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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: 1108527-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) cashed a check for a vulnerable adult (VA) and did not give the money to the VA. Date of Incident(s): April 18, 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 and law enforcement records; and through one interview conducted with a facility administrative staff person (P1). Attempts were made via telephone and mail to contact and interview the SP and the VA’s guardian (G). However, neither responded to the requests. The SP provided information to law enforcement and that information is included below. The VA’s Annual Support Plan Authorizations dated January 23, 2024, authorized the facility to manage and store the VA’s funds as well as allowed for the facility to be an “authorized signer” on the VA’s checking account. The VA’s Individual Abuse Prevention Plan stated that the VA was unable to handle financial matters. If the VA received a check, they were to be deposited onto a debit card for the VA, that staff persons were to keep secularly locked until the VA wanted to use it. The VA was to be with staff persons when the card was used and will obtain receipts for purchases. Staff persons documented receipts and the balance to ensure that “there was no tampering with” the VA’s money. The VA was diagnosed with a neurological impairment, paranoid schizophrenia, schizoaffective disorder, bipolar disorder, depression, anxiety, and a diffused traumatic brain injury. Information obtained showed that the G worked for a company who provided professional guardianship services (PGS) to persons. The G and the PGS were also the VA’s representative payee. The VA received a personal needs check from the G, once a month, for $105.00. In addition, the VA preferred to have $25 in cash on his/her person at a time. P1 provided the following consistent information in an interview with this investigator, in a separate interview with law enforcement, and in the facility’s Internal Review: · On April 18, 2024, the SP cashed a personal needs check from the G for the VA. On April 24, 2024, P1 realized that the cash, approximately $100, was missing and unaccounted for. · P1 said it was a “normal” part of the SP’s job to cash checks written out to the VA. The check in question was written out to the SP, which should not have happened. (Note: According to the law enforcement report, on May 8, 2024, a law enforcement officer contacted the PGS who issued the check to the VA. The PGS stated that on an unknown date, the SP called them and stated s/he could not cash the check because it was payable to the VA. The G then issued a new check payable to the SP.) · The facility had a copy of the check. The check for $105, was dated February 13, 2024, payable to the SP, had the SP’s name signed on the back of the check, and was cashed on April 18, 2024, at 9:30 a.m. (Note: A copy of the check provided information that was consistent with the information provided by P1.) · On April 8, 2024, the SP arrived to the facility about 9:45 a.m. At that time, the SP sent an email to P1 resigning from his/her position “effective immediately.” · There was no documentation regarding what the SP did with the money s/he received from cashing the VA’s check. The SP did not complete documentation for the VA’s finances as required. P1 called the SP for more information, but the SP did not return P1’s phone calls. · P1 stated s/he was “not sure” if there were any other times the SP took checks or money from the VA. P1 asked the VA if the SP gave him/her any cash recently and the VA stated that s/he “hadn’t gotten any.” (Note: The facility reviewed the other consumers financial accounts and found no discrepancies or concerns.) The SP provided the following information to law enforcement: · On an unknown date, the VA’s case manager went to the facility and dropped off an envelope with a check inside for the VA. On another unknown date, the SP cashed the VA’s check at a local bank, and the bank charged a fee of $8 which they took from the check. The SP stated that the teller then put the remaining cash, which was $98, in a white envelope with the VA’s name on it. · The SP then went to the facility. The SP stated s/he did not give the envelope to anyone but put it in somewhere but did not remember exactly where. The SP provided the following as possible locations: the armrest of the facility’s vehicle, on top of a stack of paperwork in the facility’s office, or in the SP’s work bag. (Note: When law enforcement followed up with P1 regarding the information provided by the SP, P1 stated that the money was not found in the facility’s vehicle or office.) · Law enforcement asked the SP why s/he put in his/her resignation letter shortly after cashing the check, and the SP stated s/he quit, due to “mental health” reasons. The SP stated that “in retrospect,” s/he believed s/he should have “checked [him/herself] into an institution” regarding his/her mental health at the time. According to the law enforcement report, on May 21, 2024, the SP was charged with theft and the case was sent to the city attorney for review. The facility’s Handling Funds and Property Policy stated, · A person living in a residential site may receive a monthly personal needs check and the money is restricted for the person’s personal use only. Lutheran Social Services (LSS) will assist in maintaining financial records for the person’s finances and accounts separately from other residents of the facility. · When a person supported needs cash, LSS team members may assist them in writing a check made out to themselves for all withdrawals. Do not request cash back from a deposit. Assist the person supported in recording the withdrawal in the check register and in the ledger on the computer. Assist the person supported in recording the transaction on the Personal Cash Record as “Cash from Checking” and record the check number. When people supported manage their own personal cash, they must sign the Personal Cash Receipt Form for the file. · “All deposits should be made with the total check mount into a person’s account. Make a photocopy in the absence of a check stub of all the person’s checks before depositing in their bank account. When depositing multiple checks, record each check separately in the check register and the Quicken ledger. Deposits to a person’s account must be made within five business days. “ The facility documentation showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adult’s Act, additional training specific to financial exploitation including “handling funds and petty cash,” the Handling Funds and Property Policy, and the VA’s plans. Conclusion: A. Maltreatment: Information showed that on April 18, 2024, the SP cashed a $105 personal needs check for the VA, the VA did not receive the cash, and the cash was unaccounted for. Although the SP did not provide information for this investigation and told law enforcement that s/he left the cash in an envelope at the facility, the SP could not recall where s/he left the cash and provided at least three different possibilities, and the cash was not located at the facility or in the locations provided by the SP. Regardless of the check being written out to the SP, the check was for the VA’s personal needs and the SP was the last person to have the money and did not give the money to the VA or anyone else at the facility or ensure that the VA got the money. Therefore, there was a preponderance of the evidence that, in the absence of legal authority, a person willfully withheld or disposed of funds or property of a vulnerable adult. 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 Reporting of Maltreatment of Vulnerable Adults Act, additional training specific to financial exploitation including “handling funds and petty cash,” and the Handling Funds and Property Policy, and on the VA’s plans. 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 did not meet statutory criteria to be determined as recurring or serious, as it did not meet either definition. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. The facility retrained staff on “financial procedures and recordkeeping” and ordered a card for the VA’s personal needs funds to be directly deposited onto. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of the Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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