MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1091220-H_CRS (Home and Community-Based Services-Community Residential Setting)
1070299-HCBS (Home and Community-Based Services)

Investigator(s):

Emily Kearns
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6513

Suspected Maltreatment Reported:

It was reported that a staff person (SP) used the debit cards of two vulnerable adults (VA1 and VA2).

Date of Incident(s): June 6, 2024 and June 8, 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 11, 2024; from documentation at the facility; and through six interviews conducted with two facility supervisors (P1 and P2), VA1’s and VA2’s guardians (G1 and G2 respectively), VA2, and the SP. This investigator met with VA1, but VA1 was not able to provide information related to the investigation.

The facility was a single-story residence with walk-out basement. The main floor consisted of three bedrooms, a bathroom, a kitchen, a living room, and a dining room space and the lower level had a bathroom, a bedroom, a staff person office, and an open area. In a corner of the main floor living room, was a small workstation with several locked cabinets. The cabinets contained medications and client debit cards. VA2’s bedroom was in the lower level and VA1’s bedroom was on the main floor.

VA1 was diagnosed with moderate intellectual disabilities, Type 2 diabetes, an anxiety disorder, and had limited eyesight. Per VA1’s plans, s/he would not recognize mismanagement of his/her finances. VA1 enjoyed word search puzzles, getting McDonald’s coffee, going out to eat, and spending time alone.

VA2 was diagnosed with mild intellectual disabilities, traumatic brain injury, paranoid schizophrenia, anxiety disorder, and explosive personality disorder. VA2 enjoyed playing cards, going on outings, and chatting with new people, and loved animals.

VA2 provided the following information:

· VA2 lived with three other clients at the facility, and one day, they all went out in the community with the SP where they made several stops. VA2 only went out once with the SP which was the date of the incident. VA2 held onto his/her debit card when s/he went out for shopping trips and showed this investigator the pouch s/he used to carry his/her identification card, checkbook, debit card, and receipts to bring back from purchases. The day of the incident, the SP took VA2’s debit card out of VA2’s hand and said, “I need to hold on to this.” VA2 said that s/he needed to have the card back and the SP said, “Well, it will be okay.” VA2 did not feel like it was going to be “okay” because s/he had “always had the right to keep” his/her debit card. VA2 seldomly used his/her checkbook but used his/her debit card when spending money. The card and checkbook were stored in the medication cabinet at the facility when they were not in use.

· The SP took VA2 to Walmart and used VA2’s debit card to purchase a cell phone on a separate receipt at the electronics counter in the back of the store and then later, when VA2 was paying for his/her items at the front of the store, which included a box of chips, a bag of candy, some hair ties, and deodorant, the SP also added deodorant and a bag of candy to VA2’s items to purchase. VA2 did not know that the SP did that at the time and learned of it later. VA2 could not recall what the cell phone looked like. VA2 did not have any cell phones and only had one deodorant, one bag of candy, the chips, and the hair ties in his/her possession.

· The SP took VA2 to McDonald’s where the SP ordered a coffee and breakfast sandwich for him/herself and a Dr. Pepper soda for VA2. The SP used VA2’s debit card to pay for VA2’s and the SP’s orders. VA2 could not recall how much that orders cost.

· The SP took VA2 to Culver’s and purchased lunch for both the SP and VA2. At the time, VA2 thought that the SP was purchasing lunch for them both with the SP’s card but later learned that the SP used VA2’s card.

· The SP then drove to a Walgreens or CVS Pharmacy where there was an automated teller machine (ATM). VA2 tried to get out of the vehicle and stated that s/he wanted to come into the store, but the SP told VA2 that s/he would be okay alone in the vehicle and shut and locked the car. The SP said that s/he was going into the store to look for hair ties for VA2. The SP did not come out with hair ties but VA2 later said that $100 cash was taken out of his/her account. The SP never gave VA2 cash that was withdrawn from VA2’s account. VA2 had no unsupervised time in the community. VA2 was left for approximately five minutes and was not harmed. VA2 was “scared” while in the car without supervision and had not previously been left without supervision by staff persons while out in the community.

P1 and P2 provided the following information:

· After the last weekend of May 2024, P1 balanced all the accounts for the four clients at the facility and all balanced correctly. On June 4, 2024, when P1 and P2 did “month end” where each clients’ ledgers were balanced and sent into the main facility office, P1 and P2 noticed that cash was missing from VA1’s and VA2’s petty cash files. VA1 was missing $20 and VA2 was missing $26. The facility never kept more than $30 petty cash per client on hand. The cash was stored inside each clients’ files inside the medication cabinet which was locked with a three-digit dial combination. All staff persons knew the combination. When staff persons took the clients out to eat or to go shopping, they brought back receipts to show where the funds had been used. The receipts were also stored in the locked cabinet, and they were balanced monthly.

· P1 notified his/her supervisor of the missing money, but after years of working at the facility, thought that it would “show up” after a staff person realized that they still had it in their own wallet or pocket and forgot to return it after bringing a client out. The cash did not turn up which had never happened before at the facility. There was no way for sure to determine what staff person took the cash funds, but those that were asked and worked during that time, denied taking it. The facility paid back VA1’s and VA2’s accounts to replace the missing funds.

· VA1’s and VA2’s bank statements were accurate at month end for May 2024. On June 21, 2024, P1 was showing VA2 how to log into his/her own account and view the balances and discovered “fraudulent” activity with VA1’s and VA2’s debit card that had not been there on June 4, 2024, when “month end” was completed.

· P1 stated that the SP signed out the facility vehicle and took VA1 out on June 6, 2024. The SP and VA1 went to Culver’s for a meal. There were two charges for Culver’s with two different amounts on VA2’s debit card account but only one receipt that matched one transaction and no receipt for the other. There were receipts from June 6, 2024, from purchases that VA1 made and then there were other receipts that were not purchases that VA1 made. According to VA1’s bank, VA1’s debit card was set up on a monthly “recurring” Xfinity Mobile payment for $128.61 which one was taken out and the second payment was set to come out on July 6, 2024. The debit card was canceled by the facility prior to that date so the second payment was not taken. VA1 did not have a Xfinity account.

· P1 stated that VA1 could not give P1 a “straight answer” on what happened while they were out on June 6, 2024, but VA2 was “pretty good,” though “not always reliable.” VA2 was very “upset” and “mad” about this and was “capable” of remembering information. P1 believed what VA2 was telling P1.

· P2 stated that on June 6, 2024, VA1 and another client went out into the community with the SP, stopping at Culver’s for a meal and at McDonald’s for coffee. The SP was not supposed to take anyone out for food that day, due to dietary restrictions of VA1, so this “surprised” P2. This was the first time the SP had driven any clients in the facility vehicle anywhere, including going shopping, as s/he had just recently been signed off on driving. It took longer to train the SP on driving duties since s/he was a “float staff.”

· P1 stated that the SP signed out the facility vehicle and took VA2 out on June 8, 2024, to run errands and get food. There was a $7 McDonald’s charge with no receipt, and two charges for $89.29 and $52.51 at Walmart in Brooklyn Park on VA2’s debit card. Some of the items on a larger Walmart receipt were things that VA2 purchased, but the items on a smaller Walmart receipt were not items that VA2 purchased or had in his/her possession; one was a large bag of candy (VA2 also purchased one but only brought one home) and a cell phone. VA2 did not have a cell phone. On the larger receipt, there was also a charge for “Native” brand deodorant which VA2 did not use or have with him/her and two bags of candy, only one of which VA2 had. Another charge with no receipt was for $23.09 at Culver’s. It is believed that the SP and VA2 each had a meal on that receipt that was purchased with VA2’s card.

· Additionally, there was an ATM cash withdrawal at an ATM machine located at CVS Pharmacy for $103.25. When P1 contacted VA2’s bank, they stated that the withdrawal was for $100 cash with a $3.25 ATM fee. Later, another $3.50 charge showed up on VA2’s bank account as an out of network ATM use fee.

· P1 asked VA2 how the SP used his/her debit card. VA2 stated that the SP made VA2 give the SP his/her debit card because other staff persons had told the SP that the SP needed to “hold on” to VA2’s debit card because VA2 was “not allowed to hold it.” This was “totally false” and VA2 was allowed to hold his/her card. The SP then told VA2 to stay inside the vehicle while the SP ran into CVS to “look for hair ties.” VA2 had already purchased one package of hair ties at Walmart earlier in the day. Staff persons were not allowed to leave clients unsupervised in in the community, including in vehicles.

· P1 was not sure if there was a policy on returning receipts back to the office by a certain time for client purchases, but typically, there were forms that staff persons filled out when debit cards or petty cash was used. Purchases were also written down on a ledger and the receipt was placed in a pouch.

P2 provided information consistent with P1’s information and added the following:

· The SP did not use any of the other client’s money, but that client kept his/her debit card on a neck lanyard. VA1 was described as “passive” and if a person asked for his/her debit card, s/he would likely hand it over, and not ask for it back.

· VA1 was limited to one dark beverage per week and enjoyed coffee and dark sodas. On June 6, 2024, the SP allowed VA1 to have a dark soda and a coffee at Culver’s and McDonald’s, respectively. After P2 talked to the other client who went with on the outing, P2 deduced that the other client paid for his/her own meal at Culver’s, recalling to P2 what s/he ordered. The SP and VA1 ate meals at Culver’s using VA1’s card. Later, they went to McDonald’s and the other client ordered a coffee and paid for his/her own coffee. The SP ordered a coffee for VA1 and for the SP and VA1 paid for those two coffees. The client did not know if the SP used VA1’s debit card, but only asked if his/her debit card was used.

· P2 was also working on June 8, 2024. When the SP and VA2 returned from Walmart VA2 showed P2 all his/her purchases and P2 helped VA2 label his/her food items and put them away. Some of those items included one bag of candy, a box of chips, one pack of hair ties, and a two pack of Suave deodorant. The first receipt showed that two bags of candy were purchased, and “Native” deodorant was purchased. P2 went to Walmart to get a copy of the smaller receipt, which was not present even though there was a second charge on VA2’s account the same date that they went to Walmart. The second receipt’s purchase contained a cell phone and VA2 did not have or use a cell phone. The SP left several hours before the end of his/her scheduled shift that day.

· VA2 told P2 that the SP paid for the Culver’s for both the SP and VA2. P2 told VA2 that staff persons could not purchase items for clients and clients could not purchase items for staff persons, per facility policy. As P2 was talking to VA2, it was discovered that the SP and VA2 went to McDonald’s before going to Walmart. There was a charge at McDonald’s for $7, but the SP had kept the receipt. VA2 said that the SP got coffee at McDonald’s. The facility was not able to get a copy of the original receipt from Culver’s or McDonald’s as they were no longer kept by those companies.

· After it was discovered that VA2’s card was used for a cash withdrawal of $100 plus the $3.25 fee, P2 looked in VA2’s petty cash book and there was no money in the book to account for the $100 cash withdrawal. Staff persons generally did not go to random ATMs to get cash out for clients because they would typically get cash back on a Walmart purchase to avoid an extra stop and fees.

· The SP drove VA2 to CVS and the SP stated that s/he was going into the store to look for more hair ties for VA2. The SP said that they could not find any at Walmart, despite purchasing a pack of them at Walmart. VA2 was asked why s/he did not tell anyone sooner that s/he was left in the car without supervision during the CVS Pharmacy stop and VA2 “did not know” but asked to go inside the store and the SP told him/her no and locked him/her inside the car.

· Both VA1 and VA2 were capable of and able to hold their own debit cards when out shopping. At times, staff persons would need to assist VA1 or VA2 with putting the card in the machine correctly, but they both knew how to enter in their own debit card personal identification number (PIN). VA1 would “not verbalize” his/her PIN, but VA2 tended to tell people his/her PIN. When VA2 used cash to pay, s/he would get the change back, but would not know how to count the change, however staff persons would do that when the ledger was balanced.

· Some of the “fraudulent” purchases were reimbursed by the facility, and some were not yet reimbursed as they were being disputed with the bank but would be reimbursed if the bank did not refund the funds.

· After it was discovered that money was missing, the combination code on the cabinet was changed.

· P2 personally trained the SP on each of the clients’ plans at the facility, including dietary restrictions for VA1. The SP was signed off to drive clients at the facility as of June 3, 2024.

G1 was contacted by the facility to let him/her know that some funds had been missing from VA1’s account. G1 said that on June 11, 2024, when s/he went out with VA1 to Perkins, that there was not an amount of money on the Perkins’ gift card that there should have been.

G2 provided the following information:

· G2 was contacted by the facility to let him/her know that some funds had been missing from VA2’s accounts sometime during the middle of June 2024, and that the facility would be replacing any missing funds that were not able to be disputed.

· One of the places that funds were used was Walmart and that cash was also withdrawn from an ATM. G2 was told a little bit later that the facility determined that the SP used VA2’s funds.

· VA2 was “pretty upset” about it and was “angry” with the SP, naming the SP to G2. The SP no longer worked at the facility and had not worked there very long, according to VA2. VA2 also told G2 that the SP left VA2 unsupervised in the facility vehicle while they were out doing errands at a CVS store, which was where the ATM cash withdrawal with VA2’s debit card was done. VA2 was “happy” that s/he got reimbursed by the facility.

· VA2 would be able to provide information, if asked about the incident.

The SP provided the following information, and during the interview, the SP ended the call and did not call this investigator back, so no further questions were asked:

· The SP put in her notice of resignation because s/he had gotten another job at another facility but had several shifts scheduled at the facility near the end of his/her resignation. The SP stated that his/her most recent time working at the facility was March 2024, when s/he was hired, then later stated that s/he worked at the facility in early June 2024 for the last few shifts s/he worked.

· The SP was not working at that facility for very long and s/he had not been trained to drive clients yet, so the SP denied ever taking any clients, including VA1 and VA2 out into the community in a facility vehicle. The SP was asked several times if s/he had ever driven VA1 and VA2 anywhere in the community and denied driving clients anywhere.

· The SP had “no understanding” of why his/her name would be on the vehicle sign out sheet for June 6 and 8, 2024, during the time in which s/he was scheduled at the facility.

· The SP denied having any training on how to use the clients’ debit cards or checking accounts and stated that those items were stored in a locked medication cabinet, to which s/he did not have access.

· The SP stated that the facility had “lied” regarding receipts that were linked to the VA1’s and VA2’s outings with the SP and stated that the facility had “accused [the SP] of stuff that I am not doing.”

· The SP denied purchasing a cell phone with VA2’s debit card because s/he “already had a cell phone.”

· The SP denied ever using VA1’s or VA2’s debit cards.

· The SP denied that s/he would be on camera footage in the community with any of the clients, including VA1 and VA2. The SP then ended the phone call and did not return this investigator’s subsequent calls.

Facility records and the SP’s timesheet showed that the SP was scheduled from 8 a.m. to 4 p.m. on June 6, 2024, and worked 7 hours and 45 minutes. On June 8, 2024, the SP was scheduled from 9 a.m. to 7 p.m. and worked five hours total.

A Walmart Asset’s Protection employee provided a description of the Walmart transactions that took place on June 8, 2024, which matched the two transaction amounts spent on VA2’s debit card. Video described by the employee was consistent with the description of the SP and VA2. The SP was seen purchasing a cell phone at the electronics checkout counter.

All staff persons interviewed for this report were trained in the reporting Maltreatment of Vulnerable Adults Act and VA1’s and VA2’s plans.

Conclusion:

A. Maltreatment:

Consistent information showed that on June 6, 2024, the SP took out VA1 and another client and they went to McDonald’s and Culver’s and VA1’s debit card was used at both stops to pay for both VA1’s and the SP’s food and beverages. VA1 would not verbalize his/her debit PIN but the card was set up for a recurrent payment from Xfinity Mobile that was charged June 6, 2024, and was set up to continue charging that card on the sixth of each month going forward.

Consistent information showed that on June 8, 2024, the SP took VA2 out in the community where they made stops at McDonald’s, Culver’s, Walmart, and a CVS Pharmacy. The SP used VA2’s debit card to purchase him/herself and VA2 food and/or beverages at McDonald’s and Culver’s. While at Walmart, the SP was seen on surveillance video using VA2’s card to purchase a cell phone at the electronics counter. The SP also placed personal items, such as deodorant and a bag of candy in with VA2’s purchases, but those items were not in VA2’s possession when his/her purchases were inventoried by P2. The SP also took VA2’s debit card, and left VA2 inside the facility vehicle for approximately five minutes without supervision in the community and then used VA2’s debit card to withdrawal $100 cash from an ATM at CVS Pharmacy. An ATM usage fee and a bank fee were added to the transaction for using an out of network ATM.

On June 4, 2024, P2 was doing “month end” on all the clients’ accounts, and it was discovered that VA1 was missing $20 cash and VA2 was missing $26 cash from their petty cash pouches. Petty cash was stored inside the locked medication cabinet. All staff persons had access to the code. The cash was present and accounted for on May 26, 2024, when P2 last balanced the accounts, and P1 determined that the cash had to have gone missing between May 27, 2024, and June 3, 2024. The SP filled in at the facility on May 28, 29, and 30, 2024.

The SP denied being trained on driving clients at the facility, denied knowing the combination code for the medication cabinet, denied ever driving any clients anywhere in the community, including VA1 or VA2, and denied that s/he would be on video footage or still images anywhere out in the community with VA1 or VA2. However, the SP was trained on driving as of June 3, 2024, there was documentation that the SP signed out the vehicle and took clients out on days consistent with the questionable receipts, that the SP was seen on Walmart video with VA2 purchasing a cell phone, and VA2 provided consistent information that the SP took and used VA2’s debit card for multiple purchases at multiple businesses that day.

Given that there was consistent information including video that the SP was present for purchases made by the SP with VA1’s and VA2’s debit cards that were not for the VAs and not in their possession, and that the SP had reason to minimize his/her actions for fear of consequences, there was a preponderance of evidence that the SP willfully used VA1’s and VA2’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).

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 SP was responsible for 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 maltreatment because the SP used the funds of two VAs each on more than one occasion.

The SP was disqualified from providing direct contact services.

Action Taken by Facility:

The facility completed an Internal Review, and it showed that policies and procedures for balancing the clients’ accounts were followed and adequate. There was no need for additional staff training. The facility canceled VA1’s and VA2’s debit cards and new ones were issued. The SP no longer worked for 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.

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