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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: 1102467-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that while a staff person (SP) was on a leave of absence, a review was done of a vulnerable adult’s (VA’s) financial records. It was determined that the SP had the VA’s debit card, which was used multiple times. The facility found unaccounted purchases and withdrawals totaling $6,261.96 made on the VA’s debit card. Date of Incident(s): Ongoing, prior to June 13, 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 2, 2024; from documentation at the facility and law enforcement records; and through two interviews conducted with a facility administrative staff person (P1) and the VA. An attempt was made by letter to contact the SP, but the SP did not respond to the request for an interview. The VA enjoyed going to church, going shopping and out to eat, going to the movies, riding his/her bicycle, and spending time with his/her family members. The VA’s diagnoses included attention-deficit hyperactivity disorder (ADHD), an anxiety disorder, unspecified mood disorder, moderate intellectual disabilities, epilepsy, and diabetes. The VA attended a day program and was employed at a community business. The VA’s Annual Plan stated that the VA’s guardian (G) managed the VA’s checkbook and assisted the VA with making bill payments. The G sent petty cash to the facility for the VA’s use. The staff persons secured the cash, tracked expenditures, and maintained receipts. The VA had no unsupervised time in the community. The facility’s Investigation Report and Summary provided the following information: · Up until November 2019, the VA’s debit card was kept at the facility. At that time, the G was told that s/he needed to take over management of the VA’s bank funds. The VA had a petty cash account, which was managed by the staff persons. The G was aware that the SP had the VA’s debit card and had approved the SP to purchase personal needs items for the VA. None of the other staff persons at the facility were aware that the SP kept the VA’s debit card at the facility. From May 21 to June 17, 2024, the SP went on a leave of absence. During that time, the SP withdrew $500 from the VA’s bank account. S/he later returned $100 to the G. The VA had no unsupervised time in the community. · On June 12, 2024, a staff person (P2) went to the facility to gather the VA’s financial records to use when renewing the VA’s medical insurance. P2 found one of the VA’s bank statements and learned that the SP had the VA’s debit card and was making purchases with the card. There were no receipts found for the purchases made on the VA’s debit card. The bank statement withdrawals did not match the deposits on the petty cash documentation. P2 called the SP, who told P2 that s/he would mail the VA’s debit card and the receipts to him/her. On June 12, 2024, the VA’s debit card was cancelled. The G did not give approval for the SP to make cash withdrawals with the VA’s debit card. · A staff person (P3) provided information that each day the VA took $3 – $5 from his/her petty cash fund to work with him/her to purchase snacks and would return any change and receipts to a staff person when s/he returned to the facility. The VA frequently made purchases at Walmart that included iTunes cards, water, creamer, craft items, and hygiene items. The SP sometimes purchased items for the VA on the SP’s Amazon account. · The G provided information that the VA’s former guardian apparently gave the SP the VA’s debit card and code. The G did not know that the SP withdrew money from the VA’s card instead of using the card to make purchases for the VA. In March 2024, the G approved a withdrawal of $300 from the VA’s bank account for a casino trip with the SP. The G did not know why $600 was withdrawn from the bank account. S/he also approved purchases that were made at Walmart. The G never withdrew cash from the VA’s bank account. The SP texted the G and told him/her that s/he would mail the VA’s debit card and receipts to the G. On June 24, 2024, the G received “some” receipts, $100 cash, and the VA’s debit card. · The SP sent a text to the facility saying that s/he was out of the state and unable to talk to anyone at the facility. The SP “had nothing to say” other than s/he did what the G asked him/her to do. The VA purchased scratch-off lottery tickets, went shopping, and went to the casino. The SP “failed to keep good enough track of [the VA’s] money.” The SP sent the VA’s debit card, some cash s/he “anticipated returning to give to [the VA],” and all of the receipts s/he “could find” to the G. · According to the VA’s bank statements, between December 26, 2023, and June 13, 2024, there were six cash withdrawals from the VA’s bank account totaling $4,050. During that period of time, there were six deposits made into the VA’s petty cash fund totaling $773. Between December 28, 2023, and May 21, 2024, there were 32 Amazon purchases totaling $1,340.86, but only three validated purchases totaling $104.06. Between November 25, 2023, and May 23, 2024, there were 39 purchases from other vendors totaling $3,629.10, but only 20 validated purchases totaling $1,797.01. The SP provided receipts for two cash purchases totaling $83.93. · The total for the cash withdrawals, Amazon purchases, and other purchases was $9,019.96. The total amount shown on the petty cash fund ledger, the validated debit card purchases, and validated cash purchases totaled $2,758. The total amount not accounted for was $6,261.96. The VA stated that s/he worked at a day program three days each week and at a local grocery store two days each week. In the past, the VA kept his/her debit card in his/her bedroom. The VA had asked the SP to purchase gift cards for the VA, but did not know that the SP was using the VA’s debit card to purchase things the VA did not ask for. P1 stated that the SP worked with the VA for “a long time” and they had a close relationship. In June 2024, the SP took a leave of absence from the facility. The facility learned about the discrepancies in the VA’s financial records while the SP was away from the facility. The other clients at the facility were responsible for their own financial management and the SP did not have access to their funds. The facility’s Policy and Procedure Concerning Individual Finances and Funding Sources stated that the staff persons were to maintain “complete and absolute separation” between the clients’ property and the property of the staff persons. The staff persons were to maintain complete and accurate records of the property of the clients. Receipts or invoices for all expenditures were to be collected and maintained. The clients’ cash was to be tracked on a Cash On Hand form. The staff persons were not permitted to borrow money from a client. Facility documentation showed that the SP and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: A. Maltreatment: Consistent information was provided that the SP was the only staff person who had the VA’s debit card. Between December 26, 2023, and June 13, 2024, there were six cash withdrawals from the VA’s bank account totaling $4,050 and six deposits made into the VA’s petty cash fund totaling $773. Between December 28, 2023, and May 21, 2024, there were 32 Amazon purchases totaling $1,340.86, but only three validated purchases totaling $104.06. Between November 25, 2023, and May 23, 2024, there were 39 purchases from other vendors totaling $3,629.10, but only 20 validated purchases totaling $1,797.01. The SP provided receipts for two additional cash purchases totaling $83.93. The total for the cash withdrawals, Amazon purchases, and other purchases was $9,019.96. The total amount shown on the petty cash fund ledger, the validated debit card purchases, and the validated cash purchases totaled $2,758. The total amount not accounted for was $6,261.96. Given that there were no receipts or purchased items that correlated to the $6,261.96 that was missing from the VA’s bank account, that the SP was in possession of the VA’s card when the purchases were made, and that the G did not make the purchases nor did the VA, there was a preponderance of the evidence that in the absence of legal authority the SP willfully used the VA’s funds in the absence of legal authority. 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. The SP was responsible for maltreatment of the VA. 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 used the VA’s debit card multiple times between November 25, 2023, and May 23, 2024, for cash withdrawals and purchases that were not made for the VA. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but were not followed. The SP no longer worked at 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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