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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: 1069180-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Judie Schwanke Suspected Maltreatment Reported: It was alleged that two vulnerable adults (VA1 and VA2) were missing money: · VA1 was missing $221.37 on his/her prepaid MasterCard gift card; and · VA2 was missing $562. Date of Incident(s): Multiple dates between April 15 and July 27, 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 three interviews conducted with VA1, VA2, and a facility staff person (P). Several attempts were made via telephone and US mail to contact and interview the SP, but the SP did not respond to the requests. The SP provided information to law enforcement and that information is included below. VA1’s Coordinated Services and Supports Plan showed that VA1 enjoyed reading books, watching crime shows on television, and listening to music. VA1 also enjoyed shopping. VA1 had various physical and mental health diagnoses. VA1 was able to keep “some money” on his/herself. If VA1 had a “substantial” amount of money, staff persons helped VA1 keep his/her money “safe.” VA1’s Individual Abuse Prevention Plan stated that VA1 was susceptible to financial exploitation because VA1 had a “history” of being “easy going” with his/her finances and would not understand if someone tried to “take advantage” of his/her finances. Staff persons were to assist VA1 in making “good decisions,” and “build money management skills.” VA2’s Coordinated Services and Supports Plan showed that VA2 enjoyed reading magazines, listening to music, and being out in the community. VA2 like to go to a local gas station daily and his/her favorite soda was Dr. Pepper. VA2 had various physical and mental health diagnoses. VA2’s Individual Abuse Prevention Plan showed that VA2 was susceptible to financial exploitation because his/her “mild cognitive issues” and “memory loss.” VA2 relied on staff persons to help balance his/her checkbook, buy personal items, and pay bills. The P provided the following information: · Clients’ funds and “books” were kept in a cabinet near the kitchen and all staff persons had access. Facility staff persons were to “look at” each client’s book at each shift change, but not all staff persons did that. · VA2 received a $30 check each week but sometimes (once a month) it was $80. VA2’s checks were put in the “front pocket” of his/her book until s/he could be driven to a bank to cash them. When the P took VA2 to the bank, VA2 “signed” the back of his/her check and then the P drove VA2 to the bank. Through a drive thru window, the checks were cashed. The P then held onto VA2’s money and drove VA2 to a local gas station, where the P went inside and bought VA2 items s/he had requested while VA2 stayed in the vehicle. The P obtained a receipt for the item(s) purchased and when they returned to the facility, the P logged the cash and purchase and put the receipt in VA2’s book. Any remaining cash was kept in a bag in a “locked cabinet” near the kitchen. The P stated that VA2 was “always” supposed to go to the bank with a staff person to cash his/her checks. · On an unknown date, the P and VA2 were going to go to the bank to cash VA2’s checks and then go shopping. The P said s/he knew that there were “three checks” in the front pocket of VA2’s book because s/he had seen them. When the P went to get the checks, they were not there. At that time, the P thought that maybe another staff person or VA2’s family member had taken VA2 to the bank. Because VA2 did not have cash, VA2 was not able to go shopping. VA2 called his/her family member, and the family member brought some items to VA2. · VA1 had a prepaid MasterCard that s/he kept in his/her wallet. On an unknown date, the P took VA1 to a local grocery store and VA1 spent approximately $40 from the prepaid card. On an unknown date after, the P checked the balance on the card which was $277. On August 1, 2024, the P was shopping with VA1. When they were shopping, and VA1 was checking out the prepaid card was declined. The P called the number on the card and learned the balance on the card was $10. · The P was “suspicious” and “thought something was going on” because of VA1’s missing money from the gift card and VA2’s missing checks, the P told a facility supervisor, and an investigation was started. · Once the investigation was underway, the P learned that some of the purchases from VA1’s card was for pet cats and that VA2 did not sign his/her checks. The P stated that VA1 did not own a cat and there would be no reason for VA1 to buy pet items. The P also stated that there was no reason that staff persons would need to sign the back of VA2’s check because VA2 signed the back of his/her checks and staff persons took VA2 to the bank to cash his/her checks. · The P did not recall the training s/he received regarding clients’ funds but stated it was “common sense” to get a receipt for what the client spent. Facility documents including VA1’s and VA2’s Petty Cash Resource Records, an Incident/Emergency report, the Internal Review that was completed by an administrative staff person, VA1’s Leisure Record, Daily Log Notes, copies of VA1’s checks, VA2’s End of the Month Financial Report, and the SP’s time records provided the following information:
· The Incident/Emergency report and Internal Review showed that on August 1, 2024, P1 took VA1 to a store to purchase “snacks” using VA1’s “prepaid MasterCard gift card.” The prepaid MasterCard should have had a balance of $277.35 but the card was declined when it was used. P1 called the number on the card and was told that the MasterCard balance was $10.73. · On August 12, 2024, VA1’s prepaid MasterCard had a balance of $300. VA1 made purchases for him/herself that totaled $67.90. There were six unauthorized purchases on the card including: o On July 25, 2024, at Walmart for $90.75; o Three on July 26, 2024, at Kohls for $8, at Target for $33.99, and at Jimmy Johns for $18.26; and o Two on July 27, 2024, at Target for $61.55 and at McDonalds for $8.82. o The six charges totaled $221.37, leaving a remaining balance of $10.73. · VA1’s Leisure Record and Daily Log Notes showed that each day on July 25, 26, and 27, 2024, VA1’s “friends” came by to “visit.” There was no documentation that VA1 left the facility on those dates. · The Internal Review stated that VA1’s prepaid MasterCard was a gift from a friend and VA1 “believed” the card was “always” with him/her and that “no one else” used it. The card no longer had money on it and VA1 did not know what happened to the money. · Copies of VA2’s checks showed that between April 15 and July 15, 2024, VA2 received 18 checks, 15 of those checks were endorsed, “Pay to the order of [the SP’s name]” and cashed at US Bank, totaling $562. Three checks were signed by VA2 and cashed at Bremer Bank, totaling $202. · VA2’s Petty Cash Resource Record showed the following deposits into VA2’s petty cash at the facility: o April 11, 2024, $116; o Two deposits on May 8, 2024, $50 with a note “deposit from” his/her family member and $34.51 with a note “deposit from casino;” o May 19, 2024, $0.50 o June 2024, there were no deposits; and o July 8, 2024, $116. o Total deposits (minus the deposits from the family member and casino) from April to July 2024 was $232.50. A law enforcement Incident Report provided the following information: · On August 1, 2024, a law enforcement officer (LEO) went to the facility for a report of possible financial exploitation of VA1 and VA2. · VA1 told the LEO that s/he did not give anyone permission to use his/her prepaid MasterCard and s/he did not have knowledge of anyone using the card. · Six of the nine charges on VA1’s prepaid MasterCard were disputed and included the July 25 (Walmart), 26, and 27, 2024, charges totaling $221.37. The SP worked July 25, 2024, from 8 a.m. to 3 p.m.; July 26, 2024, from 8 a.m. to 3 p.m.; and July 27, 2024, from 8 a.m. to 8 p.m. · The LEO went to Walmart and obtained video footage for Walmart purchase made on July 25, 2024. In the video, the SP was “checking out numerous items,” including animal toys, food, and snacks. The SP paid for the items using a Walmart app on his/her phone. · Fifteen of VA2’s checks were “signed” in a “suspicious way” because they were endorsed on the back with “pay to the order of [the SP]” and what “appeared” to be VA2’s “forged” signature. The checks totaled $562. · The LEO saw that the SP had initialed VA2’s petty cash log “dozens and dozens” of times when s/he noted deposits or withdrawals for VA2 (which was in accordance with his/her training and facility policies and procedures). · The LEO spoke with the SP who initially denied using VA1’s card for his/her personal use. The LEO then showed the SP photographs from Walmart security footage. The SP identified him/herself in the photos and “finally admitted” that s/he used VA1’s card at Walmart. The SP told the LEO that VA1 told the SP that s/he could do so, and that the SP would pay VA1 “back.” The SP stated that s/he had repaid VA1 but s/he was not able to provide “proof” of the repayment. The SP denied using VA1’s card for any other charges. · Initially, the SP stated s/he did not “know anything” about VA2’s checks and told the LEO that s/he had taken VA2 to Bremer Bank “one time” to cash his/her check. Then the LEO asked the SP why 15 of VA2’s checks were “pay to the order of [the SP],” and the SP told the LEO that s/he did not know why. Later that day, the SP texted the LEO and said s/he cashed VA2’s checks because VA2 “asked” him/her to do it and that s/he gave “all” the money from the checks to VA2. The SP told the LEO that VA2 liked to keep some money with VA2 so s/he could get his/her family member to buy him/her things. · “Later” the same day, the LEO spoke to the SP by phone and the SP told the LEO that when s/he cashed VA2’s checks, VA2 was not with because it was “difficult” to get VA2 in the vehicle, and that s/he had given the cash from the checks to VA2. The SP also told the LEO that s/he was “not sure” if s/he was to “record transactions” on VA2’s Petty Cash Resource Record. · The LEO compared the dates the checks were cashed to the dates the SP worked and determined that 14 of the 15 checks were cashed on days the SP worked and of the 14 checks, 10 were cashed during the SP’s work hours and 4 were cashed “outside” of the time the SP worked. · The LEO received banking information from US Bank and determined that 14 of VA2’s 15 checks were deposited into the SP’s bank account. In addition, there were no withdrawals made on the SP’s account that matched the deposit amounts. · The LEO submitted the report to the county attorney for review of possible charges. VA1 stated that s/he liked watching The Price is Right and crime shows on television. When staff persons took VA1 shopping, they went to Aldi and VA1 bought food using either cash or a card. VA1 did not give permission for any staff persons to use his/her cash or card. VA1 did not have a pet cat. VA1 did not know there was money missing from his/her card. VA2 stated that s/he “liked” it at the facility when the facility was “staffed.” VA2 liked it when his/her family member visited him/her and on occasion the family member took VA2 shopping. VA2 like “soda” and bought Dr. Pepper. VA2 used his/her money and his/her family member’s money to buy things. Facility staff persons “kept” VA2’s money and VA2 asked them for his/her money when s/he needed it. VA2 received checks and staff persons took VA2 to the bank to cash the checks. VA2 stated staff persons did not cash his/her checks without him/her and s/he never gave staff persons permission to cash any of his/her checks without him/her. VA2 then gave staff persons cash to purchase items for him/her at a store. Typically, staff persons purchased the items and brought the items and change back to VA2. VA2 stated that s/he was aware some of his/her checks were missing but s/he did not have additional information regarding the missing money/checks. The facility’s Funds and Property Procedures of the Individuals We Serve showed that a summary of client’s funds is completed monthly and that staff persons could not “borrow money,” or have clients “purchase” items for them. Facility documentation showed that the P and the SP were each trained on VA1’s and VA2’s plans, the facility’s Funds and Property Procedures of the Individuals We Serve policy, and on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion:
A. Maltreatment: Information was consistent that that VA1 was missing $221.37 from his/her prepaid card and VA2 was missing checks that totaled $562.00. Given that only staff persons had access to VA1’s and VA2’s petty cash/cards/financials, that VA1 said s/he never gave any staff person permission to use his/her gift card, that VA2 stated s/he never gave anyone permission to cash his/her checks without him/her present, and that the LEO documented that VA2’s checks were “signed” in a “suspicious way” because they were endorsed on the back with “pay to the order of [the SP]” and what “appeared” to be VA2’s “forged” signature and the checks were deposited into the SP’s bank account, there was a preponderance of the evidence that in the absence of legal authority, a staff person willfully used, withheld, or disposed of funds 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 facility’s policies and the Reporting of Maltreatment of Vulnerable Adults prior to the incident. Regarding VA1: The SP provided inconsistent information regarding VA1’s card. Initially the SP denied using VA1’s card for his/her personal use, then after being shown the Walmart video, the SP acknowledged that s/he used it but had VA1’s permission to do so and that s/he had repaid VA1. The SP did not have documentation to show VA1 was repaid and VA1 said s/he never gave anyone permission to use his/her prepaid card. Although the SP denied using VA1’s card for any other charges, the SP’s credibility was diminished based on his/her initial denial of never using VA1’s card. Therefore, it was more likely that the SP was responsible for the six disputed charges from VA1’s card. The SP was responsible for the maltreatment of VA1. Regarding VA2: The SP provided inconsistent information regarding cashing VA2’s checks. The SP initially denied cashing VA2’s checks and stated s/he only took VA2 to the bank one time, but later said that s/he cashed the checks at VA2’s request and that s/he gave all the money to VA2, and later stated that VA2 was not with him/her at the time the checks were cashed. VA2 stated that s/he did not give any persons permission to cash his/her checks without VA2 present. The checks were made payable to the SP, and 14 of the 15 checks were deposited into the SP’s bank account, and there was no withdrawal from the SP’s account to support the SP withdrawing cash in the check amounts. Therefore, the SP was responsible for maltreatment of 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 took money from both VA1 and VA2 on more than one occasion each.
The SP was disqualified from providing direct contact services.
Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but were not followed at the time of the incident. The facility retrained staff persons on the definition of Financial Exploitation, the facility’s Funds and Property Procedures of the Individuals We Serve policy, and Prohibited Employee Conduct. 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 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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