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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: 1071054-HCBS (Home and Community-Based Services) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA) debit card to withdraw cash from the VA’s bank account. Date of Incident(s): On and possibly before April 14, 2025. The Minnesota Department of Human Services was not made aware of the allegations until July 28, 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 was obtained during a site visit conducted on August 13, 2025; from documentation at the facility and bank statements provided by the VA; and through two interviews conducted with a facility staff person (P) and the VA. This investigator contacted the SP and arranged a time to interview the SP via telephone. The SP did not answer the telephone at the scheduled time and did not respond to a subsequent voicemail or a certified mail request. The VA resided alone and received seven hours per week of Individual Community Living Supports (ICLS) services. The SP was the only staff person who worked with the VA from approximately October 2023 until May 1, 2025. The SP assisted the VA with getting into the community and finding community activities for the VA to participate in. According to the VA’s Individual Abuse Prevention Plan, the VA did not have a history of financial exploitation. There was no other information about the VA’s finances in his/her plans. The VA provided the following information: · On multiple previous occasions, the VA noticed that s/he did not have as much money in his/her bank account as s/he should have. Prior to April 14, 2025, the VA gave the SP his/her debit card to go to the store and buy food for the VA while the VA stayed home. On April 14, 2025, after the SP went to the store with the VA’s debit card, the VA looked at his/her bank statements and saw that there were two cash withdrawals totaling $150 at the location where the SP purchased the VA’s food. · The next time the SP worked, the VA asked the SP about the cash withdrawals and the SP denied using the VA’s debit card for cash withdrawals. The VA called the P at the main office and told him/her about the two cash withdrawals. · Later on, the VA and a community person (CP), who was the VA’s friend, went through the VA’s bank statements and saw multiple purchases and cash withdrawals since the SP began working that totaled $8340 that were not made or authorized by the VA. The VA did not know any other persons, other than the SP, who had access to his/her debit cards, the VA rarely left his/her house, and the VA never gave the SP permission to use his/her debit card for the SP’s personal use. The P and an email between the P and the SP dated May 1, 2025, provided the following information: · On April 29, 2025, the VA told the P that on April 14, 2025, the SP made two cash withdrawals totaling $150. The VA said that s/he gave his/her debit card to the SP to go get the VA food while the VA stayed home. While at the store, the SP used the debit card at the ATM to withdraw cash without the VA’s permission. The P learned this was a “common occurrence” for the VA to give the SP his/her debit card to go to the store, which was not according to the training the facility provided staff persons. Staff persons were trained to “never” handle clients’ funds. · On May 1, 2025, the P emailed to the SP who acknowledged that s/he used the VA’s debit card to withdraw a total of $150 from the VA’s bank account and said it was a “misunderstanding” but did not provide any other information. Later on, the VA told the P that the SP used the VA’s debit card on multiple other occasions without the VA’s permission. The P requested that the VA send him/her bank statements showing the withdrawals but the VA did not do so. The VA’s bank statements provided the following information: · On April 14, 2025, there was a purchase at a gas station for $24.77. There were also two ATM withdrawals at the same location: one for $100 and one for $50. · Between October 1, 2023, and April 16, 2025, there were multiple charges, including but not limited to food delivery companies, grocery stores, and other ATM withdrawals from the same ATM machine as April 14, 2025, marked by the VA as purchases and cash withdrawals totaling $8340 that s/he did not make or authorize. According to the facility’s Standards of Conduct and Ethics Policy, staff persons did not borrow money, vehicles, equipment, or any other items from clients. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information from the VA, the P, and an email between the P and the SP was consistent that on April 14, 2025, the SP used the VA’s bank card to make two withdrawals totaling $150 cash from an ATM without the VA’s permission. In addition, there were other multiple other purchases and cash withdrawals totaling $8340 that the VA said s/he did authorize. The SP did not provide information for this investigation. The VA stated that did not know any other persons, other than the SP, who had access to his/her debit cards, the VA rarely left his/her house, and the VA never gave the SP permission to use his/her debit card for the SP’s personal use. Therefore, 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 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA’s plans, the facility’s Standards of Conduct and Ethics Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP acknowledged in an email to the P using the VA’s debit card for two cash withdrawals totaling $150. In addition, given that the SP was the only other person who had access to the VA’s debit card and that the unauthorized purchases began and occurred during the time the SP worked with the VA, it was more likely that the SP made additional purchases/withdrawals using the VA’s debit card. 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 s/he used the VA’s debit card on more than one occasion. The maltreatment did not meet the definition of serious. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility and $150 was taken out of the SP’s last paycheck and given to the VA. A verbal reminder to all staff persons was provided at a staff meeting to “never” handle clients’ funds. 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. On October 2, 2025, the facility was issued a Correction Order for failing to comply with background study requirements. On October 2, 2025, the facility was issued a $200 fine for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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