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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: 1075536-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) took four money orders that belonged to a vulnerable adult (VA), forged his/her name on the money orders, and cashed them for him/herself totaling $3,216. Date of Incident(s): Prior to September 8, 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through seven interviews conducted with three facility supervisory staff persons (P1, P3, and P4), two administrative persons (P2 and P6), the VA’s case manager (CM), and the VA. Attempts were made via telephone, mail, and e-mail to contact and interview the SP, but the SP did not respond to the requests. The VA’s Community Support Plan stated the VA was a quiet, calm, and creative person. The VA was also really good with computers and was interested in graphic design and his/her dream was to have a career in creating animation on the computer. The VA was diagnosed with unspecified anxiety disorder, persistent depressive disorder, and reactive attachment disorder. The VA was working on his/her financial skills and knew when bills were due but was still learning how to pay them. Staff persons verbally walked the VA though the steps for each bill and helped the VA complete paperwork. The VA was at risk for self-neglect due to cognitive impairments and an inability to manager his/her finances. The VA was not subject to guardianship. Requests were made to review the VA’s Individual Abuse Protection Plan (IAPP). The IAPP provided was implemented and signed after the incidents. The facility was unable to locate an IAPP for the VA that was in place at the time of the incident which was a violation of Minnesota Statutes section 245D.071, subdivision 2, which states that prior to or upon initiating services, the license holder but develop, document, and implement an abuse prevention plan according to section 245A.65, subdivision 2. The SP’s job description included responsibility for the culture and programming of their assigned area. (Note: The SP oversaw three different facilities/sites within the company, one of which the VA resided at.) The SP was responsible for developing, implementing, and monitoring individualized programming and plans, assuring effective implementation when created, or changing an individual’s plan. The SP worked with the site managers (one manager at each facility) to supervise, develop, motivate, and evaluate them. The SP was to maintain a current profit and loss statement assuring fiscal integrity and assure appropriate expenses for each assigned facility and that financial responsibility was maintained by adhering to assigned programming budgets. The SP was responsible to monitor, collect, and submit resident rental payments directly to the operations manager on a monthly basis. The facility’s Internal Review provided the following information: · On August 9, 2023, P1 dropped off the VA’s rent check, dated July 26, 2023, to the facility’s main office and learned that the VA was behind on his/her rent payments. It was “suspected” that rent payments were previously not turned in; however, P1 found no other checks (money orders) at the facility for the VA. · On September 6, 2023, P1 went to the facility’s main office again to drop off the VA’s rent payment, dated August 30, 2023. On the way home from the office, P1 called the VA and asked if s/he previously received money orders each month to pay rent. The VA said that s/he had and that s/he turned them into staff. P1 then told the VA s/he was behind on rent and asked if the VA would be okay going with P1 to the bank to find out more information to which the VA agreed. · On September 7, 2023, the VA and P1 went to the VA’s bank and received a printout of the VA’s account and money orders the VA had previously purchased. At that time, they were unable to get any further information and the bank manager told them to call the next day to inquire about obtaining additional pictures of processed and cashed money orders. The following day, P1 and the VA called the bank and the bank manager said it would be best to come back in person, so they went to the bank. When they arrived, they showed the bank manager the printout with the dates the money orders were purchased that they received the previous day. The bank manager asked the VA if s/he had any stubs that had been attached to the money orders. P1, with the VA’s permission, emailed copies of them to the bank manager to assist in finding the pictures of the cashed/processed money orders. The VA then received an email from the bank and forwarded it to P1. It was learned that four money orders were written out to the SP totaling $3,216.00—none of which were received by the facility for the VA’s rent. Four Personal Money Orders provided the following information: · The dates typed on the money orders were March 19, May 2, and two dated June 6, 2023. Each money order was for $804. · The SP’s name was written on the “pay to the order of” line of the four money orders. · The March 19 and May 2, 2023, money orders had the VA’s name signed as the “Purchaser’s Signature.” The two dated June 6, 2023, had a different illegible signature as the “Purchaser’s Signature.” Law enforcement (LE) records and bank records obtained by LE provided the following information: · On September 11, 2023, a law enforcement officer (LEO1) talked to P1 regarding the money orders made out to the SP. P1 said that when the VA gave staff his/her money order each month for the facility for rent ($804), the VA did not fill in the “pay to the order of” line but instead left it blank.
· The SP’s bank records showed that on June 8, 2023, the SP deposited two of the VA’s money orders (dated March 15, and May 2, 2023), into his/her personal bank account. On June 14, 2023, the SP deposited two additional money orders of the VA’s (both dated June 6, 2023), into his/her personal bank account. · On September 26, 2023, another law enforcement officer (LEO2) reviewed the SP’s personal bank records related to the four money orders and on June 25, 2023, it appeared that the majority of the money was transferred to the SP’s primary savings account because the SP transferred $3,500. LEO2 reviewed other endorsed/deposited checks and believed they were consistent with being written by the same person who signed the stolen checks from the VA. · On September 29, 2023, LEO1 talked to the VA and P1 who told LEO1 consistent information that was in the Internal Review. The VA also stated that the SP usually took the blank money orders and the VA assumed the SP brought them where they needed to go. The VA was unaware that the SP wrote his/her own name on the VA’s money orders and stated that s/he never gave the SP permission to do so. · At some point prior to September 11, 2023, the SP moved out of state. On November 11, 2023, LEO2 spoke with an out of state law enforcement officer (LEO3), who located and spoke to the SP at his/her new residence. The SP acknowledged working at the facility in Minnesota in the past. When LEO3 asked the SP if s/he knew anything about the VA’s money orders being deposited into his/her bank account, the SP denied it. However, when LEO3 told the SP that s/he was told that the SP deposited three or four of the VA’s money orders into his/her bank account, the SP then said s/he “didn’t remember” and stated that the “system they had there (the facility) wasn’t a very good system.” · On December 7, 2023, LEO2 telephoned the SP and told the SP about the allegations. The SP stated that normally s/he collected money orders and drove them to the facility’s bank in the metro area, but “towards the end” of his/her employment, s/he was not doing that because s/he was “so busy” training people. The SP told LEO2 that other facility’s s/he supervised needed money, so s/he took the VA’s money and gave cash to the sites. The SP said that it was done in the past which s/he knew was not “kosher.” The SP said that the VA’s rent was supposed to be “written off as paid,” however, LEO2 told the SP that it was not. At that point during the conversation, the SP acknowledged the funds were deposited into his/her personal bank account and s/he said s/he then withdrew the funds and gave cash to the homes “the very next day at the least” and gave it to the site managers. The SP said there was a “big cash bag” at each location to be used for the clients. The SP told LEO2 that s/he managed two different sites/facilities that were part of the same company. (Note: According to facility documentation, the SP managed three sites.) The SP said that P6 approved what the SP had done. The SP initially stated s/he thought that P6 meant that the SP should cash the money orders but then s/he stated “maybe [P6] meant [the VA] should.” The SP denied having personal “money problems” at that time but understood “how this looked.” After LEO2 told the SP more information regarding his/her bank account transactions, the SP then said that s/he was “struggling” at the time, but that “a lot” of money was given to the sites s/he supervised but that s/he kept “half” of the money if s/he had to “ballpark it” for him/herself. The SP said, “It was stupid, it was dumb,” and s/he “wished” s/he “never” would have done it, but that s/he did it and made “the choice” and said s/he would “never do it again.”
· On May 1, 2024, LEO2 talked to P6, who was aware of the allegations regarding the VA’s money orders. P6 said s/he was not involved with the exchange of money orders and around that time, the SP was telling the staff that the VA did not have money to pay rent. P6 said that if the SP received funds, it was his/her responsibility to tell the facility so that it could be properly recorded. P6 said the SP was “never authorized” to do anything like s/he did, and they did not authorize an employee to deposit client’s funds into their own personal accounts. P6 said every site had credit cards and cash for the staff to use for the facilities and was not aware that the SP sent money electronically to other staff persons and would not have advised the SP to do that. P6 also stated that before the SP left the facility, s/he told P6 “good luck” with getting the VA’s money from his/her team. Sometime later, P6 felt the SP stated that as if s/he was trying to portray the situation as something different and be “deceptive.” P6 said the SP was “in charge” of three different sites and that there was a cash bag with low amounts of cash for programming activities approximately $70 but the SP also had a credit card she could have used. · The facility reimbursed the VA so the VA no longer owed the facility any rent. · The SP was charged with two counts of financial exploitation of a vulnerable adult and one count of theft by swindle. The VA provided information during his/her interview that was consistent with the information the VA provided in the Internal Review and the LE reports. The VA said that a couple months prior to October 2023, the facility manager changed from the SP to P1 and at that time the VA was told s/he was missing four rent payments. The VA was “pretty sure” s/he turned them in because s/he obtained money orders for them and then gave them to the SP. The “pay to the order of” on the money orders were blank which the VA had been doing that since shortly after s/he moved into the facility in 2020. The VA had no previous concerns with the SP and said the SP was “very nice.” P1 provided information during his/her interview that was consistent with the information P1 provided in the Internal Review and the LE reports. P1 said s/he replaced the SP’s position, which oversaw three facilities at the company, one of which the VA resided in. P1’s position reported to P6. If any of the three facilities needed something purchased such as groceries, household activities, cleaning supplies, med envelopes, or other basic things, P1 and each site manager had a company credit card or checkbook they could use. P1 never had to use his/her own money for the company, but one time remembered s/he used his/her own credit card for an Amazon purchase but was able to get reimbursed for it. Normally, P1 used his/her personal Amazon account but linked the company’s credit card for company purchases and then submitted receipts. The site managers did not need to send each other money for company use and did not need to use their own money. P2 said that sometime in September 2023, P2 was made aware of the situation with the VA and his/her rent money orders and that the SP had written three or four of the VA’s rent money orders to him/herself. The SP was responsible for collecting the VA’s rent payment and giving it to the facility. P3 and P4 each worked at different facilities from where the VA lived. Each did not have direct knowledge of the allegations including the SP taking and cashing the VA’s money orders.
P6 provided information during his/her interview that was consistent with the information s/he provided to LE. P6 stated s/he did not give the SP permission to cash or deposit the VA’s rent money orders into his/her personal account and there would not be a reason for the SP to have done so for the company. The CM said s/he heard about the incident from P1, and that after the incident staff persons now had the bank write out who the “pay to the order of” was for on the VA’s money orders. The SP, P1, P3, and P4 were trained on the Reporting of Maltreatment of Vulnerable Adults Act which included training on financial exploitation of vulnerable adults. The SP and P1 were trained on the VA’s plans. Based on P3’s and P4’s position at the facility they were not required to be trained on the VA’s plans. Conclusion: A. Maltreatment: Information was consistent that the SP deposited four of the VA’s money orders (totaling $3,216) into his/her personal bank account. The SP did not provide information for this investigation but when s/he talked to LEO1, s/he initially denied having done so. But then told LEO2 that P6 gave him/her permission to do so and to disperse the cash to the different sites. P6 denied giving the SP permission to do so and the VA was not subject to guardianship and handled his/her own finances, so P6 would not have the legal authority to authorize the SP depositing the VA’s money orders into the SP’s personal account. In addition, the VA said s/he did not give the SP permission to do so. The SP acknowledged keeping approximately “half” of the VA’s money for him/herself, but according to the SP’s bank records obtained by LE, it appeared that the majority of the money was transferred to the SP’s primary savings account because s/he transferred $3,500. Therefore, 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 received training on the Reporting of Maltreatment of Vulnerable Adults Act, which included training on financial exploitation of vulnerable adults, and on the VA’s plans. The SP stated s/he deposited the VA’s money orders into his/her personal bank account and dispersed half the money and kept half the money. The SP was responsible for the 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 but not serious maltreatment. The SP deposited four of the VA’s money orders on two dates June 8 and 14, 2023. Action Taken by Facility: The facility completed an Internal Review which stated that their policies and procedures were adequate, but not followed. Additionally, corrective action was put in place that all residents would be encouraged to mail their rent payments to the corporate office. Should a resident not be able to or is unwilling to mail the rent payment, they will hand deliver the rent payment to the designated manager or the program director, who will provide the resident with a receipt and make sure that the rent payment is filled out correctly. If a resident hands in a blank money order or check, the supervisory staff person will educate the resident on the importance of filling it out correctly. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On September 20, 2024, the facility was issued a correction order for the violation outlined above and for failing to have training records for a staff person. In addition, the facility was issued an Order to Forfeit a Fine of $200 for failing to initiate a background study on a person who was required to have a background study.
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