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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: 1080284-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden 651-431-2155 Suspected Maltreatment Reported: It was reported that staff withdrew cash from three vulnerable adults’ (VA1-VA3) checking accounts for various amounts, which was then accounted for. Date of Incident(s): Ongoing prior to June 7, 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 site visits conducted June 21 and July 31, 2024; from documentation at the facility and law enforcement records; and through ten interviews conducted with VA1’s and VA2’s guardians (G1 and G2, respectively), VA3, VA3’s day services facility staff (DSF), facility staff persons (SP2, P1, and P2), and two supervisory staff persons (SP1 and P3). VA1’s case manager (CM) was also contacted but did not provide additional information. Law enforcement investigated this case in collaboration with the Department of Human Services. At the completion of this investigation, no criminal charges have been filed. Support plans, including Individual Abuse Prevention Plans, provided the following information: · VA1 and VA2 did not understand the concept of money and would not recognize mismanagement of their finances. The facility was responsible for managing VA1’s and VA2’s petty cash accounts, recording all cash transactions, and intervening and reporting suspected mismanagement. [Note: VA1 also had a debit card connected to his/her checking account, which some staff knew about and others did not. The facility did not manage or encourage debit cards for any of their clients.] · VA3 managed his/her own finances and typically kept his/her debit card and petty cash in his/her wallet. · VA1-VA3 were each diagnosed with intellectual disabilities. Facility documentation, P1-P3, G1, G2, and a Hutchinson Police Incident Report provided the following information: · P1-P3 each said that VA1’s/VA2’s petty cash was stored in separate envelopes in the staff office. Staff took cash out when needed, logged the amount taken on the respective housemate’s Petty Cash Log, and then returned any change and/or logged what was spent. Every staff person had access to VA1’s/VA2’s petty cash. VA3 was responsible for his/her own petty cash; however, VA3 was blind and needed help from staff to count out money for purchases and ensure proper change. · P1 and P2 each said that although any staff could help VA1/VA2 with shopping, SP1 and SP2 handled all of the shopping and managed all of VA1’s/VA2’s petty cash; other staff rarely did. SP1 or SP2 typically shopped alone, meaning VA1/VA2 would stay home or be at work when SP1/SP2 shopped using the VA’s money. · P3 said that staff should always bring VA1/VA2 with when shopping with their money. However, the facility did not have “definitive training” stating this was a requirement. · P1 and P2 each saw at various times, VA1/VA2 wearing new clothing or clothing with store tags still attached, which they associated with being purchased by SP1/SP2 using their respective money. · In early June 2024, G1 reviewed VA1’s bank statements and raised concerns, which prompted a review of all finances raising additional concerns. · VA1’s-VA3’s bank statements, receipts, Progress Notes, Leisure Logs, and Petty Cash Logs included the following: Regarding VA1: o Two separate receipts at a sports bar for a hamburger and tap beer Busch Lite for $16.85. VA1 did not drink alcohol and there was no documentation regarding a sports bar outing in VA1’s Progress Notes, Leisure Logs, and Petty Cash Logs. o Multiple receipts showing VA1’s debit card used for breakfast items and coffee during times when VA1 was at home, at work, or asleep. G1, P1, and P3 each said that VA1 sometimes drank coffee. However, P2 believed the specific coffee drinks on the receipts (e.g., turtle mochas) were “odd” for VA1, and P2 did not recall seeing VA1 with a coffee drink from Caribou Coffee or seeing a staff show up with coffee for VA1. The DSF worked with VA1 and never saw VA1 arrive at work with a breakfast or coffee, and never knew of staff to deliver such things to VA1 at work. o Multiple ATM cash withdrawals using VA1’s debit card, and multiple checks cashed from VA1’s checking account for $100s made payable to SP1 or SP2. There was no documentation in VA1’s receipts, Progress Notes, Leisure Logs, and Petty Cash Logs regarding these, and there was no record of the cash being added to VA1’s petty cash envelope. o P2 and P3 each said that a housemate’s checks should be made payable to “petty cash” and not to a staff person. o Two checks from VA1’s checking account to Great Clips. VA1’s hair was cut by P1 at the house. o G1 calculated the “suspicious purchases” on VA1’s accounts as $8,636.94. Regarding VA2: o VA2’s Petty Cash Logs showed 24 biweekly in-home massages for $65 each between August 2023 and March 2024. There was nothing in VA2’s medical records requiring routine massages. Phone calls to area massage locations did not find anyone who provided in-home massages or had VA2 as a client. The masseuse or massage location was never identified. o G2 reviewed VA2’s bank statements between October 2023 and April 2024 and saw multiple checks for $100s made payable to SP1 or SP2 with only one specifying “petty cash” on the memo line. There was no documentation in VA2’s receipts, Progress Notes, Leisure Logs, and Petty Cash Logs regarding these, and there was no record of the cash being added to VA2’s petty cash envelope. The total amount unaccounted for was $4,900. Regarding VA3: o VA3’s bank statements showed VA3’s debit card used to make multiple withdrawals for $100s every month between January 2023 and April 2024, totaling $7,705. There was no documentation in VA3’s Progress Notes or Leisure Logs indicating what happened to this cash. o P1 said that VA3 did not go many places and might buy a snack or soda at Walmart. P1 did not know why there would be 100s withdrawn from VA3’s checking account on a regular basis. VA3 kept cash in his/her wallet and might have a couple 20s. P1 never saw VA3 with $100s in cash. SP1 and SP2 each said that they were trained to make checks payable to themselves when withdrawing cash to replenish a housemates’ petty cash. SP1 and SP2 each shopped without the respective housemate present and outside of SP1’s/SP2’s work hours and were never informed this was not allowed. SP1 and SP2 each stated that they always recorded in the housemates’ Petty Cash Log and did not know about withdrawals or purchases made that were not recorded. Every staff person had access to VA1’s/VA2’s debit card and/or petty cash, and any staff person might help VA3 withdraw cash. SP2 sometimes brought breakfast and coffee into the facility or work for VA1 because VA1 liked coffee. SP1 and SP2 denied taking or misusing the housemates’ funds. Facility documentation stated that P1-P3, SP1, and SP2 received training on VA1’s-VA3’s Individual Abuse Prevention Plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information was provided that VA1’s-VA3’s finances contained transactions that were not accounted for by bank statements, receipts, Progress Notes, Leisure Logs, and Petty Cash Logs. Given that some of the transactions were for purchases which were not identified as being for the respective VA (e.g., alcohol, haircuts, specialty coffee drinks, massages), it was more likely that at least some of these were made without VA1’s-VA3’s awareness, approval, or benefit. In addition, information obtained showed that only staff persons had access to VA1’s and VA2’s accounts and that VA3 and staff persons had access to VA3’s accounts. Therefore, there was a preponderance of the evidence that in the absence of legal authority, VA1’s-VA3’s money was willfully used by a staff person. 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. P1-P3, SP1, and SP2 received training on VA1’s-VA3’s Individual Abuse Prevention Plans and the Reporting of Maltreatment of Vulnerable Adults Act. Although VA1’s and VA2’s cashed checks were made payable to SP1 and/or SP2, that SP1 and/or SP2 were more likely to do the shopping with or for VA1-VA3, and that VA3 had multiple withdrawals but no history of going anywhere or making purchases, all staff persons had access to VA1’s and VA2’s finances and/or might be with VA3 in the community or when VA3 was using his/her debit card. Therefore, it was not able to be determined who was responsible for the financial exploitation of VA1-VA3. The responsibility for the financial exploitation of VA1-VA3 was inconclusive. Action Taken by Facility: The facility completed internal reviews and determined that policies and procedures were adequate but not followed, this included safe keeping of the housemates’ funds and access to the housemates’ funds. The facility provided additional training to staff and SP1 was no longer employed. The facility planned to reimburse VA1-VA3 for any missing funds. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time. However, should the Department obtain new information, it will be reviewed for possible additional action.
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