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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: 1069737-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069733-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) used a vulnerable adult’s (VA) bank account to make unauthorized transactions. Date of Incident(s): Multiple incidents from November 2023 to August 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 (LE) records; and through two interviews conducted with a facility supervisor (P1) and the VA’s case manager (CM). The VA’s guardian (G) was contacted regarding the alleged maltreatment, and the VA was aware of the situation. The VA was not interviewed because persons who were familiar with the VA thought it would cause emotional distress to the VA. This investigator attempted to contact the SP by mail, however, the SP did not respond. Additionally, LE attempted to interview the SP, however, LE was unable to locate the SP. The VA’s client specific information showed the VA enjoyed participating in community activities and interacting with friends and family. The VA liked to have a “nice” bedroom, and enjoyed his/her television and radio. The VA could become “upset” if staff persons discussed incidents around him/her. The VA was diagnosed with cerebral palsy, developmental disabilities, epilepsy, depression, and intermittent explosive disorder. The facility was authorized to assist the VA with the safekeeping of his/her finances, as the VA required assistance to manage his/her checking account and debit card. The VA’s Funds and Property Authorization stated the VA had a petty cash binder, and staff persons would complete daily counts of the VA’s cash for accuracy. The VA’s checkbook was also kept in the petty cash binder, and staff persons had access to the VA’s account number and Personal Identification Number (PIN). Staff persons withdrew money from the VA’s petty cash account for the VA to make purchases. The CM said the VA’s bank statements showed multiple unusual withdrawals from an automatic teller machine (ATM), and the CM believed the SP was identified “on camera” as the person making the withdrawals. The withdrawn money did not “show up” in the VA’s petty cash. There were other transactions from the VA’s account that were also suspicious. LE records provided the following information: · There were multiple suspicious transactions that involved the use of the VA’s debit card at an ATM, as well as other suspicious transactions. · The total amount withdrawn from ATMs was $4,000. LE obtained security video recordings from three of the ATM withdrawals. Below are the ATM withdrawals of concern: o November 11, 2023: $300.00 o November 20, 2023: $300.00 o December 11, 2023: $400.00 o December 27, 2023: $400.00 o December 29, 2023: $400.00 o January 2, 2024: $400.00 o January 23, 2024: $400.00 o January 24,2024: $400.00 o April 3, 2024: $200.00 o June 13, 2024: $300.00 (ATM security video) o July 14, 2024: $300.00 (ATM security video) o August 1, 2024: $200.00 (ATM security video) · There were several other suspicious purchases found in the VA’s bank statements during 2023 and 2024, totaling $1,722.37. The G identified the suspicious purchases, and said the VA did not have the ability to make the following purchases: o August 16, 2023: $46.27 at Menards in Eden Prairie, Minnesota. o November 21, 2023: $78.63 at Menards in Richfield, Minnesota. o December 20, 2023: $10.83 at Best Buy in Minnetonka, Minnesota. o January 31, 2024: $43.34 at Best Buy in Eden Prairie, Minnesota. o May 12, 2024: $214.74 at Amazon (online). o May 13, 2024: $630.59 at Amazon (online). o May 13, 2024: $209.36 at Amazon (online). o May 16, 2024: $488.61 at Amazon (online). · P1 said the facility held a management meeting on August 15, 2024, to discuss the concerning transactions. During the meeting it was shared that LE was contacted and looking into the situation. It was unknown at the time of the meeting who was involved in the alleged fraudulent transactions. The SP was present for the meeting, and after the end of the business day the SP returned to work at 8 p.m., while no administrative personnel were at the office, and left his/her resignation letter. · LE confirmed the withdrawals were made using the VA’s debit card and the correct PIN. · LE showed P1 a still photo from security videos of the VA’s suspicious ATM withdrawals, and P1 confirmed the SP was the person in the photo. Additionally, the SP’s vehicle was identified from a security video, as the vehicle had a unique body type, as well as a personalized license plate. P1, P2, and a community person (CP) confirmed the SP had a personalized license plate, and drove the car in the security video. Based on video evidence, LE connected the three of ATM transactions captured on video to the SP. · LE made multiple attempts to contact the SP, however the SP did not respond to phone calls, a text message, or after LE left a business card at the SP’s address. · The SP was charged with criminal “Financial Transaction Card Fraud-Use-No Consent.” The VA’s Petty Cash Trackers provided the following information: · From January to May 2024, the VA’s petty cash balance did not change and maintained a balance of $6.48. There were no cash deposits documented, and it was documented the VA used his/her debit card for one purchase in the amount of $33.50 on March 2, 2024. · The facility was unable to locate the VA’s Petty Cash Tracker for the months of November and December 2023, and June through August 2024. P1 provided the following information: · The VA’s debit card and petty cash were stored in a locked cabinet within the locked staff office at the facility. All staff persons at the facility, including the SP, had access to the VA’s debit card and petty cash. · The SP was responsible for ensuring the safety of the VA’s finances by reviewing the VA’s bank statements, and the VA’s petty cash records and balance. However, in investigating this allegation of financial exploitation, the facility discovered that the VA’s suspicious ATM withdrawals (as documented in the LE Records above) were not documented within the VA’s Petty Cash Trackers. The facility’s Policy and Procedure for Safeguarding Funds of Individual Served included the following: · Staff persons were not allowed to borrow money from an individual served by the program. · Staff persons would immediately document receipt and disbursement of the funds of individuals served. · Staff persons would obtain an itemized receipt for each transaction of cash and/or automatic teller machine (ATM), and an on-going balance of cash resources would be maintained on a form each month. · On a weekly basis, an administrative staff person was responsible for counting all cash on hand, reviewing receipts, and comparing the monthly expenditure form for cash to ensure accuracy. The administrative staff person would follow up with staff immediately with all inaccuracies. · On a monthly basis, the administrative staff person was responsible for balancing the cash, and documenting the amount carrying over to the next month. · Any known or suspected maltreatment of a vulnerable adult, including misappropriation of funds, would be reported to the facility’s “Chain of Command” immediately, a Minnesota Adult Abuse Reporting Center (MAARC) report would be filed, and an investigation would be initiated. P1, P2, and the SP completed training on the VA’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. In addition, the SP completed trainings on client finances, petty cash, handling vulnerable adults’ funds, and the prohibition of borrowing or lending items between staff persons and vulnerable adults. Conclusion: A. Maltreatment: It was reported the SP used the VA’s debit card to make unauthorized transactions. From August 16, 2023, through August 1, 2024, there were $5,722.37 in suspicious transactions made with the VA’s debit card and PIN ($4,000 in ATM withdrawals and $1,722.37 in items purchased at Best Buy, Menards, and Amazon). The cash withdrawals were not documented in the VA’s Petty Cash Trackers and the VA’s petty cash balance did not change to reflect the cash withdrawals. ATM security videos from multiple suspicious ATM withdrawals showed the SP, and/or the SP’s vehicle, were present when the withdrawals were made. In addition, the SP was responsible for reviewing the VA’s bank statements and petty cash on a regular basis but there was no information that the SP identified or reported any concerns about the VA’s finances during this time. LE and this investigator attempted to contact the SP, but the SP did not respond to interview requests. The SP was charged with criminal financial transaction card fraud for use of the VA’s debit card without consent. Based on the information above, it was more likely than not that the SP used the VA’s debit card to complete multiple unauthorized transactions, and that the funds were not used for or by the VA. Therefore, there was a preponderance of the evidence the VA’s funds were willfully used of without 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. Video footage showed that the SP made at least three of the suspicious ATM withdrawals using the VA’s debit card. In addition, the SP was responsible for the oversight and accuracy of the VA’s petty cash. The SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s client specific information. 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 made at least three unauthorized withdrawals using the VA’s debit card on multiple dates. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility completed staff training, specifically related to safeguarding persons served funds. 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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