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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: 1069354-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA1’s) funds for a down payment on a sofa that was delivered to the SP’s home and then secured a loan, in VA1’s name, to finance the remaining portion of the purchase. During the investigation, it was reported that the SP used a vulnerable adult’s (VA2’s) debit card to make purchases for the SP and that another vulnerable adult’s (VA3’s) funds were unaccounted for. Date of Incident(s): Prior to January 3, 2024 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, from the SP’s bank statements, from VA1’s bank statements, and through five interviews conducted with the SP, a community person (CP) who worked at a furniture store, a facility management staff person (P), VA1’s legal representative (G1), and VA3’s legal representative (G3). VA2 was not subject to guardianship. VA1, VA2, and VA3 were each not able to participate in an interview due to their respective disabilities. Regarding VA1: VA1’s support plan showed that s/he enjoyed watching “old-time” TV shows and was a “strong advocate in the past.” The plan showed that VA1 was vulnerable to financial exploitation. VA1’s CSSP Addendum and Support Services Assessment showed that some of his/her diagnoses were a traumatic brain injury (TBI), dementia, and depression. The P provided the following information: · In December 2023, the P began overseeing the facility and reviewed the clients’ bank statements and financial records. · When the P asked the SP to provide receipts, the SP gave the P a document regarding a loan purchase for bedroom furniture for VA1. The document showed a down payment of $50 on April 28, 2023, and then monthly payments, beginning on May 18, 2023, in the amount of $97.23. The P believed that it was the SP that wrote the written narrative at the top of the document, which stated, “For [VA1] bedroom furniture this is for American First Financial.” VA1 did not have any new bedroom furniture. The SP denied writing that on the document. · The P also found a sales receipt from American Freight showing VA1’s name and address as the “customer” for a lamp collection, delivery charge, and two sofas (the SP provided the same document to this investigator, but the SP’s name and address was listed as the customer and not VA1’s name and address). The document stated that the delivery date was May 3, 2023. G1 said that VA1 would not have the ability to make purchases for new furniture and G1 was not aware of any new furniture that VA1 received. The CP stated that s/he did not have much access to past customer information but provided the last four digits on file of the bank card used to make the initial purchase. The P stated that the last four digits of VA1’s bank card were different than what was on file for the purchase so was not VA1’s bank card. The SP provided the following information: · In May 2023, the SP purchased furniture at the store. The SP secured a loan, in his/her name, and set up monthly payments in the amount of $97.23 to be taken from his/her bank account, beginning in June 2023. · In September 2023, the store called the SP because they were unable to take funds from the SP’s account because the SP had closed that account and not provided a new card number. · The SP was working so after a community outing with VA1, the SP and VA1 went to the store. When they got to the store, the SP “didn’t pay attention” and gave the store VA1’s card, which would be used for future monthly payments. · The SP thought that money was coming out of his/her account after that and had not checked his/her bank statements to ensure the payments were being made. The SP was not aware until told by the P that VA1’s card was being charged $97.23 for each payment. The SP’s loan information provided the following information: · The “loan agreement” for the furniture store began on April 28, 2023, and showed the SP as the “borrower.” · The SP financed a total of $1,1417.50 (which included a loan origination fee of $67.50) and set up payments “every two weeks starting on [May 5, 2023],” in the amount of $97.23 and then one final payment of $97.33 on October 31, 2024. The SP’s bank statements provided the following information: · On May 18, 2023, a payment was made to the furniture store in the amount of $97.23. · On June 1, 15 and 29, 2023, payments were made to the furniture store in the amount of $97.23 each. · On July 13, 2023, a payment was made to the furniture store in the amount of $97.23. VA1’s bank statements provided the following information: · On August 14, 2023, a payment was made to the furniture store in the amount of $97.23. · On September 11, 2023, a payment was made to the furniture store in the amount of $97.23. · On October 10 and 30, 2023, payments were made to the furniture store in the amount of $97.23 each. The P stated that VA1’s account was closed in November 2023, so no further payments were taken. Information from the investigation showed that the SP repaid VA1. Regarding VA2: VA2’s support plan showed that s/he enjoyed “coloring,” watching television, and “playing games” on his/her “personal computer.” Although information showed that VA2 had a mild developmental disability, VA2’s file did not provide information in terms of his/her ability to make purchases or his/her ability to handle financial transactions. When the P reviewed VA2’s financial records, the P noted several transactions that the P thought were questionable and for purchases not made by VA2, such as online purchases from Amazon. The P also stated that there were unopened boxes shipped to the facility with VA2’s name on the box for purchases, such as dishes, but when the P asked VA2 about the purchases, VA2 did not remember making them. The P stated that VA2 would need assistance to make online purchases. The P believed that about $700 was unaccounted for from VA2’s account. A review of VA2’s bank statements showed several online purchases to various companies such as Target.com and Amazon. The P stated that VA2 was in possession of some of these items. The SP stated that VA2 did have the ability to make online purchases and did so several times. The SP denied using VA2’s funds for purchases for the SP. Regarding VA3: The P stated that when s/he reviewed client records in December 2023, s/he noted that approximately $600 of VA3’s funds, which were stored in a locked safe (all staff persons had access to the safe) were unaccounted for because there were “very few” receipts. The P stated that G3 would periodically drop off various amounts of cash at the facility to be used when VA3 wanted to go into the community and make purchases. When the P checked the safe, there was no money left and “very few receipts.” There was no ledger kept so when the P saw VA3 had no money in the safe, s/he asked G3 how much money “recently” had been brought to the facility for VA3. G3 said “around” $600. The P believed that the SP was responsible for the missing money but did not state why s/he thought that. G3 stated that s/he or another family member provided the following amount of money to the facility: · On February 18, 2023, $200 was dropped off. · On April 14, 2023, $200 was dropped off. · On June 8, $200 was dropped off. · On July 22, 2023, $200 was dropped off. · On October 6, 2023, $200 was dropped off. · On November 10, 2023, $200 was dropped off. The facility had a Financials policy, which stated that staff persons were to “provide receipts and disbursements of client’s funds or property, and include the signature of the client, conservator or payee as appropriate,” and “provide a statement itemizing receipts and disbursements of the client’s funds or other property of the client and/or legal representatives at least annually.” The SP denied taking any of VA3’s funds but stated that there were numerous occasions when the SP took VA3 into the community to shop and/or go out to eat or have coffee and when that happened, the SP left receipts in the safe. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to December 2023. Relevant Rules and/or Statutes: Minnesota Statute 245A.04, subdivision 13 requires the license holder to document receipt and disbursement of client funds. A. Maltreatment: Regarding VA1 In December 2023, the P reviewed VA1’s bank statements and financial records and found a loan document for bedroom furniture for VA1, but VA1 did not purchase or receive that furniture. The document showed a down payment of $50 on April 28, 2023, and then payments, beginning on May 18, 2023, in the amount of $97.23. The SP stated that s/he purchased the furniture for his/her personal use and the SP’s bank statements showed that s/he made five payments ($97.23 and a total of $486.59) from his/her account. The SP stated that s/he closed that account and inadvertently did not provide a new account number for future payments to be taken from. When the SP heard that from the finance company, the SP went to the store and provided a new account number and mistakenly gave the clerk VA1’s debit card (the SP and VA1 were in the community at the time). The SP stated that s/he had not checked his/her account to ensure that the payments were coming out of his/her account and was not aware this was happening until the P told the SP. VA1’s bank statements showed that VA1 made a total of four payments ($97.34 each for a total of $389.36) from August 14, 2023, through October 30, 2023 (VA1’s account was closed in November 2023). Although some of the documentation showed conflicting information, such as the name of the “customer” on the sales slip in which the P had a copy with VA1’s name on it and the SP had a copy with the SP’s name on it, the SP’s bank statements, and loan document supported that the SP took out the loan in his/her name and made payments until July 2023. In August 2023, the SP provided VA1’s card instead of his/her own for the remainder of the payments. Although the SP paid VA1 back and said s/he gave VA1’s card by mistake, given that there were four payments taken from VA1’s account before anyone, including the SP, realized this was happening totaling $389.36, that the SP as a staff person was responsible for safeguarding VA1’s funds, and that VA1 did not have those funds to use during that time, there was a preponderance of the evidence that the SP withheld VA1’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). Regarding VA2: The P saw that VA2 had several online purchases. Although the P thought that VA2 did not have the ability to make online purchases, the SP, who denied using VA2’s funds, stated that VA2 had that ability and there was no information in VA2’s plans to suggest that VA2 had an impairment in that area. The P stated that some of the items purchased online were in VA2’s possession and some boxes at the facility had VA2’s name on them with contents purchased with VA2’s account. Given that there was no further information how the purchases were made, that VA2 had items that were purchased in his/her possession, and that the SP denied using VA2’s funds, there was not a preponderance of the evidence whether the SP used VA2’s funds in the absence of legal authority. It was not determined whether 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 VA3 G3 stated that between February 18 and November 10, 2023, G3 or another family member dropped off a total of $1,200 at the facility for VA3. When the P reviewed VA3’s finances, the P saw that VA3 did not have any money at the facility and “very few” receipts. The P asked G3 how much money was “recently” brought to the facility for VA3 and G3 stated around $600. With that information, the P determined that $600 was unaccounted for. However, the facility did not keep a ledger of VA3’s funds which was a violation of Minnesota Statute 245A.04, subdivision 13, so there was no documentation of how much money was dropped off, used, or remaining. Although the P believed that the SP took or used VA3’s funds not for VA3, given that all staff persons had access to the safe, that the SP stated s/he took VA3 to make purchases and provided receipts, that other staff persons could have taken VA3 out to spend money and not brought back receipts, and that there was no further information regarding how VA3’s money was spent because of the lack of documentation, there was not a preponderance of the evidence whether the SP or any other staff person used VA3’s funds without legal authority. It was not determined whether 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. Given that the SP was trained in the reporting of Maltreatment of Vulnerable Adults Act, the SP was responsible for financial exploitation of VA1. 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 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 four occurrences where VA1’s money was used. The substantiated financial exploitation was not “serious” maltreatment because it did not meet the definition. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that although policies and procedures were adequate, they were not followed, but the review did not indicate what was not followed. The review also determined that additional training was not needed. 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. On April 26, 2024, the facility was issued a correction order for the violations outlined in this report.
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