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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: 1068646-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a staff person (SP2) used funds of four vulnerable adults (VA1, VA2, VA3, and VA4) to make purchases that should have been purchased by the facility for the VAs and that a supervisory staff person (SP1) did not review the purchases made by SP2. Date of Incident(s): Multiple dates in 2023during and prior to 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 seven interviews conducted with four supervisory facility staff persons (P1, P2, P3, and SP1), VA1’s and VA4’s guardians (G1 and G4, respectively), and SP2. Due to VA1’s, VA2’s, VA3’s, and VA4’s abilities and lack of involvement in their finances, they were not interviewed for this investigation. Attempts to contact each G2 and G3 via phone and United States mail were unsuccessful. VA1’s Individual Abuse Prevention Plan (IAPP) stated that staff persons were to handle VA1’s money when making purchases and “must” obtain a receipt. The facility’s program manager (SP1) was to, “track monthly expenditures and balance [VA4’s] cash,” which included “checking all receipts.” VA1’s plans also stated that s/he was “verbal” and was able to understand “simple prompts and directions” but had an “inability to handle financial matters.” VA2’s IAPP stated that s/he was unable to manage his/her financial resources and that staff persons were to assist with, “Making purchases, collecting receipts, balancing [his/her] petty cash book, and [ensuring] it was accurate.” VA’2 plans stated that s/he understood “basic” questions and directions, would respond, “Yes,” and “No,” and used an iPad and Picture Exchange Communication System (PECS) for communication. VA3’s plans stated that s/he was “non-verbal” but used “gestures” to communicate. Staff persons were to handle VA3’s money when making purchases and would obtain a receipt. The facility’s program manager (SP1) was to track expenses and balance cash on a “weekly basis.” VA4’s IAPP stated that the “Program Supervisor or someone in the chain of command” would handle documenting VA4’s finances. Staff persons were to carry VA4’s money while out in the community, pay for his/her items, and obtain receipts to turn into the “Program Supervisor or someone in the chain of command.” VA4’s plans also stated that s/he answered yes and no questions, made choices when given options, and telling staff persons what s/he wanted. VA4 understood “simple requests” but sometimes responded with, “No,” or ignored staff persons. According to clients’ plans, VA1 was diagnosed with autism and a moderate intellectual disability. VA1 liked listening to music, playing video games, drinking soda, and anything related to Nintendo’s Mario character. VA2 was diagnosed with autism, anxiety, and a seizure disorder. VA2 enjoyed swinging, being outside, spending time with family, and eating out. VA3 was diagnosed with atypical autism, and mild to moderate intellectual disability based on visual and auditory processing. VA3 enjoyed spending time with family, having time to his/herself, and eating out. VA4 was diagnosed with autism, severe intellectual disability, and bipolar disorder – manic phase. VA4 enjoyed going out for drives, dancing, and spending time with family. P1 and P2 provided the following information: · P2 conducted “back audits” of financial documents across several facility locations along with other supervisory staff persons. The audits included reviewing client and facility petty cash balances, looking for “large” purchases, and comparing them to the receipts. · P2 noticed that there were “discrepancies” with larger food purchases logged in one of the client’s petty cash accounts by SP2 during the 2023 calendar year. P2 informed P1 of this. Both stated that this was unusual and that there was “no reason” for grocery purchases to come out of a client’s accounts because the facility had an account set up at a specific grocery store where staff persons could charge monthly grocery expenses for all four clients. · P1 did not see any record of reimbursement from the facility to clients around the time of the purchases. P2 understood if a “snack or something smaller” had come out of a client’s petty cash account, but it was a “red flag” when, for example, there was a purchase larger than that for food purchased at the grocery store. All purchases in question were made and initialed by SP2 and signed off by SP1. P2 did a broader search and found food and hygiene purchases like this for VA4 in 2023 and for VA1, VA2, and VA3 in 2024. · According to P2, SP1’s role was to oversee client and facility petty cash accounts. This included scanning receipts from purchases that staff persons made with the clients’ petty cash accounts, looking through the charges, looking into “red flags,” ensuring the transactions were accounted for, balancing accounts, and submitting a report on a monthly basis. This included “investigating” expenditures as they occurred and having conversations with facility staff persons to verify that purchases were used for clients. P2 felt that SP1 was either “not thoroughly checking” the transactions or was “just writing down” the transactions monthly without further investigating. P2 did not think that the ledgers were improperly balanced, but rather, P2 was unsure if the items purchased using clients’ petty cash were at the facility for client use. · In addition to a variety of food purchases at the grocery store made by SP2 on various dates, there were several purchases using VA4’s petty cash for other things. One was for “82 Kitchen” (said to be an 82-piece pot and pan set) in the amount of $32.55, a $55 gift card, and purchases made for spices at an African store for $22.98. P1 could not “imagine” VA4 stating, “I really need these seasonings from this African grocery.” None of the clients should have had to pay for groceries, cleaning supplies, or kitchen supplies. · Typically, client petty cash was used for personal hygiene items, activities, bedding, things the clients wanted, eating out, or getting snacks. VA1’s questioned purchases totaled $114.24. VA2’s questioned purchases totaled $121.24. VA3’s questioned purchases totaled $92.92. VA4’s questioned purchases totaled $555.39. · P1 and P2 stated that cash was the only form of money on hand at the facility, which meant no debit or credit cards were on hand. The amount of available petty cash varied for each client and there was no limit as to how much money could be in each account. According to P1, if staff persons were doing things “right,” they would bring clients with them when they spent that clients’ petty cash. · In addition to food charges, P1 and P2 stated that SP1 approved an expenditure in the amount of $150 for a locksmithing service to install a lock on VA1’s bedroom door. P1 found documentation that SP1 had gotten approval from a supervisor to pay for the locksmith service out of VA1’s account even though the facility “would have” been the one to pay for it. According to P1, this transaction was no longer questioned after P1 located written communication of the approval to SP1. · P1 stated that all clients had been reimbursed, including VA1 for locksmithing services. · P1 had no prior concerns regarding SP1’s handling of finances, but there was a time where SP2 was grocery shopping for the facility, taking between three and four hours to shop while using the facility’s account which was “concerning” but nothing else. G1 was not aware of approving VA1’s funds to be spent on a locksmith. SP2 provided the following information: · One of SP2’s duties was to get groceries and cleaning supplies for the facility. After making a list, SP2 would shop for the items at a designated grocery store, charging the items to the facility’s account. Sometimes, these items were purchased using the facility’s petty cash account. SP2 would get a receipt and turn it in. SP2 typically did not take the clients with during these shopping trips. · SP2 first stated that clients did not pay for groceries for the facility, stating the clients would only use their petty cash if they wanted to eat out. Before taking a client’s petty cash, staff persons would count the cash to make sure it matched the amount on the ledger. Then, staff persons would go to the store, purchase what was needed, log the purchase back on the ledger, and balance the ledger. This process also applied to the facility petty cash account. · The ledgers for the facility and clients’ petty cash were audited every one to two weeks by SP1 and then forwarded onto another supervisory staff person, then to another supervisory staff person for verification. If there was a question about a purchase, SP1 would go over the purchases with SP2. P1 also went through the receipts. · SP2 initially denied, but then stated that s/he recalled a time when s/he used petty cash to purchase food items for all four clients from the designated grocery store and that it was for their lunches. SP2 “always had receipts” and “always logged” the receipts. SP2 recalled a time period where staff persons had to use client money for items because the facility ran out of petty cash. SP2 stated that this was during a time where the facility did not have a manager so SP2 was “told” to purchase things with the clients’ petty cash accounts. SP2 stated that s/he was “authorized” by SP1, P1, or a “higher up” and that it was not a “recurring thing” but that there was not any facility petty cash. SP2 “didn’t just do it” on his/her own. · SP2 provided conflicting information that s/he was authorized to use the clients’ petty cash accounts for their own food purchases when there was no facility petty cash due to there not being a manager and also stated that SP1, who was a manager gave SP2 permission to use the clients’ petty cash accounts. SP2 later said that there was about 18 months when there was not a manager, before SP1 was hired. · SP2 denied purchasing facility household items from the clients’ petty cash accounts except for an 82-piece kitchen set which SP1 approved for SP2 to purchase with VA4’s petty cash. SP2 also bought spices from an African grocery store for the house with VA4’s petty cash. · At one point, a supervisory staff person stopped SP2 from doing grocery shopping. There was also a time where “it was messed up” and staff persons could not go to the grocery store to get groceries and then it changed back, where staff persons could use the store account to get groceries. · SP2 stated that the items purchased were mainly breakfast foods, because they were out of those items and sometimes lunch food. Body wash and personal hygiene items, such as absorbent undergarments were also purchased. Typically, absorbent undergarments would have been covered by the facility, but if a client needed it, SP2 had purchased them with client money from time to time. · SP2 denied using any petty cash from VA1, VA2, VA3, or VA4 for anything for him/herself and stated that everything spent using clients’ petty cash was either approved by SP1 or another facility staff person. SP2 denied ever getting his/her own lunches paid for by the clients. · SP2 was unsure if the facility reimbursed the clients for purchases made that should have been covered by the facility. SP1 provided the following information: · When SP1 started working at the facility, one of SP2’s duties was to purchase groceries for the facility by charging groceries to the facility’s account. There was a time when facility administrative staff persons, including SP1 and P1, thought that SP2 was spending “way too much” money at the grocery store. The facility’s petty cash balance was usually gone by the 20 of each month. SP1 told P1 of his/her concerns. For a period of time, SP2’s ability to charge groceries to the store was removed but then facility administration “flip-flopped.” It “didn’t make any sense” that administrative staff persons “suspended” SP2 from grocery shopping and then gave the responsibility back. As a result of them suspending the grocery shopping privileges, sometimes there was no food. VA4 typically ate more than the other clients but all clients “ate a lot” and “enjoyed food.” During that time, SP1 got approval from P1 to use clients’ money and told SP2 s/he could use clients’ petty cash to purchase food for the clients. · SP1 verified everything that was spent using clients’ personal petty cash accounts, ensuring the items were there and that it was items that each client would eat. SP1 was “new,” and the facility was · SP1 was not told what the “exact number” was for the facility grocery budget. SP1 had been told by administrative staff persons that they could use clients’ personal money or facility petty cash money to take clients out to eat. The only time the budget was addressed was when SP2 was “going over the top” with spending. · A $55 gift card, using VA4’s petty cash was purchased by SP2. SP1 explained that since the facility did not have any debit or credit cards on site, SP2 purchased a gift card so that s/he could make an online purchase for something for VA4. This was also an approved purchase. · SP1 was “suspicious” of a purchase of spices from an African store because the store did not offer receipts and SP2 had to “hand write” a receipt for that purchase but saw that the spices were ordered for the facility. · SP1 got approval from P1 to allow SP2 to purchase an 82-piece pot and pan set for the facility. A receipt showed that VA4’s petty cash was used for the purchase. Pots and pans regularly got “burnt” and would be thrown away. SP1 did not know why VA4’s funds were used to purchase the kitchen set and said SP1 “guessed” that SP2, “probably did something that [s/he] shouldn’t have” by using VA4’s petty cash for facility items. SP1 did not recall “authorizing” SP2 to use VA4’s petty cash for that purchase. SP1 stated that s/he may have said, “Yeah, you can buy pots and pans,” but did not say SP2 could use a clients’ petty cash for it. SP1 would have been one of three people checking that receipt purchase. · SP2 “sometimes” took clients along with him/her when s/he used clients’ petty cash but “not every time.” SP1 was not aware of a policy requiring staff persons to bring clients along when their petty cash was used. · Part of SP1’s monthly duties were to match all receipts with the purchases in the clients’ logbooks, then send that off to an accountant who ensured everything balanced. A purchase could not be submitted without a receipt to accompany it. The receipts and ledgers were also looked at by supervisory staff persons. If a receipt was missing, SP1 was questioned by supervisory staff persons. · In general, staff persons did not need permission to access clients’ petty cash accounts as long as it was being spent on the clients. With three of the clients being “non-verbal,” food was the main thing that they knew those clients wanted when it came to spending their money. Purchases made by clients for staff persons would have gotten “flagged right away.” For example, if SP1 saw that a client purchased “two meals” instead of one, SP1 would have wanted to know why. SP1 did not recall ever seeing two meals paid for by clients. · SP1 did what s/he could do to bring “minor suspicions” regarding spending forward to P1. · VA1 needed a lock put on his/her door because s/he was “complaining” that s/he did not have one. SP1 remembered that s/he asked supervisory staff persons who would pay for that because SP1 would not “just wing it” with purchases and s/he did not know whose financial responsibility it was. SP1 recalled getting approval from G1 for the locksmith service purchase. P3 provided the following information: · P3 did not work at the facility during the time when the questioned purchases were made, but explained that petty cash was kept in the safe and taken out from time to time for staff persons to spend money for the clients’ personal needs, which included client outings. P3 monitored the balances and made sure money was added to each account and estimated when more money might need to be added to cover more expensive items such as clothing or shoes. · Staff persons “always” took clients with them when staff persons used a client’s petty cash and returned with a receipt. Staff persons initialed each client’s petty cash ledger with where they went, what they bought, how much they spent, and what the new balance was, which allowed P3 to track the purchases. · P3 went through the petty cash purchases on Mondays and Fridays. On Fridays, after checking the purchases for the week, P3 ensured that each client had petty cash for the weekend. On Mondays, P3 checked the ledgers for weekend purchases and made sure that all receipts were accounted for, then made sure the accounts were properly balanced. P3 spoke with facility staff persons about the purchases and would ask for explanations about expenditures, when needed. At the end of each month, P3 entered every purchase found on client ledgers, scanned the ledgers and receipts, and sent them into the quality assurance department. · P3 was responsible for shopping for the monthly groceries and charged them to the facility’s account. If a client wanted something special like a soda pop or snack, a staff person would go with the client. It would be uncommon for a staff persons to spend client petty cash at a grocery store and P3 described a “substantial” purchase as anything over $30. When the facility needed food, the facility’s petty cash account was used if food had not already been purchased using the grocery store account. · All staff persons currently working at the facility were trained on how to handle client petty cash accounts. Staff persons never used clients’ petty cash for staff person outings or meals. · VA1’s petty cash was typically spent at Speedway gas station. VA2’s petty cash was typically spent at Subway. VA2 was at school a lot and ate there. VA2 typically did not spend money while at home. VA3 spent his/her petty cash money at the zoo and Subway. VA4’s petty cash was spent on Subway and haircuts. VA4 was not at a day program or at school and was home more to go spend petty cash. G4 provided the following information: · P1 informed G4 that there had been some “irregularities” in VA4’s accounting and resources. In general, G4 felt “trusting” of the facility and of those in charge. G4 felt like the facility did a “very good job” helping VA4 “have the best life” that s/he could have. · VA4 lacked the “verbal communication skills to be able to tell someone if something happened or to describe an event. VA4 did not know anything about money or its “value.” VA4 was “unaware” of the “significant or insignificance” of money. The facility’s Funds and Property of Persons Served policy stated, “The Designated Coordinator will ensure that all receipts and disbursements of persons served funds and property are documented,” and “The Designated Coordinator will ensure that the program and staff [persons] will not . . . Require a persons served to purchase items for which the program is eligible for reimbursement.” The policy also stated, “The Designated Coordinator will provide additional detailed oversight in cases where financial exploitation has been identified in the person’s Individual Abuse Prevention Plan. Staff [persons] who have the responsibility of assisting persons served with budgeting or banking will have additional accountability for the assistance that they provide. Staff [persons] will have to provide their supervisors with accurate documentation of transactions and balances of the persons account each month.” All staff persons interviewed were trained on the clients’ plans and Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and Statutes: Minnesota Statutes, chapter 245A.04, subdivision 13, paragraph (b), and paragraph (d), clauses (4) and (5), stated that the license holder must ensure separation of funds of persons served by the program from funds of the license holder, the program, or program staff and license holders and program staff must not require a person served by the program to purchase items for which the license holder is eligible for reimbursement or use funds of persons served by the program to purchase items for which the facility is already receiving public or private payments. Conclusion: Information from P1, SP1, and SP2 showed that SP2 was responsible for purchasing facility groceries on behalf of the facility and part of that duty was to charge the groceries to a facility grocery account. P2 noticed that there were “discrepancies” with larger food purchases logged in one of the client’s petty cash by SP2. SP1 stated that three of the four clients “loved to eat” and a lot of food was purchased for the facility. According to P1 and SP1, there had been concerns about SP2’s grocery spending and time spent shopping, which resulted in SP2 being suspended from grocery shopping for a brief period. SP1 stated that the facility’s petty cash balance was usually gone by the twentieth of each month. SP1 brought the concerns about SP2 to P1’s attention. For some food purchases and a locksmith purchase, SP1 got approval from P1 to use clients’ money and told SP2 s/he could use clients’ petty cash to purchase food for the clients. SP1 verified everything that was spent using clients’ personal petty cash accounts, ensuring the items were there and they were items that each client would eat. SP2 denied using any clients’ petty cash accounts for personal use or anything other than for the clients. SP2 stated that s/he “always had receipts” and “always logged” the receipts. On occasion, SP2 had to use client money for items because the facility ran out of facility petty cash. SP2 denied purchasing facility household items from the clients’ petty cash accounts except for an 82-piece kitchen set which SP1 approved for SP2 to purchase with VA4’s petty cash. P2 stated that the clients’ petty cash accounts were balanced properly by SP1, but P2 was unsure if SP1 was either “not thoroughly checking” the transactions or was “just writing down” the transactions monthly without further investigating. SP1 stated that s/he asked permission of P1 or the chain of command when s/he did not know if a purchase could be made. Although SP2 and SP1 had reason to minimize their actions for fear of the consequences and SP2 used client money for some food and items used by all facility clients which was a violation of Minnesota Statutes, chapter 245A.04, subdivision 13, paragraphs (b) and (d), clauses (4) and (5), given that there was no information to confirm or dispute that the clients’ petty cash accounts were used for anything other than the clients and that there was no information to show that any of the items purchased with client funds did not make it to the facility or were for staff persons, there was not a preponderance of the evidence whether in the absence of legal authority, SP1 or SP2 willfully used, withheld, or disposed of the VAs’ funds. 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’s Internal Review stated that the quarterly financials for 2023 and 2024 were not done until sometime in 2024. The facility’s policies and procedures were not followed but were adequate. The event was not similar to previous events and there was not a need for additional staff person training because SP1 and SP2 no longer worked for the facility. The facility implemented further actions to be taken including deadlines for each monthly and quarterly financial review. Action Taken by Department of Human Services, Office of Inspector General: On June 5, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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