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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: 1105167-ADC (Adult Day Care) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA’s) electronic benefit transfer (EBT) card was used without authorization. Date of Incident(s): April 4 to 27, 2023 (The Department of Human Services received the report on May 29, 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 was obtained during a site visit conducted on August 9, 2024; from documentation at the facility and county EBT records; and through five interviews conducted with an administrative staff person (P), two supervisory staff persons (SP1 and SP2), the VA, and the VA’s case manager (CM). Another attendee (A) of the facility, who was also a family member of SP1, declined to be interviewed. Law enforcement was aware of the incident but was unable to obtain videos of the purchases or information regarding purchases. The VA was diagnosed with diabetes. The VA enjoyed playing games, going out into the community, watching TV, and traveling to visit family. The VA attended the facility from October 6, 2021, to December 1, 2023, five days a week. The VA’s Individual Abuse Prevention Assessment and Plan stated the VA was not susceptible to financial exploitation. The VA provided the following information: · The VA lived in the same building as the A. At the facility, the VA played games, socialized with others, went shopping, and exercised. The VA was able to complete his/her own purchases and transactions when out in the community. The VA “trust[ed]” SP1 because SP1 helped the VA with his/her mail and insurance information. · SP1 was able to access the VA’s EBT balance information to show the VA. On approximately two occasions, SP1 “offered” to withdraw money for the VA from the EBT account. The VA agreed and gave the SP the EBT card and the personal identification number (PIN). SP1 kept the VA’s PIN on his/her phone and was the only staff person who knew it. · On April 3, 2023, the VA left the country to visit family. On an unknown date prior to leaving, the VA asked SP1 to hold on to his/her EBT card while s/he way away because the VA did not want to bring the EBT card with him/her and s/he thought SP1 would keep it “safe.” When the VA gave the card to SP1, VA did not tell SP1 that s/he could use it while the VA was gone. · On May 4, 2023, (one month later) the VA returned from his/her trip and soon began attending the facility again. Around that time, SP1 gave the VA back his/her EBT card. About one week later, the VA went with the facility to shop at Walmart. When the VA went to pay there was “no money” in the account. · When the VA returned to the facility, s/he went to SP1’s office and asked about the EBT card balance because the VA had not given SP1 permission to use it. SP1 told the VA that s/he “needed” to use the VA’s card due to “an emergency.” SP1 did not explain what the emergency was and told the VA that s/he planned to pay the VA back. The VA and SP1 were the only people in the office when the conversation happened and the VA did not tell anyone at that time about the conversation. · About one month later on an unknown date, SP1 had not paid the VA the missing funds, SP1 asked the VA to come into his/her office. SP1 told the VA that if the VA told others about the missing EBT funds, SP1 was going to “suspend” and “remove” the VA from the facility. · Afterward this, when others were not around, SP1 was “always threatening” to have the VA removed from the program if s/he talked about the missing EBT money. The VA did not tell others about the missing EBT funds because s/he was “afraid” of SP1 and being “kicked out” of the program. · After the situation with the card, the VA thought SP1 was “always against” the VA, treated the VA “like a child,” and gave the VA a “negative response” when they talked. SP1 made the VA “feel bad” and “discriminat[ed] against.” SP1 did not respond to the VA’s greetings and gave the VA “very little” food at mealtimes. · On December 1, 2023, the VA decided to stop attending the facility. Afterwards, SP1 continued to call the VA even though the VA’s services had ended. The VA was never reimbursed for the missing money. · The VA denied that SP2 encouraged him/her to leave the program. The VA gave inconsistent information on his/her continued relationship with SP2. Initially the VA said s/he had no additional contact with SP2, but then stated s/he called SP2 and got help with insurance paperwork after s/he was no longer at the facility. The VA’s EBT statement showed the following transactions occurred while the VA was out of the country: · April 4, 2023, $15.63, at Hy-Vee. · April 5, 2023, $29.98, at Sam’s Club. · April 18, 2023, $241.56, at Sam’s Club. · April 22, 2023, $36.98, at Trader Joe’s. · April 27, 2023, $25.04, at Bymore Super Mercado. The CM provided the following information: · On an unknown date in March 2022, the CM began to work with the VA and met him/her one time. The VA was “alert and orientated,” but had “minor forgetfulness” and “repeat[ed]” things “over again.” The VA’s memory was “not 100%.” · The VA “loved” the facility when s/he attended it. The VA had no family in the area and the facility offered opportunities for the VA to socialize, go shopping, and assistance with various paperwork. The VA was able to shop without the assistance of staff persons. The VA’s relationship with SP1 was “amazing,” until there was an “incident” between the VA and an attendee related to SP1. While the facility “took action” to prevent the incident from happening again, the VA felt the facility did not do enough to resolve the issue. Afterwards, the VA felt “singled out” and was “not being taken on activities.” · On January 8, 2024, SP1 called the CM and said that the VA stopped attending the program the end of November 2023, the VA stopped attending the program and would not return SP1’s calls. SP1 also told the CM that SP2 was no longer working at the facility after allegations that s/he took money from the VA and other attendees’ EBT cards. SP1 said that the VA stopped attending the facility when SP2 left because SP2 “helped” the VA. SP1 was trying to let the VA know that if the VA wanted to return, there was a new staff person the VA could work with. · The CM never talked to the VA about the missing funds. The VA had listed SP2 as his/her emergency contact and SP2 was “still involved” in the VA’s life. The CM suspected the VA did not believe SP2 took any funds, and the CM never had any contact with SP2. SP1 provided the following information: · The VA began attending the facility to reduce his/her isolation, get help with appointments and paperwork, and to get out into the community. SP1 had a “wonderful” and “close” relationship with the VA. SP1 went out of his/her way to assist the VA beyond facility roles and hours even when the VA was on SP2’s caseload. · At times the VA was “challenging,” and got “upset over little things” such as if the VA did not like how someone looked at him/her, s/he yelled at them and “complain[ed].” The VA “exaggerate[ed]” at times and incidents were “blown out of proportion.” The VA was “gossipy,” and had “falling out[s]” with several groups of attendees at the facility. · When the VA shopped, staff persons did not assist the VA in anyway. Staff persons were not involved in the VA’s finances but assisted the VA with paperwork as needed. SP1 and the VA used SP1’s cellphone to access the VA’s accounts so the VA could see his/her available balances. A “couple of times” the VA asked SP1 to take the VA’s EBT card and PIN to the bank to withdraw cash. SP1 did so and then returned and gave the card and the money to the VA. SP1 stated that SP2 also did this for the VA and knew the VA’s PIN. · SP1 said that the VA “trusted” SP1 to assist with planning and purchases for his/her trip out of country, despite being on SP2’s caseload at the time. The VA and the A were “close,” and s/he also helped the VA look at flights for his/her trip. SP1 was an emergency contact person for the VA’s family if the VA had a problem while on the trip. · On an unknown date in March 2023, the VA asked to switch caseloads from SP1 to SP2. This occurred at times if the VA thought s/he was not being helped enough or that others were favored over him/her. · Also on an unknown date in March of 2023, SP1 learned that SP2 used the VA’s EBT card without the VA’s permission but SP1 provided conflicting information regarding how s/he learned of the incidents. SP1 told the DHS investigator that the A told SP1 that the VA said when s/he began attending the facility, SP2 used the VA’s EBT card without permission. However, SP1 had in his/her written notes that the VA came into his/her office and told SP1 that on two occasions SP2 used the VA’s EBT card and spent $200 each time. The VA was not given the purchased items, and s/he was not paid back by SP2. SP1 told the VA the EBT benefits were for him/her only and were not to be used by others. · On an unknown date in April 2023, SP1 asked SP2 about using the VA’s EBT card. SP2 denied it and told SP1 that the VA was a “fucking lying bitch.” SP1 had known SP2 for “several decades” and “did not want to believe it,” but thought SP2 was “capable of stuff like that.” When the VA returned to the facility after his/her vacation s/he was changed back to SP1’s caseload. · SP1 denied that the VA asked him/her to hold the VA’s EBT card while s/he was away. The other staff persons who could have had that discussion with the VA was SP2 or the P, but the P did not speak the VA’s primary language. SP1 denied having access or using the VA’s EBT card, denied telling the VA that s/he used the VA’s EBT card for an emergency, denied talking to the VA about missing funds, and denied telling the VA that s/he would be removed from the program for telling others about missing EBT funds. SP1 thought it was possible the VA gave the EBT card to the A or another attendee while s/he was out of the country. · The facility had a Sam’s Club membership and SP1, SP2, the P, the A, and a family member of SP1 had card. SP1 was not able to see who made what purchases when using the facility membership. SP2 was responsible for buying items for the facility. On an unknown date after August 2023, SP1 took over purchasing items for the facility because it was unknown whether all of the items purchased were getting to the facility. · On an unknown date the middle of November 2023, the VA was again on SP2’s caseload when there was a “huge fighting argument” between them. The VA made comments about SP2 “being mean” and “not being cared for by [SP2].” The VA said SP2 did not help him/her, helped everyone else, and caused the VA to miss a medical appointment. SP1 told SP2 the VA was now on SP1’s caseload and the SP2 “blew up.” SP2 called the VA “a bitch.” SP1 said SP2 cannot talk about attendees that way. · On November 30, 2023, SP2 no longer worked at the facility and on December 1, 2023, the VA along with 17 other attendees stopped attending. SP1 thought SP2 called attendees and “encouraged” them to not attend the facility. SP1 called the VA about his/her decision to stop attending and was told it was due to the incident with the A, not because of SP2. SP1 offered to continue to support the VA despite him/her no longer attending the facility so the VA did “not get stuck at home.” The A later told SP1 that s/he saw the VA leave their building and get into SP2’s car. Another attendee also told SP1 that when SP2 was no longer with the facility, SP1 also called him/her and said to not attend and that SP2 planned to open his/her own facility. · SP1 thought that SP2 “encourage[ed]” and “coerced” the VA to tell others SP1 misused the EBT funds. SP2 was “always about what is beneficial to [him/her].” After SP2 left the facility other attendees also said SP2 used their EBT cards to buy groceries. SP2 provided the following information: · SP2 did not want to talk in detail about SP1 and said s/he was “scared” of SP1. SP1 was “very intelligent,” but s/he “lies a lot.” SP2 thought that SP1 “can do a lot of harm to people” and did not want to “speak good or bad” about SP1.
· The VA was “quiet” and a “good person” who did not have family members in Minnesota. While at the facility, the VA ate meals, talked with others, played games, did arts and crafts, and exercised. The VA was “direct,” wanted feedback, and to be “congratulated.” The VA got along with others “fine” and was “close” to the other attendees, but sometimes the VA “was not comfortable” with them and changed who s/he was friends with. · SP2 got along with the VA “very good” and “always” talked together. SP2 gave inconsistent information regarding why the VA changed caseloads between SP1 and SP2 and also stated that s/he did not know why the VA changed caseloads. SP2 also said that the VA did “not want [SP2] to see [his/her] mail or paperwork.” · The staff persons brought the VA into the community for outings, shopping, and to appointments. At times, SP2 also took the VA to the bank and the VA took out his/her own money. SP2 denied s/he or any other staff person withdrew money from the VA’s account without the VA present. SP2 denied s/he knew the VA’s EBT PIN. · SP2 knew SP1 had access to attendees’ bank account balance information on his/her phone through an app. The VA “trusted” SP1 and s/he helped the VA with online shopping. When SP2 was asked by attendees to look up their account balance, SP2 was not able to because s/he did not want to download the app as “that information was confidential.” · SP2 used the facility’s Sam’s Club membership for a while, until SP1 took over the facility shopping. SP2 believed that only s/he and SP1 had access to the Sam’s Club card. SP2 denied using the VA’s EBT card for his/her personal use at any time. SP2 said that there was no point in which s/he was accused of using it and had no discussions about missing EBT funds. · When the VA planned his/her trip, s/he was on SP1’s caseload. The VA was “very protective” of his/her EBT card. SP2 did not have any conversations with the VA about any safekeeping of the VA’s EBT card while the VA was away. · After the VA returned to the facility from vacation, everything was “normal” until an incident with a family member of SP1. Afterwards, the VA wanted to switch again to SP2’s caseload. The VA told SP2 that s/he “did not feel comfortable with the program.” The VA “did not trust” SP1 but “did not want any problems.” The VA was concerned because SP1 had all of the VA’s paperwork. · After the VA no longer attended the facility, the VA called SP2 from a new phone number. The VA told SP2 that s/he “felt harassed” by the calls from SP1 so s/he changed his/her number. The VA also told SP2 that s/he changed his/her EBT card number because s/he “did not trust” SP1 who had the VA’s information. The VA then asked SP2 to be the VA’s emergency contact. SP2 and the VA “still got along” and were “talking like always.” On an unknown date, when the VA told SP2 about the missing funds from his/her EBT card, s/he said it was because s/he did “not want others to suffer” like s/he had from SP1. The P provided the following information: · The P did not speak the same language as most of the attendees of the facility, so the P relied on other staff persons to interact with the attendees at the program. The P was “very protective” of the attendees and tried to work with them as much as s/he was able. SP1 got along with the attendees “well” and was a “giving person.” SP1 was “caring,” listened to the attendees, and “help[ed] with everything.” · SP2 had a “good personality,” but s/he “wasn’t a good person sometimes.” SP2 had a “vindictive or vengeful streak” and “wanted to get people to favor [him/her] and not [SP1].” SP2 “had animosity with some people” and had “great relationships[s]” with others. The P said, “Some people liked [SP2], some people hated [SP2].” Although SP2 was bilingual, s/he did “not always understand English.” The P’s limited proficiency in the same language as the attendees, meant the P did not fully understand the issues between SP1, SP2, and the attendees. · Some attendees occasionally wanted to switch between SP1’s and SP2’s caseloads. When the attendees switched caseloads, it did not appear to cause issues between SP1 and SP2 because they often “help[ed] each other out.” There were attendees, including the VA, who at times had issues with either SP1 or SP2 and switched back and forth between their caseloads. The VA was “demanding” at times and wanted items taken care of “immediately.” The P was not involved in the attendee caseloads. · The attendees were taken shopping weekly and SP2 was typically the staff person who drove them. There were times when the P drove and while shopping s/he did not assist any person with their purchase or transactions. · The P had no role in the VA’s finances. SP1 and SP2 were asked at times to review the attendees bank statements and benefits paperwork for them. The P was not aware that SP1 and SP2 sometimes withdrew money from attendees’ bank accounts or that SP1 looked up the VA’s balances on his/her phone. · When the VA was out of the country, the P was not aware of any discussions of his/her EBT card being kept at the facility or used during that time. The P did not use the facility’s Sam’s Club membership and denied using the VA’s EBT card without permission. The P was not aware of any conversations between the VA, SP1, and/or SP2 regarding the VA being removed from the program for any reason. · Around October 2023, SP1 told the P that the VA “gave some EBT cards to [SP2] and [the VA] complained to [SP1] that [SP2] never gave [the VA] the money back and kept the items for [him/herself]” and that SP2 denied the allegation. The P thought they “smoothed it out and figured out a solution” which the P was not aware of. The P was not aware of how much money was used or “if the funds came from an EBT card.” The P did not talk with SP2 or the VA about it. · On November 30, 2023, SP2 no longer worked at the facility. The P drove the VA home that day and s/he told the P, “See you tomorrow,” but did not show the next day. The P did not know why the VA stopped attending and had not spoken with the VA since. Law Enforcement was unable attain video footage of the alleged misuse of the VA’s EBT card from the stores due to the length of time that passed between the transactions and the report. Facility documentation showed that SP1, SP2, and the P were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s care plan. Conclusion: Information obtained showed that while the VA was out of the country his/her EBT card was used five times. The VA said that prior to leaving the country, s/he gave his/her EBT card to SP1 for safe keeping but that s/he did not give SP1 permission to use the card. The VA also said that when s/he returned SP1 told the VA that s/he used the VA’s EBT card and that s/he would repay the VA, but SP1 did not do so. SP1 denied that the VA asked SP1 to hold the EBT card when the VA was out of the country, denied using the VA’s EBT card, and denied telling the VA that s/he had used the EBT card. SP1 also stated that either another attendee at the facility or the VA told him/her that SP2 used the VA’s EBT card on two occasions for $200 each time. However, SP2 denied having done so. Because it was over one year from the time of the incidents to the Department of Human Services receipt of the report, the Departments ability to obtain credible information was hindered, including the video of whoever used the EBT card on each of the five occasions was not able to be obtained. Therefore, given the conflicting information regarding who may have had access to the EBT card and who may have used the VA’s EBT card, there was not a preponderance of evidence whether either SP1 and/or SP2 used the VA’s EBT. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but were not followed by the staff persons. After the incident, staff persons were retrained on the facility’s policies for maltreatment reporting. Action Taken by Department of Human Services, Office of Inspector General: Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one staff person failed to report suspected maltreatment as required. A letter from DHS was sent to the individual regarding his/her failure to report the suspected maltreatment and potential consequences for future such failures. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was issued a correction order for failure to report maltreatment.
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