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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: 1070742-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) took $1,300 from each of three vulnerable adults (VA1, VA2, and VA3) between January of 2024 and February of 2025. The missing funds totaled $3,900. Date of Incident(s): Prior to March 20, 2025 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 law enforcement records; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP who were all supervisory staff persons), VA1’s guardian (G1), VA1’s case manager (CM), VA2’s guardian (G2), and VA3’s guardian (G3). The VAs did not know their funds might be missing and had limited communication abilities so were not able to provide information for this investigation. Facility documentation showed that the VAs were diagnosed with developmental disabilities and the facility was responsible for assisting them with financial matters. VA1 enjoyed taking walks and liked eating sweet treats. VA2 did not like changes to his/her routine, but s/he had a great sense of humor and was resilient. VA3 liked listening to music and relaxing in his/her bedroom. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · P1 said that on February 13, 2025, the CM raised concerns regarding the SP’s interpersonal skills and his/her “approach” when providing care to VA1. P1 noted the CM’s concerns, talked with P2 about them, then P2 interviewed staff persons about the concerns. · During interviews with staff persons, P2 learned that the SP was usually at the facility on weekday mornings, but not at the facility in the afternoons or other times, which did not match the times the SP documented that s/he worked on his/her timecard. When the SP was asked about the timecard, s/he denied “wrongdoing,” and resigned his/her position. · The CM said that his/her concern regarding the SP was that the SP was reluctant to implement some of the suggestions from VA1’s team that might improve or enrich VA1’s life because they might be “too expensive.” · P1 said that after the SP resigned, s/he temporarily took over some of the SP’s job responsibilities, including managing the VAs’ finances, until a new supervisor was hired. When P1 reviewed the VAs’ bank statements and financial information, s/he discovered that the SP withdrew about $100 each month between January of 2024 to February of 2025 from each of the VAs’ accounts. P1 continued reviewing the financial records and when this report was received, each VA was missing about $1,300, with no explanation or documentation showing how the funds were used. The SP was to assist the VAs with their finances but should have documented the withdrawals and noted how they were used. According to P1, the SP’s documentation of the VAs’ finances was not consistent with the facility’s policies. P1 realized in hindsight that s/he should have reviewed the VAs’ financial documentation monthly and s/he planned to actively monitor the VAs’ finances on an ongoing basis. · The SP said that s/he worked at the facility for several years with no issues and supervised several other service locations in addition to the facility. In February of 2025, P1 talked with the SP about concerns regarding the hours worked that the SP documented on his/her timecard. There was a conflict between the SP and P1, and the SP resigned his/her position because s/he disagreed with P1. The SP was not aware of concerns with the VAs’ funds until after s/he resigned, but said that years ago, P1 instructed him/her to keep the VAs’ binders with petty cash pouches and financial information in them, on the kitchen counter. The SP thought that the financial binders should have been locked in the facility office because all staff persons, the VAs, and anyone who visited the facility had access to the binders when they were in the kitchen. The SP said that s/he withdrew money from the VAs’ accounts when it was needed to make purchases for the VAs and put the money s/he withdrew in the VAs’ binders or left it with any staff person who was on shift at the facility but denied that s/he used the funds to buy items for him/herself. · P3 said that s/he had worked at the facility for several years and the financial binders for VA1 and VA3 were routinely kept on the main level on the kitchen counter to the right of the sink. VA2’s financial binder was kept in an unlocked cabinet in the kitchen on the facility’s lower level. P3 was unsure when it became common practice to keep the binders in unlocked locations, but the binders had been in unlocked areas of the facility for the duration of his/her employment. P3 said that P1 came to the facility about three or four times a year, but the SP was at the facility several days each week and assisted him/her and the VAs to obtain funds from the VAs’ accounts as needed. P3 had no concerns about the way the SP handled the VAs’ finances, and the SP obtained funds for the VAs consistently when items needed to be purchased. After concerns with finances arose, the facility moved the VA’s financial binders to the facility office, and the binders were presently locked in the office. · P1, P2, and P3, provided consistent information that the VAs’ debit cards, cash, gift cards, financial ledgers, and receipts, were kept in the financial binders. P1 said that s/he did not instruct the SP or other staff persons to keep the VAs’ financial binders in the kitchen and added that the binders should have been locked in the facility office and that the VAs’ funds should have been counted at the end of each shift. · The Gs provided consistent information that they were aware of the incidents investigated in this report. G1 said that s/he could have obtained VA1’s financial information from the facility, but s/he did not ask for it and had no previous concerns regarding VA1’s finances. The SP might have been careless with his/her paperwork/documentation, which made it difficult to determine whether anything was taken. G2 did not have concerns regarding VA2’s care at the facility. G3 thought that the facility was generally “stable” and planned to become more involved in VA3’s finances. Records from the law enforcement agency were requested on April 7, 2025, but were not received when this report was written. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Relevant Rules and/or Statutes: Minnesota Statues, section 245D, subdivision 4, paragraph (a) stated that whenever the license holder assists a person with the safekeeping of funds, the license holder must immediately document receipt and disbursement of the person’s funds at the time of receipt or disbursement. Conclusion: After the SP stopped working at the facility, P1 took over some of the SP’s duties and determined that the SP withdrew about $100 a month from each of the VAs’ accounts between January of 2024 and February of 2025, which totaled approximately $3,900. There was no documentation showing how the money the SP withdrew was used, which was not consistent with the facility’s policies and procedures according to P1. Information was consistent that the VAs had limited abilities to communicate and were unaware that their funds might be missing. The VAs were unable to provide information for this investigation. The SP said that in February of 2025, there was a conflict between the SP and P1, and the SP resigned because of the conflict. The SP learned of concerns about the VAs’ funds later and said that P1 instructed him/her to keep the VAs’ financial binders, which contained the VAs’ debit cards and petty cash, on the kitchen counter. The SP thought that the binders should have been locked in the office because staff persons, the VAs, and facility visitors had access to them in the kitchen. The SP withdrew money from the VAs’ accounts to make purchases for the VAs, then put money in the binders or left it with staff persons at the facility to put in the binders. The SP denied that s/he used the VAs’ funds to buy items for him/herself. P3 said that the VAs’ binders were regularly kept in unlocked parts of the facility but was unsure when that became a common practice. The SP was at the facility several days a week and obtained funds from the VAs’ accounts as needed. P3 had no concerns about the SP’s handling of the VAs’ finances, but after concerns were raised about missing funds, the binders were locked in the office. G1 did not ask for documentation about VA1’s finances and thought that the SP might have been careless with documentation, which made it difficult to know whether funds were missing. G2 had no concerns regarding VA2’s care at the facility and G3 planned to become more involved in VA3’s finances. Records from the law enforcement agency were requested but had not been received when this report was written. The SP withdrew funds from the VAs’ accounts and the VAs’ financial transactions were not fully documented, which was a violation of Minnesota Statues, section 245D, subdivision 4, paragraph (a). However, given that information was consistent that the VAs’ binders containing cash and debit cards were stored in unlocked areas of the facility where anyone at the facility, including community persons, had access, that the SP denied using the VAs’ fund for him/herself, that P3 stated the SP obtained funds for the VAs when they needed money, and that the lack of documentation made it unclear how the VAs’ funds were used, there was not preponderance of the evidence whether in the absence of legal authority the SP or any staff person willfully used, withheld, or disposed of the VAs’ funds or property. 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 which determined that their policies and procedures were adequate but were not followed. Staff persons were retrained on the facility’s policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: On May 23, 2025, the facility was issued a correction order for the violation outlined in this report.
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