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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: 1082370-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070470-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson/ Samantha Wueste scout.peterson@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA’s) debit card for his/her personal use. Date of Incident(s): Between September 7 and 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; from documentation at the facility and law enforcement records; and through three interviews conducted with two facility supervisory staff persons (P1 and P2) and the VA’s case manager (CM). Subsequent attempts were made to contact P1 and P2 for additional information, but the attempts were not successful. Attempts were also made by phone and U.S. mail to contact and interview a staff person (SP) and the VA’s guardian (G), but the attempts were not successful. The VA was unable to provide information for this investigation due to his/her diagnoses. The VA was diagnosed with a developmental disability, bipolar disorder, schizophrenia, major depressive disorder, moderate intellectual disability, and DiGeorge syndrome (genetic condition caused by a missing part of a chromosome). The VA enjoyed spending time with others, watching TV, and doing crafts. The VA received medical assistance that included a personal needs allowance of $125 per month. The VA had a prepaid debit card with access to an online account that allowed him/her to receive these monthly payments electronically and then make purchases as needed. The funds on the debit card were managed through a mobile application or “a digital banking app with an admin portal.” (Note: The word “bank” will be referred in this report to describe the VA’s financial account or financial documents pertaining to the prepaid debit card.) The VA’s Coordinated Service and Support Plan Addendum (CSSP) and Individual Abuse Prevention Plan (IAPP) dated June 13, 2024, provided the following information: · The VA was susceptible to financial exploitation because s/he did not understand the value of money and required assistance with all financial matters. The VA was not able to recognize mismanagement of his/her funds and the facility supervisory staff persons were responsible for managing and safeguarding the VA’s finances. · The VA’s debit card was kept locked in P1’s office and was moved to a lockbox that staff persons had access to when assisting the VA in making purchases. For planned outings, staff persons carried the VA’s debit card while in the community and assisted with all purchases. Staff persons were required to return the VA’s debit card to the lockbox after use along with a receipt for each purchase that was made. P1 was then responsible for returning the VA’s debit card back to his/her locked office as soon as s/he was able to do so. Additionally, balanced bank statements and receipts were completed monthly and provided to the CM upon request. P1, P2, the CM, the Internal Review completed by P2, and facility documentation of P2 and the SP’s conversations via phone and text provided the following information: · The VA’s debit card was kept locked in P1’s office unless the VA requested to use it. If the VA needed to use his/her debit card to make a purchase for “personal needs” or during a “planned outing,” P1 placed the card in a lockbox located in the medication room that all staff persons had access to. Staff persons were required to document when the VA’s debit card was being taken from the lockbox and return the card to the lockbox after use. P1 then returned the VA’s debit card back to his/her locked office. · On October 3, 2024, the CM requested copies of the VA’s recent bank statements from the facility to complete the VA’s medical assistance paperwork. Prior to this request, the facility did not have access to the VA’s online banking portal. · On October 7, 2024, P1 obtained the login information needed to access the VA’s online banking portal, printed copies of the VA’s bank statements that were requested by the CM, and sent them to the CM. On October 8, 2024, and upon reviewing the VA’s bank statements, the CM called P1 and asked why there were “so many” charges to Uber and Lyft in September 2024. The VA did not have an Uber or Lyft account and did not use those services. P1 then called P2 regarding the Uber and Lyft charges made with the VA’s debit card. P1 was “aware of one employee [the SP] that consistently used those services to get to work.” P2 then called the SP to ask about the Uber and Lyft charges made with the VA’s debit card. The SP told P2 that s/he did not have a Lyft account and denied using the VA’s debit card. The SP “volunteered” to provide P2 his/her Uber activity and told P2, “I didn’t do it.” · On October 8, 2024, at 2:56 p.m., P2 sent the SP a text message asking for copies of the SP’s Uber activity for the “entire” month of September, “ASAP” (as soon as possible). At 1:02 p.m., the SP sent screenshots via text message to P2 of his/her Uber activity dated from August 2 through October 1, 2024. The Uber activity provided by the SP included the date/time of service, information regarding service type, and the total amount that was charged/paid for the service. P2 asked the SP if s/he could also share the details of card information or payment type used in completing each transaction, but the SP did not provide this information. At 2:51 p.m., after P2 reviewed the SP’s Uber activity that was shared with him/her, P2 told the SP via text message that “at least five of the transactions on [the VA’s] bank statement match your history.” The SP then stopped responding and communicating with P2. The SP’s Uber activity showed that five of the Uber transactions made within the SP’s Uber account matched the dates (September 26 and 27, 2024) and exact purchase amounts that were detailed on the VA’s bank statement, totaling $40.14. · On October 29, 2024, a law enforcement officer (LEO) “determined that [the SP’s] Lyft account showed [multiple] Lyft transactions that were found on [the VA’s] bank statement, and that [the VA’s] card was used for these transactions.” At this time, the LEO told P2 that s/he was still waiting on additional information from Uber but had “enough information to charge [the SP] with financial exploitation of a vulnerable adult.” · P1 and P2 each stated that there were no similar concerns with the SP prior to this incident. Law enforcement records provided the following information: · On October 9, 2024, the LEO received a report of fraud involving the VA’s debit card and met with P2 at the facility to collect additional information. P2 provided the LEO a copy of the VA’s bank statement for September 2024 that showed “fraudulent purchases” made with the VA’s debit card to Lyft and Uber, services not used by the VA. P2 also provided the LEO copies of the SP’s Uber activity from September 17 through September 27, 2024, that the SP had sent in a text message to P2. The LEO stated that the SP’s Uber activity showed that “some” of the charges listed on the SP’s account “matched” and “lined up” with the dates and purchase amounts for Uber services that were listed on the VA’s bank statement. The LEO’s attempts by phone and email to contact the SP were not returned. · The LEO obtained the SP’s Lyft and Uber accounts that showed detailed transaction history and information completed by the SP when using the ride service applications. The SP’s Lyft account showed that on September 7, 2024, the SP used the VA’s debit card to pay for his/her Lyft ride for $10.94. The SP also used the VA’s debit card on September 10, 2024, to pay for two Lyft rides for $9.93 and $13.99 respectively, totaling $23.92. These dates and amounts charged to the SP’s Lyft account were the same service dates and amounts shown on the VA’s bank statement. · The information Uber provided to the LEO showed that the SP used the VA’s debit card to make five purchases between September 24 and 27, 2024, totaling $50.75. The LEO stated that four of the five purchases matched the exact dates and dollar amounts found on the VA’s bank statement. · Criminal charges were filed against the SP for Financial Exploitation-Vulnerable Adult-Uses/Manages or Takes Property For Benefit of Someone Else. The VA’s bank statement showed that eight charges were made for Lyft and Uber services throughout September 2024, totaling $101.45. The dates and purchase amounts listed on the VA’s bank statement for those charges aligned with the dates and purchase amounts that were detailed on the Lyft and Uber activity provided by law enforcement records and the SP’s Uber activity provided by the SP to P2. The facility’s policies on Financial Procedures said that when managing a client’s finances, P1 was responsible in “balancing and reconciling the bank statement each month for each individual and house,” providing this information to P2. Individual checking accounts would be “reconciled by [P1] and forwarded to [P2]” that included full record of bank statements and receipts each month. Additionally, P2 was responsible in documenting that s/he reviewed these financial records that were maintained and submitted by P1 each month. Facility documentation showed that the SP, P1, and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults and the VA’s CSSP and IAPP prior to the incident. The SP was also trained on the facility’s Financial Procedures. Conclusion: A. Maltreatment: Information from all sources was consistent that on eight time between September 7 and 27, 2024, the SP used the VA’s debit card for his/her personal use for Lyft and Uber services, that totaled $85.61. Although the SP did not provide information for this investigation and denied to P2 that s/he used the VA’s debit card, given that the SP was the account holder for the Lyft and Uber accounts that used the VA’s debit card to complete eight transactions for services not used by nor authorized by the VA, there was a preponderance of the evidence that in the absence of legal authority a person willfully used the VA’s funds. 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 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP received training on the VA’s CSSP and IAPP, the facility’s Financial Procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was the account holder for the Lyft and Uber accounts that used the VA’s debit card to complete eight transactions for services not used by nor authorized by the VA. The SP was responsible for 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” maltreatment. The SP used the VA’s debit card eight times in September 2024. The SP was disqualified from providing direct contact services. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by the SP. The facility contacted the VA’s financial institution to report and dispute the fraudulent charges, to cancel the VA’s debit card, and to reissue a new card to the VA. 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. On February 27, 2025, the facility was issued a Correction Order for failing to follow the VA’s CSSP by reconciling the VA’s financial account each month as required. During the course of the investigation, it was determined that one background study violation occurred. On February 27, 2025, the facility was issued a $200 fine for the background study violation. The Order to Forfeit a Fine is subject to appeal.
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