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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: 1071922-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy 641-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA1) was missing $96.64 from his/her petty cash account. It was also reported that a second vulnerable adult (VA2) was missing $160.50 from his/her petty cash account. Date of Incident(s): Unknown, prior to January 3, 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 through interviews conducted with two facility administrative staff persons (P1 and P2). Due to their diagnoses, VA1 and VA2 were unable to provide information about the incidents. Attempts were made by telephone and letter to contact a supervisory staff person (SP), but the SP did not respond to the requests for an interview. VA1 enjoyed bowling, watching movies, baking, working on puzzle books, playing piano, going on vacation, going on community outings, and spending time with his/her friends and family members. VA1 attended a day program. VA1’s diagnoses included severe intellectual disabilities and hyperactivity According to VA1’s Risk Assessment Detail, VA1 had limited understanding of money and its value and was vulnerable to financial exploitation. When in the community, staff persons carried VA1’s money and gave VA1 money to make transactions. Staff persons ensured that VA1 gave and received the correct amounts of money during the transactions and received receipts for the transactions whenever possible. Staff persons documented purchases made and maintained petty cash counts. According to VA1’s Cash on Hand Transactions Register, on December 13, 2023, VA1 had a deposit of $121 added to his/her cash envelope, bringing the total balance to $187.08. During the remainder of December 2023, VA1 made three purchases totaling $64.99, leaving a balance of $122.09. VA1 made a total of twelve purchases in December 2023, and there were receipts for each purchase. VA2 enjoyed bowling, swimming, bicycling, going on community outings, and spending time with his/her friends and family members. VA2’s diagnoses included severe intellectual disabilities, epilepsy, and cerebral palsy. VA2 used a walker to assist with his/her mobility. VA2 had limited verbal language skills. According to VA2’s Risk Assessment Detail, VA2 might have difficulty understanding how much money was needed to purchase items. Staff persons were to handle all of VA2’s change and receipts when shopping and then document all purchases. According to VA2’s Cash on Hand Transactions Register, at the beginning of December 2023, VA2 had $47.38 in his/her cash envelope. During December 2023, VA2 made five purchases totaling $31, leaving a balance of $16.38. There were receipts for each purchase. On December 20, 2023, VA2 had a deposit of $150, leaving a balance of $166.38 in his/her cash envelope. P1 and P2, and the facility’s Report Form for Internal Investigation provided the following information: · The SP began working for the license holder in July 2023 and worked at the facility from October to December 22, 2023. The VAs’ petty cash was stored in a safe with a combination-style lock. The safe was located in the staff office and the door to the office was typically locked. Only P1, the SP, and an administrative staff person (P3) knew the code needed to access the safe. P3 did not typically work at the facility and no information was provided that P3 was at the facility between December 20, 2023, and when it was discovered that money was missing from VA1’s and VA2’s petty cash envelopes. Documentation for the petty cash accounts, including receipts, was stored in individual binders in the staff office. · P1 stated that in November 2023, P1 trained the SP on completing documentation for the VAs’ financial records using the October 2023 records. P1 believed that the VAs’ money and documentation was balanced at that time. They were unable to check the VAs’ bank account records because the October 2023 bank statements had not yet been received. When P1 later checked the bank account records, all of the money in the bank accounts was accounted for. · A short time after the SP stopped working at the facility, P1 counted the money in VA1’s and VA2’s petty cash envelopes and found that VA1’s account was missing $96.64 and VA2’s account was missing $160.50. VA1 had $25.45 in his/her petty cash envelope and VA2 had $5.88 in his/her petty cash envelope. Although the SP assisted VA2 with cashing his/her $150 “allowance” check on December 20, 2023, and listed the money in VA2’s documentation, that money was not in VA2’s petty cash envelope. P2 believed that since VA2 cashed a check for $150 on the day prior to when the SP’s last day working at the facility, there should have been at least $150 in VA2’s petty cash envelope even if the documentation was previously “off.” VA1 and VA2 did not have access to their money while it was stored in the facility’s safe and when they made purchases, a staff person held the money for the VAs. · On January 9, 2024, P2 talked to the SP and the SP told P2 that the clients’ money counts “were off” since s/he began working at the facility and had “never been accurate.” The SP never knew how much money was supposed to be in the envelopes, so s/he did not always count the money as s/he was supposed to do since the counts would be inaccurate. The SP documented all transactions that were made when s/he was present. The SP did not recall when s/he last went to the bank with either VA1 or VA2. The SP denied taking any money from VA1’s or VA2’s petty cash envelopes and did not know what happened to the missing money. The SP believed the money was missing prior to when the SP began to work at the facility. The SP was unable to estimate how much cash was in either VA1’s or VA2’ petty cash envelopes when s/he stopped working at the facility. According to the facility’s Management of an Individual’s Monetary Resources policy, staff persons were to ensure that the clients’ money was kept secure. The staff persons were not to borrow or accept any items from the clients. Each of the client’s money was to be deposited into their account in a timely manner. All financial transactions were to be promptly recorded on the clients’ transaction register and all receipts were to be collected and documented. Facility documentation showed that the SP and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s plans prior to the incidents. Conclusion: A. Maltreatment: After the SP no longer worked at the facility, P1 found discrepancies in the VAs’ petty cash envelopes when s/he reviewed their financial records. Although P3 had access to the safe where the VAs’ petty cash was stored, P3 did not typically work at the facility and no information was provided that P3 was at the facility between December 20, 2023, when the SP helped VA cash a check for $150, and a few days later when it was discovered that money was missing from VA1’s and VA2’s petty cash envelopes. The SP told P2 that VA1’s and VA2’s financial records were “off” since s/he began working at the facility and that s/he did not take any money from VA1’s or VA2’s petty cash envelopes. Neither VA1 nor VA2 had access to their petty cash envelopes when they were stored in the facility’s safe. Given the aforementioned, there was a preponderance of the evidence that money was taken from VA1’s and VA2’s petty cash envelopes by a staff person without VA1’s or VA2’s permission, resulting in $96.64 missing from VA1’s petty cash account and $160.50 from VA2’s petty cash account. 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, P1, and P3 each had access to VA1’s and VA2’s petty cash envelopes. The SP told P2 that s/he did not take any money from VA1’s or VA2’s petty cash envelopes. The SP did not respond to requests for an interview and did not provide information about the incident to this investigator. Given that three staff persons had access to VA1’s and VA2’s petty cash envelopes and that it was unclear when the cash was removed from the facility, the responsibility for the financial exploitation of VA1 and VA2 was inconclusive. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but were not followed. The facility reimbursed VA1 for $96.64 and VA2 for $160.50. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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