prime $7.54 o April 27, 2023: Amazon Audible $16.05 o April 27, 2023: Amazon Prime Video $9.70 · No discrepancies were found in the finances of the two other consumers who lived at the facility. In the facility’s internal review, P1 and P2 each stated that VA1 and VA2 did not use Amazon services, and VA1 did not receive any new clothing or personal items from Amazon. In the facility’s internal review documented on June 16, 2023, the SP stated: ‘Up until today, I didn’t know about this issue.’ [The SP] explained that [s/he] had been using [his/her] personal Amazon account for [VA1 and VA2] since December of 2022, and that [s/he] had been unaware that if a credit card did not have the correct balance on it to cover [an expenditure], the account would use the next credit card on file for the account, and that this was apparently why both [VA1 and VA2’s] cards were charged for [the SP’s] own [expenditures]. The SP provided the following information: · The SP did not use Amazon Audible but was an Amazon Prime member. Regarding the Amazon Music purchase, the SP stated s/he “did not even buy [. . .] the Amazon Subscription.” Regarding receipts from Amazon for the purchases, the SP stated that s/he provided the receipt was for the $195.59 Amazon purchase, and that the items were for VA1 and included “tee shirts, no socks, and zip things.” When requested, the SP did not provide the receipt for the $195.59 purchase to this investigator. · Both VA1’s and VA2’s bank cards were on the SP’s personal Amazon account, because s/he used her personal Amazon account to buy things for the VAs with their funds. · Some of VA1’s expenditures defaulted to VA2’s card and vice versa. · The SP had to pay back the facility as it was not the “fault” of either of the VAs, and s/he could not use one of their funds to reimburse the other. · The only non-Amazon expenditure found on VA2’s bank account was at Sam’s Club. Items purchased were for VA2, but the SP no longer had the receipt. · The SP denied making any expenditures with VA1’s money that were not for VA1 and denied making any expenditures with VA2’s money that were not for VA2. · The SP denied any of the charges to the VAs’ accounts were for his/her personal expenditures. Amazon receipts for the dates listed in the internal review were requested from the SP. The SP provided this investigator with four Amazon receipts and stated, “I was able to find the things I purchased, some of the dates are not accurate that you have I have never made this many purchases through Amazon.” None of the following purchases were dates of the discrepancy’s: · December 22, 2021, $3.23 for a movie purchased (unknown for which VA). · December 7, 2022, $23.99 for a purchase for VA2, shipped directly to VA2. · December 24, 2022, for a $74.99 purchase for VA2, shipped directly to VA2. · December 24, 2022, for a $21.20 purchase for VA1, shipped directly to VA1. The SP did not provide receipts for any other amazon expenditures. P2 stated that s/he conducted the review of VA1’s and VA2’s finances. The review uncovered more “red flags” including charges on the facility’s credit card and petty cash. P2 questioned staff persons regarding the VAs’ use of Amazon membership subscription services, and the staff persons denied that any of the consumers used those services. P2 stated that s/he discovered the SP was making the purchases, as the purchases were all from the SP’s personal Amazon account. P2 said the facility reimbursed VA1 and VA2. According to Amazon.com: · (About Payment Declines - Amazon Customer Service), “If you placed an order on Amazon and your card was declined, we’ll send you an e-amil asking you to submit your card details again. If the card is again declined, the order will be cancelled. If you still want to purchase the item, you’ll need to place another order.” · (Amazon Prime Terms & Conditions – Amazon Customer Service), regarding memberships, “If all eligible payment methods we have on file for you are declined for payment of your membership fee, you must provide us a new eligible payment method promptly or your membership will be cancelled.” The SP, P1, and P2 provided consistent information regarding the handling of finances at the facility. The VAs’ bank cards, and petty cash were locked in a safe. Facility staff persons had access to the finances and sought supervisor approval for large purchases. After a purchase was made for a resident with his/her funds, the receipt was to be kept in the safe with the card. On a monthly basis, administrative staff persons reviewed the finances and tracked what was spent in a report. P2 did not complete the reports for April and May 2023 until June 2023. According to facility documentation, the SP, P1, and P2 were each trained on the Reporting of Maltreatment of Vulnerable Adults, the facility’s policies and procedures, and the VAs’ care plans. Conclusion: A. Maltreatment: Information was consistent that VA1 and VA2 were vulnerable to financial exploitation. The VAs’ bank cards and funds were locked in a safe at the facility and all staff persons had access. A check of VA1’s and VA2’s finances in June 2023 showed that some of VA1’s and VA2’s funds were unaccounted for, and their bank statements included expenditures for Amazon membership subscription services that neither VA1 or VA2 used. In addition, there was another expenditure for Sam’s Club for which there was no receipt. The review determined that VA1 was missing $293.76 and VA2 was missing $98.81. The SP denied making unauthorized expenditures on VA1’s and VA2’s debit cards and stated that some of VA1’s expenditures were charged to VA2’s bank card and vice versa. However, 16 of the 17 unauthorized expenditures were made on Amazon for which no receipts were provided that included Amazon subscription services that the VAs did not use. One additional purchase was made at Sam’s Club, which the SP stated was used to buy items for the VA but s/he no longer had the receipt. The SP was the only staff person who made purchases for VA1 and VA2 via Amazon and therefore would have been the only staff person who had VA1’s and VA2’s bank card information in an Amazon account. In addition, the SP provided conflicting accounts to the facility and to this investigator regarding how the expenditures occurred.
Regarding VA1 Although the SP denied making purchases for VA1 that were not for him/her and stated that all staff persons had access to VA1’s funds, given that the SP had previously made purchases via Amazon for VA1, that the SP had VA1’s bank account information in his/her Amazon account, and that all eight expenditures were made on Amazon with VA1’s funds for which no receipts were provided that included Amazon subscription services that VA1 did not use, there was a preponderance of evidence that, in the absence of legal authority, a staff person willfully used funds of VA1. 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). Regarding VA2 Without a receipt, it is unclear whether the purchase at Sam’s Club was for VA2. Although the SP denied making purchases for VA2 that were not for him/her and stated that all staff persons had access to VA2’s funds, given that the SP had previously made purchases via Amazon for VA2, that the SP had VA2’s bank account information in his/her Amazon account, and that eight expenditures were made on Amazon with VA2’s funds for which no receipts were provided that included Amazon subscription services that VA2 did not use, there was a preponderance of evidence that in the absence of legal authority, a staff person, willfully used funds of 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 received training on the Reporting of Maltreatment of Vulnerable Adults Act and the VAs’ care plans. The SP had VA1’s and VA2’s bank cards on his/her personal Amazon account. VA1’s and VA2’s personal accounts were charged for Amazon expenditures for which no receipts were provided, including Amazon subscription services that neither used. The SP was responsible for financial exploitation 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 maltreatment because the SP used VA1’s and VA2’s bank cards for expenditures on multiple dates. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed. The facility reimbursed VA1 and VA2. P2 received additional training in reviewing finances and reconciling funds. 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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