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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: 1109095-H_CRS (Home and Community-Based Services-Community Residential Setting)- Closed August 31, 2023 Investigator(s): Kimberly Huettl Anderson 651-431-6553 Suspected Maltreatment Reported: It was alleged that three vulnerable adults (VA1-VA3) were missing money. · VA1 was missing $2062.25 from his/her bank account and there were no receipts for expenditures; · VA2 had a $400 transferred from his/her bank account to “CashApp” and three charges from DoorDash where alcohol was purchased; and · VA3 was missing $115 from his/her petty cash and that there were no receipts for expenditures. Date of Incident(s): ongoing prior to August 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 eight interviews conducted with VA1, VA2, and VA3, VA2’s and VA3’s guardians, and facility staff persons. Attempts were made via telephone and U.S. mail to contact and interview the SP. However, the SP did not respond to the requests. The SP was interviewed by law enforcement and that information was included below. VA1’s Admission Form and Data Sheet stated that VA1 was diagnosed with intellectual developmental disability. VA1’s Community Supports Plan stated that VA1 enjoyed going to church and hanging out with his/her housemates and staff persons. VA1 was proud that s/he earned his/her own money by working. VA1 managed his/her own finances with the assistance from staff persons. VA1’s Individual Abuse Prevention Plan stated that VA1 worked with staff persons to make shopping lists so VA1 did not overspend his/her budget. VA1 had a debit card that was stored in a locked area that was accessible by staff persons. Staff persons were to maintain a ledger with receipts for expenditures to document VA1’s money that was coming in and going out. VA1 was not subject to guardianship. VA2’s Admission Form and Data Sheet stated that VA2 was diagnosed with mild intellectual developmental disorder, Down syndrome, and anxiety. VA2’s Coordinated Services and Supports Plan stated that VA2 loved shopping, eating out, and spending time with his/her family. The VA worked three days a week and enjoyed his/her job. The VA2’s Individual Abuse Prevention Plan stated that VA2 loved to give gifts but had a limited budget. Staff persons were to work with VA2 to maintain his/her budget by maintaining receipts for expenditures and documenting all transactions. VA2’s Funds and Property Authorization stated that the facility aided VA2 with storing cash, budgeting for purchases, and documenting receipts for purchases. Staff persons were to contact VA2’s guardian (G2) in the event that VA2 wanted to purchase items over $50. VA3’s Admission Form and Data Sheet stated that VA3 was diagnosed with autism and mild intellectual developmental disorder. VA3’s Coordinated Services and Supports Plan stated that VA3 enjoyed watching television, staying home, and playing games. VA3’s Individual Abuse Prevention Plan stated that VA3 had the inability to handle his/her own financial matters and that staff persons were to keep a ledger of VA3’s cash transactions and to keep VA3’s cash locked in the office. VA3’s Funds and Property Authorization stated that staff persons were to assist VA3 with the safekeeping of his/her money, assist with transactions, collect receipts and document in a ledger. The facility stored VA3’s cash and checking account card locked in the facility’s office. Staff persons were to contact VA3’s guardian (G3) for purchases over $30. The facility’s General Event Reports and Internal Reviews for VA1, VA2, and VA3 provided the following information: · On July 27, 2022, a facility management person (P1) learned that VA1’s debit card was used to make “at least” fifty-six unauthorized transactions between June 27 and July 27, 2022. The unauthorized transactions included cash app transactions, order food from multiple restaurants through Grubhub and DoorDash, and purchases at a liquor store in Maple Grove. VA1 had a total of $2062.25 that was unaccounted for with receipts for expenditures. · On June 16, 2022, G2 discovered “suspicious” activity in VA2’s bank account when there were purchases from DoorDash on June 13, 14 and 15, 2022, totaling $400. A representative from DoorDash told G2 that the transactions occurred in an area with 55369 zip code and that the purchases included alcohol. DoorDash refunded VA2’s money. · On August 16, 2022, P1 discovered that VA3’s finances had not been properly documented between January and July 2022 and that VA3 was missing $115 from his/her petty cash. There were no receipts for expenditures to account for the $115. Information from VA1, VA2, VA3, G2, and G3 provided the following information: · VA1 stated that s/he did not know who used his/her bank card to make purchases through DoorDash or Grubhub and s/he never gave anyone permission to use his/her bank card. VA2 stated that s/he did not purchase items from DoorDash and s/he never gave permission for anyone to use his/her bank card. VA3 stated that s/he did not give anyone permission to use his/her petty cash. · G2 stated that s/he managed VA2’s finances and was notified by the bank that there had been three internet charges of $400 on VA2’s account and there was another attempt for $800 that was declined by the bank. The bank credited the money back to VA2’s account and contacted the bank’s fraud unit. Initially G2 thought the transactions occurred from a cyber-attack until P1 told G2 that s/he suspected a staff person from the facility misusing VA2’s bank card. · G3 stated that s/he managed VA3’s finances and that VA3 only kept petty cash at the facility. G3 was notified by P1 stating that VA3 had $115 unaccounted for with receipts for expenditures. A law enforcement officer’s (LEO) Event Report provided the following information: · On July 27, 2022, the LEO received a report stating that VA1 had approximately forty unauthorized transactions totaling $2500 on his/her bank card and that VA2 had two unauthorized transactions totaling $800 on his/her bank card. · P1 supplied the LEO with VA1’s bank statements and showed the LEO that at least two of the CashApp transactions were connected to the SP telephone number. · The LEO obtained information from CashApp, DoorDash, and Grubhub stating that the transactions in question on VA1’s bank statement were linked to the SP’s name, the SP’s address, and the SP’s significant other. The LEO obtained information confirming that the unauthorized transactions on VA2’s card were linked to the SP’s significant other. · On June 8, 2023, the LEO met with the SP. At that time, the SP denied using VA1’s and VA2’s bank cards to make purchases through CashApp, DoorDash, and Grubhub. The SP confirmed that his/her and/or his/her significant other’s telephone number and address matched the information from each transaction in question. · The LEO submitted the report to the county attorney for charges. P1 and two additional management persons (P2 and P3) provided the following information: · In June 2022, G2 told P1 that there were “lots of suspicious” transactions on VA2’s bank statements that were discovered by a bank representative and believed to have been fraudulent through an online scam. In August 2022, P1 reviewed VA1’s bank statements and discovered that VA1 had questionable transactions and a “large” amount of money that was unaccounted for with receipts for expenditures. P1 notified VA`s bank of the unusual transactions, closed VA1’s account, and filed a fraud report with the bank and law enforcement. · According to P1, P2, and P3 VA1’s, VA2’s and VA3’s financial information was stored in a locked cabinet in the facility’s office, but all staff persons who worked at the facility had access to VA1’s and VA2’s bank cards and VA3’s petty cash. · P1 stated that during the time frame that the money was missing, the facility did not have any “permanent” staff persons working at the facility. P1, P2, and P3 attempted to contact all of the staff persons who worked at the facility during June and July 2022. P1, P2, and P3 each stated that no one was aware of the missing money. P1 traced two of the CashApp transactions totaling $70 from VA1’s bank statement that were “linked” to a staff person’s (SP) account showing that VA1 had sent the SP money. The SP told P1, P2, and P3 that s/he “had no idea” about the transactions. · P2 and P3 each stated that the facility’s management person “abruptly” stopped working at the facility in December 2021 and P1 did not start until May 2022 which caused a lapse in the monthly oversight of VA1’s, VA2’s, and VA3’s finances. P2 stated that s/he trained P1 on managing the finances at the facility and ensured that P1 and other facility staff persons were using ledgers and maintaining receipts. · According to P1, VA3’s situation was different because VA3 did not have a bank card at the facility and only had petty cash. VA3 typically went shopping with G3 so it was possible that the missing money was from missing or lost receipts that were missed when VA3 was with G3. The facility reimbursed VA3 for the $115 that s/he was missing because it was likely due to the lack of management at the facility. The facility’s personnel files showed that the SP completed training on the facility’s Financial Exploitation procedures on June 10, 2022, and on the Reporting of Maltreatment of Vulnerable Adults Act on April 18, 2022. P1, P2, and P3 were all trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information showed that between June 27 and July 27, 2022, VA1 had unauthorized transactions on his/her bank account totaling $2062.25; in June 2022, VA2 had three unauthorized transactions on his/her bank account totaling $400; and that between January and June 2022, VA3’s petty cash usage was not properly documented and VA3 was missing $115. VA3’s missing petty cash was most likely a result of mismanagement of VA3’s receipts for expenditures, therefore it was not determined that a staff person used VA3’s money without legal authority. It was not 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). However, given that the SP’s and the SP’s significant other’s names, telephone numbers, and address were linked to VA1’s and VA2’s transactions in question, and that the SP’s significant other’s connection to VA1’s and VA2’s money was solely via the SP, there was a preponderance of the evidence that the SP willfully used VA1’s and VA2’s money without 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. The SP was trained on the facility’s Financial Exploitation procedures and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for the 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 financial exploitation for which the SP was responsible was recurring maltreatment because there were multiple transactions for both VA1 and VA2. However, it did not meet the statutory criteria to be determined serious. 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 at the time of the incidents. All current staff persons were retrained on completing money counts after each shift and storing receipts for expenditures. 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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