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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: 1075641-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that three vulnerable adults (VA1, VA2, and VA3) were missing money and that a supervisory staff person (the SP) who was responsible for managing VA1’s-VA3’s finances took their money. Date of Incident(s): Ongoing prior to July 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 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 four interviews conducted with a facility administrative staff person (P1), two facility staff persons (P2 and P3), and a human resources staff person (HR). This investigator spoke to VA2’s and VA3’s guardians but neither had additional information to provide related to this investigation. Attempt were made via telephone to contact VA1’s guardian but VA1’s guardian did not return messages left. Attempts to contact one additional facility staff person (P4) were unsuccessful. In addition, attempts were made via telephone and certified and regular mail to contact and interview the SP, but the SP did not respond to the requests. Additional information obtained showed that the SP moved out of state after the report was made and when contacted by law enforcement, the SP provided limited information which is included below. VA1 was diagnosed with a seizure condition and moderate intellectual disability. The VA enjoyed cleaning and getting his/her haircut. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 was susceptible to financial exploitation due to his/her inability to handle financial matter and because s/he lacked an understanding of financial matters. VA1 had an outside company who acted as his/her representative payee, however, facility staff helped VA1 “manage and budget [his/her] personal needs money and [his/her] work checks.” VA2 was diagnosed with autism spectrum disorder and moderate intellectual disability. VA2 enjoyed volunteering, spending time in the community and amusement park rides. According to VA2’s IAPP, VA2 was susceptible to financial exploitation due to his/her inability to handle financial matters. VA2 did not “know the value of money” and “did not seem to care about it.” VA2 had an outside company who acted as his/her representative payee. VA2’s social security was directly deposited into his/her checking account and s/he brought home a check from his/her place of employment for facility staff to deposit into VA2’s bank account. Facility staff were “involved in all transactions to ensure [VA2] is paying only for what [s/he] needs and wants and is paying a fair price.” Additionally, VA2’s money was to be counted daily by staff persons and facility staff “double-check [VA2’s] ledgers regularly.” VA3 was diagnosed with mild intellectual disability. VA3 enjoyed exercising, bowling and playing baseball. According to VA3’s IAPP, VA3 was susceptible to financial exploitation due to his/her inability to handle financial matters. VA3 was “not able to recognize any kind of financial mismanagement.” VA3’s guardian was his/her representative payee and responsible for handling VA3’s financial matters other than VA3’s petty cash that was kept at the facility. Facility staff also had access to a debit card for VA3’s account to purchase things for VA3. The facility’s Internal Review as well as bank statements, receipts, and ledgers for VA1-VA3 provided by the facility, dated May and June 2024, provided the following information: · VA1 was missing funds totaling $899.95. · VA2 was missing funds totaling $938.25. · VA3 was missing funds totaling $85.30.
· Four staff persons (P2-P5) worked at the facility and the SP was the designated coordinator at the facility. · On July 11, 2024, the HR and P1 went to the facility because they had conducted an internal accounting review and determined that there was money missing from the facility’s bank account. The SP left the facility prior to the HR and P1’s arrival. When they got to the facility, the HR and P1 found that the safe was empty. The HR called the SP and asked when s/he would be returning to the facility and asked about the items from the safe including money. The SP told the HR that s/he “quit” and then the SP hung up the phone. · P1 and the HR called law enforcement to make a report of theft. P1 provided the following information: · The SP was the facility’s house supervisor and was “directly responsible” for the clients who lived at the facility and the staff who worked at the facility. · On July 11, 2024, P1 and the HR went to the facility to meet with the SP regarding issues not related to this investigation. Immediately prior to going to the facility, P1 received a call from an unknown staff person (later determined to be P2) who reported being “concerned” because staff persons “did not know anything” about VA1’s money and staff persons were told by the SP “not to touch” VA3’s money. · When P1 and the HR arrived to the facility, no one was there. The SP was clocked in and “should have been” at the home. P1 tried calling the SP, but the call went to voicemail. P1 then texted the SP asking where s/he was, and the SP stated s/he was at a medical appointment for him/herself. The SP apologized to P1, adding that s/he “forgot to punch out.” P1 then looked for VA1’s “money book” but could not find it and also noticed that the facility’s safe was “cleaned out,” with no money or “money books” inside. The HR called the SP again, and told the SP to come to the facility. The SP asked, “What is this about?” and P1 and the HR told the SP that they would discuss it when s/he returned to the facility. The SP then told P1 and the HR that s/he “quit” and would not be returning to the facility. The SP never spoke to the P again. · P1 and the HR contacted law enforcement to report the missing money. P2 provided the following information: · P2 worked night shifts at the facility and worked the overnight shift from July 10 to July 11, 2024, and the SP was scheduled to work in the morning and relieve P2. P2 was not involved in shopping for the facility but three other staff persons (P3-P5) and the SP were responsible for shopping for the facility and for taking VA1, VA2, and VA3 shopping. · P2 stated that “every shift” s/he counted the money book to ensure that facility and client funds were reconciled, and that staff persons for each shift were also responsible for doing so. The facility’s “money book” was locked in the facility’s medicine closet. P2 added that each time s/he reviewed the clients’ and facility’s money books, there were no issues found. When P2 counted the money for his/her shift from July 10 to 11 2024, there were no issues with the client’s or facility funds. · P2 did not have access to any client’s bank accounts. P2 said that only the SP and the client’s guardians had access to the VA1, VA2, and VA3’s bank accounts. · “Shortly after” the SP began working at the facility, VA1 moved into the facility. When VA1 needed to go to the bank, the SP took VA1 to the bank to withdraw cash. VA1 was “supposed to” have $20 for pocket money, but on an unknown date, the SP told P2 that VA1 was “not allowed to use cash anymore.” P2 stated that was a “red flag” and s/he told “whoever was at the office” who P2 could not recall, that the SP did not allow VA1 to have cash and the SP was “arguing” about who had access to the VAs’ money. · P2 stated that s/he never took cash from the facility and did not document having done so. P2 also stated that s/he never used any of the client’s money for things that were not for the clients and denied taking any clients money for his/her personal use. P3 provided the following information: · Facility staff persons were only responsible for tracking the VAs’ cash use in their money books that were at the facility. The SP “handled everything [else]” regarding the VAs’ finances. Prior to the SP working at the facility, P3 was in charge of the facility’s “budget book,” but after the SP “took over” supervisory duties at the facility, the SP did not allow P3 to see the book. P3 stated that P2, P4, and him/herself had worked at the facility “for years” and that “nothing like this happened” before the SP started working. · The SP, P3, and P4 took the VAs to the store to go shopping and they brought their own check books and wrote checks for their respective purchases. Debit cards were not used for purchases at stores. · P3 stated that s/he never took any cash from the facility without documenting it. P3 also stated that s/he never used any client’s money for things that were not for the clients and denied taking any clients money for his/her personal use. A law enforcement officer (LE) report provided the following information: · On an unknown date the end of July 2024, the LE called the SP to request an interview. The SP told LE that s/he was in Florida visiting family but would be returning to Minnesota in “a few weeks.” The LE then made multiple additional attempts to reach the SP by phone but were unsuccessful. · On September 17, 2024, the SP called the LE and again stated s/he was in Florida visiting family. However, prior to this, the LE obtained information that the SP was living in Tennessee. When the LE asked the SP about living in Tennessee, the SP asked how the LE knew s/he was in Tennessee and declined to provide an address of residence in Tennessee. According to the LE, the SP “denied all theft.” The facility’s Fiscal Policies and Procedures for Persons Receiving Services stated that facility staff “must complete itemized financial statements when it is responsible for safekeeping of a person’s funds and property. The financial statements will itemize receipts (money or property received) and disbursements (money spent or property disposed).” Additionally, “A cash account, located in each home or office, may be maintained for a person and used for personal needs and “will be kept in a locked area of the home.” Residents’ “cash account ledgers must be updated and documented as purchases and deposits are made.” Facility documentation showed the SP was trained on the facility’s financial policy on March 14, 2024, and again on June 4, 2024; VA1’s, VA2’s, and VA3’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: P1 and the HR provided information consistent with the facility’s Internal Review that VA1 was missing funds totaling $899.95, VA2 was missing funds totaling $938.85, and VA3 was missing funds totaling $85.30. Given that the VA’s funds were maintained in a locked safe for which only staff persons had access to and that the funds were gone from the safe and facility, there was a preponderance of the evidence that in the absence of legal authority, a person willfully used, withheld and/or disposed of the funds of VA1, VA2, and VA3. 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 facility’s Fiscal Policies and Procedures for Persons Receiving Services, the Reporting of Maltreatment of Vulnerable Adults, and VA1, VA2, and VA3’s support plans. The SP did not respond to this investigator’s request for an interview, but “denied all theft” when s/he spoke to law enforcement. However, for the following reasons, it was determined that the SP was responsible for the maltreatment of VA1, VA2 and VA3: · Information from P2 and P3 was consistent that the SP was the sole staff person who handled the VAs’ funds and P1 and the HR each stated that the SP was responsible for maintaining cash ledgers; · P2 stated that s/he worked the overnight shift from July 10 to 11, 2024, immediately prior to the SP’s shift and when P2 counted the VAs’ funds there were no issues with the client’s or facility funds; · P1 and the HR provided consistent information that on July 11, 2024, when they arrived at the facility, the safe was empty and the VAs’ funds were missing; and · P1 and the HR stated that when they called the SP and asked the SP to come to the facility to discuss items missing from the safe, the SP “quit” his/her job and hung up the call. 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 took funds from VA1, VA2, and VA3. The substantiated financial exploitation 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 determined that the facility’s policies and procedures were adequate but not followed. The facility reimbursed VA1-VA3. 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 individual s 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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