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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: 1071702-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Beth Virden 651-431-3444 christine.henne@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA’s) debit card for his/her personal use. Date of Incident(s): Ongoing between August and October 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 was obtained remotely; from documentation at the facility and law enforcement records; and through interviews conducted with the VA’s guardian (G) and two facility supervisory staff persons (P1 and P2). The VA was also interviewed; however, did not recall the incident or provide additional information. In addition, attempts were made by telephone, mail, and email to contact and interview the SP; however, the SP did not respond by the completion of this investigation. The VA’s support plan and support plan addendum provided the following information: · In April 2021, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included moderate intellectual disability. · “Working and making money is important to [the VA] because [s/he] likes to be active in [his/her] community and spend money buying things [s/he] wants.” · The VA was susceptible to financial exploitation by others and would not understand or independently report suspected financial exploitation. The VA had a representative payee (rep payee), who helped with payments and bills. The VA worked and earned a paycheck, which was deposited into a checking account. The VA then had a debit card for this checking account, which s/he used for personal needs and wants. Staff persons intervened and/or reported suspected or known financial exploitation on the VA’s behalf. The facility was a single-family home where the VA lived with three housemates. The facility provided at least one staff person 24-hours a day for care and supervision. [Note: The facility completed financial audits of all the housemates’ finances and did not uncover discrepancies, except with the VA.] A Law Enforcement Report included the following: · On October 26, 2023, a law enforcement officer (LEO) received a report of fraud involving the VA’s debit card. · Information was provided that the VA’s debit card was supposed to be stored in a staff office; however, it was not there. Staff persons and the VA could not locate the card so they called the bank to cancel the card and obtained recent bank statements. The statements showed “several purchases (and withdrawals from automated teller machines, ATMs) … not made by [the VA] due to [him/her] only staying in St. Cloud and some of the locations where the purchases were made included Minneapolis/St. Paul area and areas in St. Cloud where [the VA] does not frequent.” The purchases and ATM withdrawals, which were determined to have not been made by or for the VA, occurred between September 11 and October 4, 2023, and totaled $3092.64.
· The debit card could only be used with a personal identification number (PIN). “The only individuals who would have had access to the PIN were [the VA], [the SP], and [P1].” · The LEO obtained camera footage of a self-checkout machine at Walmart on September 11, 2023. The footage showed a person using the VA’s debit card to make a purchase of $104.66 with a $60 cashback withdrawal. “I confirmed the identity of the [fe/male] to be [the SP]. The video shows [the SP] walking to the main door to have [his/her] receipt checked by staff, which provided another angle for identification.” The VA was not with the SP. · The LEO also confirmed withdrawals using the VA’s debit card at ATMs in Minneapolis and Brooklyn Center, and areas of St. Cloud; the VA did not go to these cities or areas and would not have been able to without staff. · This matter was referred to the county attorney for review of criminal charges. The G said that the VA did not use his/her debit card independently. “[The VA] wouldn’t really know how to do that plus staff would have to take [him/her] to do it anyway.” This incident caused the VA to be without money for a period. The VA wanted to buy an iPad at one point but did not have enough money at the time due to this incident. “[The VA] really doesn’t understand why.” P1 and P2 provided the following consistent information: · On September 21, 2023, the SP’s employment at the facility ended for unrelated reasons. · At the beginning of October 2023, the VA wanted to buy a new coat for the upcoming winter season. At that time, it was discovered the VA’s debit card was not in its intended spot. The card should have been locked in a safe, in a locked cabinet, in a locked staff office but it was not there. P1 asked all staff about the card’s location, and no one knew where it was. P1 also had the VA search his/her bedroom while P1 searched the staff office but it was not found. · P2 said that the VA did not typically do a lot of shopping. “[The VA] doesn’t need many things and doesn’t ask a lot to go buy something.” Because of this, the debit card was not immediately noticed missing, and it was not known when it went missing. · The VA told P1, “I think [the SP] had [my debit card] last. I think [the SP] took my card.” The VA believed that the SP took the debit card at some point prior to his/her last day of employment. P1 added that the VA was the first person to mention the SP’s name in connection to the missing debit card. · P2 said that the VA was “upset … mad” and “didn’t understand why someone would steal [his/her] card.” · P1 and the SP shared the staff office. The SP had access to the cabinet and safe that held the VA’s debit card. One time, P1 asked the SP if s/he knew the PIN for the VA’s debit card and the SP “spouted it out to me … by heart” without needing to check any documents or look it up. · The facility did not have a way to track the debit card usage. The monthly bank statements were sent to the VA’s rep payee, not to the facility or guardian. The facility also did not have access to view the VA’s online statements for his/her debit card. Staff were supposed to keep receipts for purchases on the debit card in the safe. There were some receipts for purchases that were known to have been completed by the VA, but there were receipts missing. · The SP had family and/or frequented the areas where the debit card was used, including Minneapolis, St. Paul, and Brooklyn Center. In addition, some of the ATM withdrawals in the St. Cloud area were near the SP’s house. The transactions, which included cashback, were not something the VA ever did. The facility’s policies and procedures included the following: · The facility might assist individuals in managing their personal funds and benefits. This might include the use of a prepaid card system that includes a debit card. The facility takes its responsibility of personal funds management seriously and has specific policies and procedures in place to address how funds may be spent, who may access those funds, the process for tracking expenses, collecting and retaining receipts, and the misuse of funds or property. · Misuse or funds or property belonging to an individual might be considered misappropriation or financial exploitation and is not tolerated. · Staff were responsible to ensure funds were spent appropriately. · Staff were responsible to maintain documentation to support all transactions, including receipts. Facility documentation stated that the SP and P1 received training on the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP also received training on the VA’s support plan and support plan addendum. P1 was listed on the VA’s support plan and support plan addendum as being a creator or contributor. P2 worked in an administrative role and was not required to receive the same training as the SP and P1. Conclusion: A. Maltreatment: Information was provided that at some point prior to October 26, 2023, the VA’s debit card was removed from the facility’s safe and not returned. The bank statements associated with the debit card showed 13 transactions between September 11 and October 4, 2023, which were determined to have not been made by or for the VA that totaled $3092.64. Many of the transactions occurred in cities and areas where the VA did not go. The VA told P1 that the SP was the last person to have his/her debit card. P1 provided information that the SP had access to the staff office and the safe. The SP also had access to the VA’s debit card PIN. The LEO reviewed camera footage associated to one of the fraudulent transactions and saw the SP on camera using the VA’s debit card. The VA was not with the SP at the time. Although the SP did not provide information for this investigation, given the aforementioned there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used, withheld, and/or disposed of funds of the VA. 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 responsible for the VA’s care and supervision. The VA said the last person to have the VA’s card was the SP, P1 said s/he asked the SP if s/he knew the PIN for the VA’s debit card and the SP “spouted it out to me … by heart” without needing to check any documents or look it up; and the SP was seen on video using the VA’s card at Walmart which included cash back and the VA was not with the SP. The SP received training on the VA’s support plan and support plan addendum, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for 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 the SP was responsible was “recurring” maltreatment. The SP was responsible for misusing the VA’s debit card 13 times between September 11 and October 4, 2023. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility reimbursed the VA for his/her missing money and provided additional training to staff persons. The SP was no longer employed. 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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