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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: 1105780-AFC (Adult Foster Care) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that between September 2022 and October 2024, there were several transfers made from a vulnerable adult’s (VA’s) bank account into a staff person’s (SP’s) back account in excess of the VA’s monthly bills. Date of Incident(s): Ongoing prior to November 19, 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 bank records; and through five interviews conducted with the VA, the SP, the VA’s case manager (CM), and two supervisory staff persons (P1 and P2) for the HCBS license. Lutheran Social Service (LSS) of Minnesota is licensed to provide Home and Community-Based Services (HCBS), and McGrath Renee Lynn Adult Foster Care (AFC) is a licensed adult foster care facility. LSS contracted with the AFC to provide 245D services, meaning the SP was a direct support staff person under the HCBS license held by LSS and also an AFC staff person. P1 and P2 provided program coordination and management of the HCBS license held by LSS. Throughout this report, “facility” refers to the adult foster care facility and the services, including HCBS services, provided therein. The VA’s diagnoses included intermittent explosive personality disorder and unspecified schizophrenia. The VA enjoyed biking, fishing, camping, hiking, and grilling outside. The VA was not subject to guardianship. Facility records provided conflicting information about the facility’s role in supporting the VA with his/her finances: · The VA’s Individual Abuse Prevention Plan (IAPP) dated April 7, 2024, stated, “[The VA] has a representative payee (rep payee) who will help pay [his/her] bills and manage [his/her] social security. [The VA] does have a bank account and keeps petty cash on hand. [The VA] relies on supports to help manage [his/her] money and would not recognize misuse of [his/her] funds. [The facility] has been trained to support [the VA] in managing [his/her] funds.” · The VA’s Support Plan Authorizations dated April 9, 2024, indicated that the facility was responsible for supports with the VA’s checking account. The VA did not authorize the facility to manage his/her funds, have online access to his/her account information, or be an authorized signer on his/her checking account. It also stated that the VA did not have a representative payee. The VA said that s/he used to write checks and paid “rent” that way. The VA later stopped writing checks and was not sure how his/her rent was paid after. The VA was unaware of anyone transferring money out of his/her bank account, and the VA did not tell or give permission to anyone to transfer money from his/her bank account. P1 provided the following information during the interview and during LSS’s internal review: · The VA moved into the facility in October 2020. On October 22, 2024, at the VA’s semi-annual meeting, the SP told P1 that the SP was moving due to personal reasons and asked that the VA be moved to a different facility. The VA subsequently moved into a new facility. · On November 13, 2024, after the VA moved, P1 took the VA to the bank to obtain the VA’s most recent bank statement. At that time it was discovered that there were transfers from the VA’s bank account into another account. P1 was told by a bank representative that the account the VA’s money was transferred to belonged to the SP. It was also noted that the SP was a joint owner on the VA’s account. The VA and P1 opened a new account for the VA and kept his/her old account open with $15. · The SP was given a set dollar amount each month and that was to be used on bedding, food, and household supplies for the VA. There was no reason the SP would need to take additional money out of the VA’s bank account. P1 said that was “never” acceptable. · P1 was “under the impression” the VA had a professional rep payee, but when P1 saw the VA’s social security checks deposited into the VA’s own banking account, P1 learned the VA did not have a rep payee. P1 stated LSS did not allow a staff person or facility to act as a service recipient’s rep payee. · Because the VA was not subject to guardianship, the facility and therefore LSS were not responsible for his/her finances; however, the facility “supported” the VA to determine the need for purchases and ensured the VA received correct change back for purchases. The CM provided the following information: · The SP’s supervisors at LSS had a responsibility to look over the VA’s finances. P1 was unaware that the SP was the VA’s rep payee. It could be a “normal” thing to have a rep payee on a VA’s bank account if the VA needed help writing checks. · The CM said the transfers between the VA’s and the SP’s account could have been for a “legit” purchase that was being paid, but there should be receipts to show why the money was transferred. Transferring funds in this manner was not the “best practice” but if it happened “you really want[ed] a good paper trail.” The CM was not sure why the SP became a joint owner of the VA’s account because the SP was not initially on the account. P2 provided the following information: · P2 did not know the SP was managing the VA’s funds and since the VA was not subject to guardianship, LSS did not monitor the VA’s funds. P2 also stated that s/he told the SP to add his/her name to the VA’s bank accounts so that the SP could assist the VA with his/her financial needs. · The SP told P2 when the VA needed purchases to replace clothing and bedding as the VA had been going through clothes and bedding frequently due to incontinence. · P2 was not aware of the VA’s and the SP’s money being intermingled and it would not be approved or accepted by LSS and money was kept “very separated.” P2 did not tell the SP to set up transfers between the accounts because there would be no need to do so, and P2 was not aware of money being transferred between the VA’s and the SP’s accounts. · If the SP needed to purchase something for the VA, the SP “absolutely” should have documented the purchases by keeping receipts and showing them to the CM. P2 said the VA did not have a rep payee. · P2 knew the SP and the VA traveled, but was not aware of the SP asking for the VA to pay for part of the trip (gas, hotel, etc.). The SP provided the following information: · The SP stated the VA did not have a rep payee. The SP helped the VA purchase items for “personal needs” such as shampoo, vacations, beer, cigarettes, and other “basic needs.” The VA’s rent covered rent, electric utility, and food. The VA “usually” handled his/her own money, cash, and change. Large purchases were documented and approved by P2 or another LSS supervisor before making the purchase. The SP stated that s/he was told by LSS and the county licensor that s/he did not need to document and/or save receipts for purchases made on behalf of the VA. · The VA had fecal incontinence, so the VA went through extra clothes and bedding. [Note: The VA purchasing his/her own bedding was a violation of Minnesota Rules, part 9555.6205, subpart 4, item B, subitem, (3), which states that each resident shall be provided with clean bedding appropriate for the season.] There were times the SP went to a laundromat to clean the VA’s soiled items, and the VA covered those costs. · When the VA needed personal items, “most” of the time the SP took the VA to shop for them, but sometimes the VA was at work, so the SP picked up items for the VA and then the SP transferred money into the SP’s bank account from the VA’s bank account and put in a description of what was being purchased on the bank app. · When the VA first moved into the facility, the VA used checks, but P2 told the SP that it would be “easier” if the SP used the banking app to transfer the funds, so when the VA paid the SP, it was an automatic transfer into the SP’s account in the specific amount the SP got paid for the living expenses from the VA. The SP did not like the banking app, and s/he did not know why LSS “pushed” the SP to do that. The SP did not think the VA gave permission for the SP to be added to his/her bank account. The SP said s/he was just told by LSS to go to the bank and sign the paperwork. · The SP stated that the transfers back and forth between the VA’s and the SP’s accounts, were errors. The SP said s/he was thinking s/he was using his/her own account and accidentally transferred funds out of the VA’s account instead of the SP’s account. The SP then transferred the money back to the VA’s account. When this happened, the SP did not document the errors, s/he only told P2. · On June 12, 2023, a transfer of $600 was made from the VA’s account into the SP’s account and the SP wondered if that was the VA prepaying his/her portion of a trip they planned to take in August 2023. The SP notified P2 of this so that it was preapproved beforehand. · The SP stated there were occasions when s/he had people over to the facility and the VA stole cigarettes or cash from those people. The SP paid the people back with his/her own money and then transferred money from the VA’s account into his/her own account. · The SP denied using the VA’s money for anything other than purchases for the VA. A review of information provided by LSS showed the VA’s rent costs were as follows: · From November 2020 through June 2021, $934 a month · From July 2021 through June 2022, $954 a month · From July 2022 through June 2023, $1041 a month · From July 2023 through June 2024, $1135 a month · From July 2024 through October 2024 (when the VA moved out), $1170 a month A review of the VA’s bank statements showed that there were no memos/notes for web transfers that showed why money was being taken. In addition, from October 2020 through October 2024 showed the following: · 2020 bank statement For 2020, the VA owed rent for two months ($934 each) and the VA wrote two checks totaling that amount. · 2021 bank statement o For 2021, the VA owed rent totaling $11,328 (six months at $934 and six months at $954), and the VA wrote 12 checks totaling $11,308. [Note: The VA did not increase his/her rent to $954 for the July payment, so the VA owed the SP $20.] o The SP’s name was added to the VA’s checking account in March 2021. · 2022 bank statement o For 2022, the VA owed rent totaling $11,970 (six months at $954 and six months at $1,041), and the VA wrote nine checks totaling $8,586, and had four electronic transfers totaling $2,930, bringing the total amount the VA paid in 2022 to $11,516. [Note: The VA owed the SP $454 rent for 2022.] o In addition, on September 8, 2022, a $1,000 transfer was made into another account (based on information the bank provided P1 and the information the SP provided this investigator this was the SP’s account), and on September 9, 2022, a $1,000 transfer was made into the VA’s account from the SP’s account. On December 2, 2022, a web transfer of $522 was made from the VA’s account into the SP’s account. On December 12, 2022, a web transfer of $1,000 was made into the SP’s account from the VA’s account, and on December 12, 2022, two web transfers ($1,000 and $500) were made from the SP’s account into the VA’s account. [Note: In December 2022, the total from the VA’s account to the SP’s was $1522 and the total from the SP’s account to the VA’s was $1500. This left $22 missing from the VA’s account.] o There was an electronic transfer made into the VA’s account from the SP’s account ($30 on October 28, 2022). [Note: Taking into account the October and December 2022 transfers and the rent unpaid for 2022, the VA owed the SP $484 for 2022.] · 2023 bank statement o For 2023, the VA owed rent totaling $13,056 (six months at $1,041 and six months at $1,135). There were 48 transfers from the VA’s account into the SP’s account totaling $15,558. [Note: The SP transferred $2,502 more than the VA’s rent.] o In addition, on December 8, 2023, a web transfer of $280 was made from the VA’s account into the SP’s account. On the same date, a web transfer of $280 was made from the SP’s account into the VA’s account.
· 2024 bank statement o For 2024, the VA owed rent totaling $11,490 (six months at $1,135 and four months at $1,170). There were 43 transfers from the VA’s account into the SP’s account totaling $ 13,570.77 (including a web transfer on November 1, 2024, for $1175 when the VA no longer lived at the facility). [Note: The SP transferred $2,080.77 more than the VA’s rent.] o In addition, between December 26, 2023, and June 10, 2024, there were four instances where money was transferred out of the VA’s account into the SP’s account and transferred back into the VA’s account from the SP’s account either on the same day or within a few days. The total amount of these transfers was $292 and equaled out. The SP was unable to produce receipts for purchases or other documentation to explain the funds paid to the SP in excess of the VA’s rent charges. LSS’s host home policies and procedures for Managing Funds, Billing, and Waivers, stated that staff persons and/or the facility provider were to ensure separation of an individual’s funds from funds of the organization, home, or other individuals. Borrowing or lending money to or from an individual served by the facility was prohibited. Whenever an individual was supported with safekeeping of funds or property, LSS or the facility provider was to obtain written authorization to do so by the individual, the legal representative as applicable, and the case manager; and document receipts and disbursements of the individual’s funds. LSS documentation showed the SP received training on LSS’s host homes policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Law enforcement investigated the allegations in this report. However, at the time the DHS investigation was completed, no criminal charges were filed. Relevant Rules and/or Statutes Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a) states a license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum. Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1) states whenever the license holder assists a person served by the program with safekeeping of funds, the licensed holder must immediately document receipt and disbursement of the person’s funds at the time of receipt or disbursement.
Conclusion: A. Maltreatment: Information obtained showed that in 2020 and 2021, the VA paid his/her rent with checks and bank statements which showed no concerning discrepancies. In March of 2021, the SP went to the bank to put his/her name on the VA’s account after being told to do so by P2. P2 stated this was so the SP could assist the VA in managing his/her finances. The SP told the DHS investigator that s/he did not think the VA gave permission for the SP to be added to the VA’s account and there was no information provided that any person obtained permission from the VA for the SP to be added to his/her account. In addition, the VA’s Individual Abuse Prevention Plan and Support Plan Authorizations dated two days apart provided conflicting information regarding the facility’s support for the VA regarding his/her finances which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). The VA said s/he knew s/he previously wrote checks to pay his/her rent, but did not know how his/her rent was paid now, and did not consent to anyone else transferring money out of his/her account. In 2022, there were multiple transfers between the VA’s and the SP’s accounts which resulted in the VA owing $454 to the SP for rent and $22 missing/not being returned to the VA’s account. This left the VA owing the SP $432 for 2022. In 2023 and 2024 there were 91 electronic web transfers between the VA’s banking account and the SP’s banking account that exceeded the VA’s rent owed by $4582.77. The SP stated that the additional funds out of the VA’s account were for purchases s/he made for the VA and other reimbursements related to the VA’s care and that s/he documented those purchases on the banking app. However, the SP was unable to produce documentation to support that and the VA’s account statements did not show any memos/notes for the web transfers that explained why the money was being withdrawn, which was a violation of Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1). Although it was not able to be determined if all or some of the money was not used for the VA, given that there was no documentation to show what the money was used for; that in 2023 and 2024, the SP transferred money 91 times exceeding the VA’s rent owed by $4582.77; that on November 1, 2024, when the VA no longer lived at the facility, $1175 was transferred out of the VA’s account and into the SP’s account; and that the VA, who was not subject to guardianship, stated s/he did not did not tell or give permission to anyone to transfer money from his/her bank account, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used the VA’s funds. 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. LSS documentation showed the SP received training on LSS’s host homes policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP added him/herself to the VA’s account without the permission of the VA and then transferred money from the VA’s account to the SP’s account without the VA’s permission, including after the VA moved from the facility. The SP was responsible for maltreatment of the VA. When substantiated maltreatment is determined to have been committed by an individual who is also the facility license holder, both the individual and the facility must be determined responsible for the maltreatment, and both the background study disqualification standards under section 245C.15, subdivision 4, and the licensing actions under sections 245A.06 or 245A.07 apply. 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. The Office of Inspector General is also required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 and the facility was responsible was “recurring,” because the SP transferred funds from the VA’s account to the SP’s account on multiple occasions over multiple years. However, it did not meet the definition of “serious” maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: LSS completed an Internal Review and found their policies and procedures adequate, but not followed by the SP as the SP added him/herself as a cosigner to the VA’s banking account and transferred money between the two accounts. The SP was no longer contracted to provide services under LSS’s HCBS license. Renee Lynn McGrath Adult Foster Care did not provide an Internal Review. Minnesota Statutes section 245A.65, subdivision 1, paragraph (b), clause (1), states that license holders are required to establish and maintain policies and procedures to ensure that an internal review is completed when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. The review must include an evaluation of whether: 1. related policies and procedures were followed; 2. the policies and procedures were adequate; 3. there was a need for additional staff training; 4. the reported event is similar to past events with the vulnerable adults or the services involved; and 5. there was a need for any corrective action to be taken by the facility to protect the health and safety of vulnerable adults. Therefore, a licensing violation was determined. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Additionally, based on the determination of substantiated maltreatment and the disqualification of a controlling individual the license for Renee Lynn McGrath Adult Foster Care was revoked. The maltreatment determination and the revocation are each subject to appeal. On July 23, 2025 LSS was issued a Correction Order for failing to provide services in response to the person’s identified needs, interests, and preferences as required.
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