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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: 1112025-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Heidi Murphy Emily.kearns.2@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) transferred money from two vulnerable adults’ (VA1 and VA2) bank accounts into the SP’s account and the SP’s family member’s (FM) account. The SP also transferred money from VA1’s to VA2’s account. Date of Incident(s): Unknown dates from November 2021 to October 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 five interviews conducted with a facility supervisory staff person (P1), a facility staff person (P2), VA1’s guardian who was also a family member (G1), VA2’s guardians who were also family members (G2 and G3). Attempts to contact the SP to request an interview by phone and both certified and noncertified mail were unsuccessful. Due to their abilities, VA1 and VA2 were each not able to provide information for this investigation. VA1’s client file stated that s/he was diagnosed with profound intellectual disability, spastic quadriplegia, severe aerophagia, and cerebral palsy. VA1 liked using sensory items, going for walks and car rides, and relaxing on the patio. VA2’s client file stated that s/he was diagnosed with profound intellectual disability and generalized anxiety disorder. VA2 enjoyed using sensory items, spending time with family, going out to eat, and being outdoors. VA1’s and VA2’s Individual Abuse Prevention Plans stated that each were at risk for financial exploitation. Staff documented and saved receipts of purchases as specified by their financial consent forms. All transactions were documented and reviewed on a regular basis and reported to VA1’s and VA2’s guardians and case managers annually. The facility Internal Review showed G1 told P1 about inconsistencies in VA1’s account balances on December 9, 2024. G1 discovered $983 was missing from VA1’s bank account. At the time, the only active members listed on the account were VA1 and the SP. Between August and October 2024, there were five online transfers totaling $740 to the FM’s bank account and a $400 transfer to VA2’s account. P1 reviewed daily shift logs and found that both VA1 and VA2 never had balances that matched the amounts that were withdrawn or transferred from their accounts. Money logs for VA1 and VA2 were located and reviewed by P1. Petty cash deposits to both VA1’s and VA2’s facility petty cash funds did not match, and the SP was the staff who initialed the deposits into the petty cash funds. P1 spoke to the SP on December 10, 2024, and the SP denied knowledge of the online transfers. However, the SP returned the money that was transferred into the FM’s account. The money was returned on December 10, 2024. Law enforcement records showed that the SP’s, VA1’s, and VA2’s bank records were reviewed. Approximately $9,602 was deposited into the SP’s bank account from VA1’s and VA2’s bank accounts. When the SP cashed client checks and got cash back, the SP did not always deposit the full amount of cash back into each clients’ petty cash accounts. The check amounts written by G2 did not match deposit amounts at the bank. Cash received from checks of VA2’s that were cashed totaling approximately $1250. Approximately $695 was deposited into the FM’s bank account from VA1’s and VA2’s checking and savings accounts. The amount that the SP was believed to have taken from VA1 and VA2 was approximately $11,547. The SP sent an email to P1 that said, “I am not just sorry because it was found out, but because this is genuinely not the person I want to be. I can’t explain what I did, I feel like a complete horrible person for the decisions I made.” P1 provided the following information: · When VA1 resided at a prior facility, a bank account was set up,, with the SP’s name on the account, to cash checks for petty cash funds, which were used to buy VA1’s personal needs and wants. The facility changed ownership and the SP stayed on as a staff person and VA1 and VA2 remained at the facility. The facility did not manage residents’ funds and VA1 had no other means to cash his/her checks. The SP remained on the bank accounts, cashed the checks and brought the money to the facility for VA1. · G1 knew there should have been $1000 in VA1’s bank account. G1 went to the bank to close the account to have the money moved to a bank closer to him/her. In mid-December 2024, G1 was told there was only approximately $17 in the account. G1 notified P1 of the discrepancy on or around December 17, 2024. · G1 reviewed bank statements, and they showed money was electronically transferred from VA1’s account to the FM’s account and an account for VA2. G1 told P1 that the SP wrote out checks for cash, cashed the checks and brought the cash to the facility for VA1. P1 went to the facility and checked the petty cash logs and discovered very few funds had been deposited into VA1’s petty cash account at the facility. · The SP was responsible for filing money logs and financial documentation. · G2 and G3 managed VA2’s bank account. G2 and G3 mailed checks to the facility and the SP was supposed to cash the checks and bring the money back to the facility for VA2. Bank records showed that the SP transferred money from VA1’s account to VA2’s account. G2 and G3 sent P1 records of checks, dates and amounts that were sent to the facility. P1 checked the money logs and the amounts were not consistent with the records G2 and G3 sent. · The SP admitted to P1 that s/he took the funds that were unaccounted for that belonged to VA1 and VA2. The SP paid back $780 to VA1’s account on December 10, 2024. P1 asked the SP to provide bank statements for VA2. The SP did not provide those statements. P1 only obtained records from January 2021 through November 2024 and believed the financial exploitation had occurred prior when the facility was owned by a different company. The SP had been working with VA1 for over 15 years. · In 2024, missing money from VA2’s account totaled almost $4000. P1 believed over $10,000 was missing from VA1’s and VA2’s accounts. · Law enforcement was notified, and the case was submitted to the County Attorney for review of charges. P2 provided the following information: · P2 had gone to the bank with G1 to add G1’s name to VA1’s bank account on December 9, 2024. The bank stated they were going to issue a check in the amount of just over $17. G1 became upset and stated s/he was told two to three months prior that there was over $1000 in the account. G1 requested a printout of transactions on the account from the last three months, which showed numerous electronic transfers to the FM’s account and VA2’s account. · VA1 would not have any reason to have transferred money to VA2. · Checks for VA2 would be sent by mail or dropped off by G2 or G3 to the facility. The SP would cash the checks and tell other staff persons to let him/her know when money was needed for VA2. · Any money that was kept on hand at the facility was logged and counted every shift by two staff persons. There were never discrepancies in the petty cash on hand at the facility. · The last few times money was needed for VA2, P2 would tell the SP and the SP did not drop money off at the facility. P2 was not sure why the SP never dropped money off, as the SP lived in close proximity to the facility and the bank was in walking distance from the facility. · P2 felt VA2 did not get to go on as many outings as s/he should have or gotten extras that s/he wanted due never receiving the funds requested from the SP. G1 provided the following information: · When G1 became VA1’s guardian, G1 went through VA1’s financial documents and found an account with a company that VA1 had to pay for funeral costs, which had been set up by a previous guardian. G1 had been told by the SP the account/amount for burial had been paid off, which was approximately $11,000. G1 called the company and was told only $3000 had been paid on the account. G1 believed the SP only deposited $3000 over the years and kept the additional funds. · G1 went over VA1’s financials at the end of 2024 and asked the SP how much was in VA1’s accounts. The SP told G1 there was $1000 in the checking account and $100 in the savings account. Money was deposited into VA1’s checking account monthly, but when the SP was asked about the balance, s/he always said the balance was $1000. G1 became suspicious that the balance never increased when additional monies were deposited. G1 went over statements for the last three years. VA1 should have had $5400 in the account. G1 went to the bank on December 9, 2024, and was told there was approximately $17 in the account, instead of the $1000 that should have been in the account. · VA1’s saving account was down to “basically nothing”. The facility had said something to the SP and s/he deposited $150 back into the account on December 10, 2024. G3 provided the following information: · G3 took over as a guardian in 2016 and the SP had been the one that cashed VA2’s checks. It was never suspected that VA2 had not received the full funds that were sent. · P1 reached out to G3 and asked for financial records for VA2. G3 then spoke to P1 and was notified of the possible financial exploitation. P1 stated there was discrepancies in VA2’s personal needs account. G3 knew money was sent for that account. · In the last year, G3 recorded $4000 was sent for VA2 and s/he only received $900. G3 was unsure how long the SP had been taking VA2’s money. The SP had been working with VA2 for at least 10 years. · The checking account was opened so checks would be cashed, and the cash was available at the facility for VA2’s personal needs. · Checks were written monthly and were typically $400-$500. The last transaction was for $1000 cash on January 3, 2025. G3 got a receipt and the money was logged. G2 stated the bank account balances were not accurate with what should have been in the account for VA2. G2 had previously asked the bank for statements and never received them. G2 believed the SP has been taking money from VA2 for five years. The SP had worked with VA2 many years and G2 never suspected anything suspicious went on. Facility documentation showed that the SP and all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act. All staff were trained and required to report financial exploitation. The SP and P2 were trained on VA1’s and VA2’s plans. Conclusion: A. Maltreatment: Documentation showed that the SP electronically transferred funds from the accounts of VA1 and VA2 into his/her own account, as well as the FM’s account between November 2021 and October 2024. Money from VA1’s account was also transferred to VA2’s account. Money was also missing from petty cash funds (funds kept at the facility for spending money) for both VA1 and VA2 and burial account for VA1 was missing $8000. Money that was taken from VA1 and VA2 was more than $10,000. The SP admitted to P1 that s/he took the money from VA1 and VA2. The SP no longer worked at the facility. A law enforcement report showed the funds that were transferred from VA1’s and VA2’s bank accounts to the SP’s bank accounts and the FM’s bank account, along with money that was partially withdrawn in cash from VA2’s checks that were cashed, were estimated to be $11,547. Given that the SP admitted to taking funds from VA1’s and VA2’s accounts, that bank statements showed transfers to the SP’s and the FM’s bank account, and that not all the money from checks cashed by the SP were accounted for in the petty cash at the facility, there was a preponderance of the evidence that the SP, in the absence of legal authority, willfully used VA1 and VA2’s funds. It was determined that financial exploitation occurred (in 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 was trained on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for the financial exploitation of VA1 and VA2. 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 because the SP took funds from VA1 and VA2 on more than one occasion. Action Taken by Facility: The facility completed an Internal Review and determined that its policies and procedures were adequate, but not followed. Program coordinators/house supervisors received additional training related to personal funds/petty cash tracking and identifying financial exploitation. G1, G2, and G3 were monitoring the VAs’ funds more closely. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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