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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: 1071609-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 staff person (SP) used two vulnerable adult’s (VA1 and VA2) debit cards to purchase things and make cash withdrawals not for VA1 and VA2 and when the SP was not clocked in at work. Date of Incident(s): Multiple between April 19, 2024 and May 13, 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 was obtained during a site visit conducted on July 19, 2024; from documentation at the facility and law enforcement records; and through one interview conducted with a supervisory staff person (P). Initial contact was made with the SP via certified letter and then telephone. When the SP responded an interview was scheduled for a later date. At the mutually agreed upon time, the SP did not answer the phone and did return subsequent messages left. The SP provided information to law enforcement and that information is included below. This investigator called VA1’s guardian (G), but the G did not respond to messages left. VA2 was not subject to guardianship. This investigator met VA2, but s/he did not have information to provide regarding this investigation. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 did not understand banking concepts and was not able to manage financial accounts. The facility was VA1’s representative payee and his/her personal needs checks were deposited into a bank account that is accessed through a debit card. VA1’s account was monitored by facility supervisors and receipts were obtained for each purchase and “filed for reference.” VA1 enjoyed playing bingo, hunting, and fishing. According to VA2’s IAPP, VA2 “needs and desires assistance in managing [his/her] finances.” VA2’s funds were kept in a “locked location,” managed by the program supervisor, and reviewed by the program director “periodically.” Receipts were collected for all transactions and a ledger a was kept on site. VA2 enjoyed woodworking, shopping and drinking coffee. According to information provided by the facility, the following transactions totaling $683.55, were made using VA1’s card for which no receipts were found: · April 19, 2024, two purchases at Walmart for $123 and $126.96. · May 5, 6, and 7, 2024, at Northdale for $5.70, $6.24 and $9.42 respectively. · May 8, 2024, two purchases at Walmart for $6.45 and $109.02. · May 9, 2024, two purchases at Walmart for $101.37 and $126.95. · May 13, 2024, one purchase at Dollar Tree for $28.55 and an ATM Withdrawal for $40. According to information provided by the facility, a purchase on May 12, 2024, a purchase for $37.69 was made using VA2’s card for items that were not for VA2. According to the facility’s Financial Policy, cash on hand for each resident should not exceed $50. Methods for obtaining cash may include use of a prepaid or debit card. Additionally, circumstances that exceed the specified dollar amount require area director approval. According to law enforcement records and an interview with LE: · The SP had access to the resident’s bank cards and had been making personal transactions with VA1 and VA2’s debit cards. VA1’s bank statement showed charges totaling $683.84 for transactions that were not made for VA1. A transaction receipt from Walmart showed a purchase on VA2’s debit card for $37.69 that was not made for VA2. · Law Enforcement reviewed receipts and viewed security camera footage for the Walmart transactions and found that the SP made the following transactions at a self-checkout using VA1’s card: o April 19, 2024, at 1:16 p.m. for $123that included a belt, an NFL youth t-shirt, an NFL hat, and $100 cash. o April 19, 2024, at 1:17 p.m. for $126.96 that included men’s jeans, women’s jeans, and $80 cash. o May 8, 2024, at 7:38 a.m. for $109.02 that included a mug, an energy drink, and$100 cash. o May 8, 2024, at 7:39 a.m. for $6.45 for a mug. o May 9, 2024, at 12:14 p.m. for $126.95 that included a tumbler and $100. o May 9, 2024, at 12:15 p.m. for $101.37 that included tea and $100 cash. · Law enforcement also reviewed receipts and security camera footage that showed the SP used VA2’s debit card on May 12, 2024, at 12:04 p.m. for $37.69 that included one dozen roses and a vase. · The P stated that VA1 “usually has about $15” in cash at a time. The P also stated that VA1 did not recently have any large amounts of cash, and that s/he had typically $15 in cash “since January.” · The G told law enforcement that s/he would not have authorized the above transactions for VA1. · The SP told law enforcement s/he “pulled out cash” at the self-checkout for VA1 because VA1 requested cash to “carry around” the facility. The SP also stated that s/he had access to VA1’s card to conduct purchases on behalf of VA1. · The SP was arrested and charged with felony theft. The P provided the following information in an interview with his investigation and in the facility’s Internal Review: · The SP had access to VA1’s and VA2’s debit cards to purchase things for each. If staff persons wanted to use the cards, they were instructed to ask a supervisor for. · Around May 12, 2024, the SP offered to purchase flowers for VA2 and accompany him/her to a family members gravesite. After that weekend, “around the middle of May,” the P was told by another staff person that the SP did not take the VA2 to the gravesite or give VA2 any flowers to take to the gravesite. The P reviewed VA2’s online bank account and saw an in-store purchase at Walmart. The P then got the receipt online from Walmart that showed the purchase was for a dozen roses and a vase. The P never saw roses or a vase at the facility. · The SP was responsible for auditing VA1’s bank account and had access to VA1’s account online. On an unknown date, the P was at the facility and saw that a paper copy of VA1’s bank statement was mailed to the facility. The P reviewed the statement and then found that the SP was “hiding” older paper copies of bank statements in drawers at the facility. The P then reviewed all of VA1’s transactions for April and May 2024 and found ten transactions and an ATM withdrawal that had no receipts for expenditures, and reported what s/he found to his/her supervisor. · The P also discovered that the SP made “fraudulent” charges on his/her company credit card. (Note: The Department of Human Services did not have jurisdiction for money taken from the facility. Therefore, the focus of this investigation was solely regarding VA1’s and VA2’s accounts.) After discovering all the fraudulent charges, the P attempted to contact the SP to set up a meeting to discuss the charges but the SP “blocked” the P and other staff persons from contacting the SP. The P had no additional contact with the SP. Facility documentation showed that the SP was trained on the facility’s financial policies, VA1’s and VA2’s support plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information provided by the P and law enforcement including a review of Walmart security camera footage and receipts showed that there were at least six charges made for purchases and cash withdrawals with VA1’s card at Walmart that were not for VA1 and one charge made with VA2’s card at Walmart that was not for VA2. The SP told law enforcement that on one occasion s/he withdrew cash for VA1, however, P1 stated that VA1 never had more than $15 in petty cash. Given that the G told law enforcement that s/he did not authorize the purchases, that some of the purchases for VA1 were not in VA1’s possession, and that VA2 did not have roses or a vase at any point, there was a preponderance of the evidence that, in the absence of legal authority, a person willfully used and withheld funds or property of VA1 and VA2. 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, the facility’s financial policies, and VA1’s and VA2’s plans. 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 because the SP made multiple purchases, on multiple dates, with two VAs’ debit cards. The maltreatment was not determined to be serious, 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 found that policies and procedures were adequate but not followed and there was a need for additional staff training. The SP no longer worked at the facility. The facility reimbursed VA1 and VA2. 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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