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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: 1068811-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that there was a CashApp charge, from a vulnerable adult’s (VA) account to a facility staff person (SP1). It was also reported that there were several charges from the VA’s account that were not made by or for the VA and that another facility staff person (SP2) used the VA’s debit card to make purchases for SP2. Date of Incident(s): Prior to August 22, 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, the VA’s financial records and through six interviews conducted with SP2, a management staff person (P1), three facility staff persons (P2-P4) and the VA’s guardian (G). Consistent information showed that the VA did not have the ability to provide information in an interview. Although this investigator contacted SP1, SP1 did not respond to requests to be interviewed. The investigation showed inconsistent information in terms of where the VA’s debit card was stored at the facility. Some persons interviewed did not know that the VA had a debit card and others were aware that the VA had a debit card and said that the VA carried it on his/her person at times, but also that the card, which was accessible to all staff persons, was stored in the facility’s locked office. The VA’s support plan showed that the VA enjoyed spending time with family and friends and accessing the community. The plan also showed that the VA had a moderate developmental disability. The VA’s Individual Abuse Prevention Plan showed that the VA “does not understand budgeting” and that the G “took care of [the VA’s] bills.” The G stated that s/he did not remember the date, but looked at the VA’s financial statements, which were only available for the previous 90 days (the credit union only provided bank statements going back 90 days) and determined that there was a CashApp purchase for $50 that listed SP1’s name. (CashApp was a mobile payment system which allowed users to transfer money between their accounts.) When the G saw that, the G reviewed other statements and determined that there were other questionable purchases from the VA’s account. The G called P1. Information from the VA’s bank statements, an interview with P1, and facility documentation provided the following information: · P1 did not remember the date, but when s/he received a call from the G regarding questionable purchases on the VA’s bank statement and the $50 CashApp purchase to SP1 on August 24, 2023, P1 called SP1 to come in for an interview. When P1 talked to SP1, SP1 denied using the VA’s debit card to make the CashApp purchase and denied using the VA’s debit card for the other questionable purchases on the VA’s bank statement. · P1 noted a debit card purchase on August 17, 2023, at a gas station for $76.28 and remembered that around this date, SP1 requested a pay advance because SP1 needed to purchase gas, which was denied by the facility. · P1 found several other purchases that were unaccounted for and did not have receipts and some of those purchases were in locations that were closer to where SP2 lived than the facility. P1 suspected that SP2 made those purchases because of where the purchases were made. On August 1, 2023, SP2 was no longer employed by the facility for reasons not associated with this report. In addition, there were a number of online purchases made to www.target.com. Some of these purchases, $5.00 and $3.35, occurred before SP2 left employment and some, $38.96, $44.22, $55.72, and $215.49 occurred after SP2 left employment. · The facility’s Internal Review stated that SP2’s personal “email” was “linked” to the www.target.com account “confirming that the target account making charges to [the VA’s] debit card” was created by SP2. The charges were both prior to and after SP2 no longer worked at the facility. · Facility documentation showed that a total of $1,137.71 in purchases from the VA’s account that were not made by or for the VA. Most of which was reimbursed by the VA’s bank and the rest, $176.50, was reimbursed by the facility to the VA. P2-P4 provided information that the VA did not have the ability to make online purchases and that the VA had a friend that occasionally took the VA into the community to shop or have lunch, but it was not known how those purchases were paid for (some of the facility documentation showed that the VA’s friend returned receipts when the visits were completed). P2-P4 each denied using the VA’s debit card for their own personal use. P2 said that when the VA went out with his/her friend, the friend carried the debit card and assisted the VA with making purchases. P3 stated that s/he did not have knowledge of how the VA used the debit card because P3 had not taken the VA into the community to make purchases. P4 stated that s/he had taken the VA into the community to make purchases and when that happened, P4 carried the VA’s debit card and assisted the VA with purchases and then ensured that a receipt was brought back to the facility. SP2 denied using the VA’s debit card to make purchases for his/her personal use and stated that whenever s/he used the VA’s debit card, it was for the VA and that receipts were returned to the facility to account for the purchases. SP2 acknowledged that s/he did make a “few” online purchases with the VA’s card for the VA but using SP2’s email address because that was how online stores provide receipts. SP2 denied making purchases with the VA’s card after his/her employment ended. SP2 did not remember whether online purchases required the person to enter an email address or payment for each purchase because “Target” did it both ways. The facility’s training records showed that all staff persons interviewed for this investigation and SP1, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to August 22, 2023. Conclusion: A. Maltreatment: When the G reviewed the VA’s financial statements, s/he noticed a $50 CashApp charge from the VA’s account that listed SP1’s name on August 24, 2023, and several other charges that were questionable from the G’s perspective and not made by or for the VA. The G called P1 who did further review of the VA’s financial statements and found a purchase to a gas station on August 17, 2023, for $76.28 that occurred around the time of a request from SP1 for a pay advance, which was denied by the facility, because SP1 needed to purchase gas. P1’s review of the VA’s financial statements showed that a total of $1,137.71 in purchases were made from the VA’s account that were not made by or for the VA. P1 believed that some of those purchases were made by SP2 because those purchases were made in locations closer to where SP2 lived than the facility. Bank statements showed that the VA’s debit card was used to make online purchases associated with the SP’s email, some of which occurred before and after SP2 no longer worked at the facility. SP2 denied the allegations and stated that the purchases made when s/he worked at the facility were for the VA. Although a total of $1,137.71 of purchases were made from the VA’s account likely not by or for the VA, given that all staff persons had access to the VA’s debit card, that the VA and/or the VA’s friend sometime carried his/her debit card on his/her person, that the VA went into the community without staff persons with his/her debit card, all purchases except for the $50 CashApp with SP1’s name on it, were not able to be determined whether they were made by staff persons. However, given that SP1’s name was associated with the $50 CashApp purchase, there was a preponderance of the evidence that SP1 willfully used the VA’s funds in the absence of legal authority. 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. SP1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act. SP1 was responsible for the 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 SP1 was responsible did not meet statutory criteria to be determined as recurring or serious because the incident was a single incident and did not meet the statutory definition of serious maltreatment. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate, followed and that additional training was needed on “when and how to get approval to use resident’s bank card for personal needs.” SP1 and SP2 were no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP1. The determination that SP1 was responsible for maltreatment is subject to appeal.
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