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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: 1109221-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) took a vulnerable adult’s (VA’s) wallet and made purchases using the VA’s funds. Date of Incident(s): Ongoing, prior to August 2, 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 30, 2024; from documentation at the facility; and through four interviews conducted with a facility administrative staff person (P), the SP, the VA, and the VA’s case manager (CM). Law enforcement was aware of the allegations and did not take further actions. The VA enjoyed watching television, playing games on his/her cell phone, and spending time with friends and family members. The VA lived in his/her home with a family member (FM). [Note: The FM was not interviewed due to his/her diagnoses.] The VA’s diagnoses included anxiety, major depressive disorder, post-traumatic stress disorder (PTSD), and arthritis. The VA was not subject to guardianship. The VA’s Support Plan stated that the facility was to provide homemaking services for the VA five hours each week. The services were to include housekeeping, laundry, meal preparation, assistance with shopping, and assistance with finances. The VA and a bank statement of the VA’s provided the following information: · The facility was contracted to provide five hours of homemaking services and five hours of individualized home support services to the VA each week. The VA wanted assistance with organization and coordinating his/her appointments. On July 25, 2024, at approximately 1 p.m., the P arrived at the VA’s home. [Note: Because it was the SP’s first day working with the VA, the P was there to introduce the SP and the VA.] At approximately 2 p.m., the SP arrived and told the VA and the P that s/he was late because the bus dropped the SP far from the VA’s home. At the time, the VA’s wallet and laptop were on some boxes that the VA used as a storage area behind the dining room table. When the SP arrived at the VA’s home, s/he placed some of his/her personal items on the same boxes. After the P left the VA’s home, the SP assisted the VA with scheduling appointments and with some “technology stuff” on the VA’s cell phone and laptop computer. The SP “focused” on the VA’s Gmail account, which the VA “never used” and made the Gmail account “responsible” for other programs. Although the VA asked the SP to do things slowly and show the VA how to use the technology, the SP “went fast” and the VA did not recall much of what the SP did. · At approximately 3 p.m., the VA drove the SP home and returned home at approximately 4 p.m. Prior to leaving, the SP told the VA to take his/her cell phone with him/her even though the VA typically did so. At this time, the VA was “distracted” by looking for his/her cell phone but noticed that his/her wallet was no longer on the boxes behind the dining room table, and assumed that s/he had placed it somewhere else. The VA did not look for his/her wallet when s/he returned home because s/he did not immediately need it and believed it was somewhere in his/her home. The VA then assumed s/he had just misplaced the wallet. · The VA had no other visitors to his/her home prior to the next time the SP came on July 31, 2025, at approximately 2 p.m., which was two hours later than when the SP was scheduled to arrive. That day, the SP continued to work on the VA’s “technology items,” but “sort of hid the screens” of the VA’s cell phone and laptop computer as they worked. When the VA entered his/her passwords to “many different” sites, the SP clicked on the passwords so that they were visible and asked the VA to confirm that the passwords were accurate. The SP changed the VA’s wi-fi password and wanted to transfer data from the VA’s old cell phone to his/her new cell phone. The SP telephoned the VA’s cell phone carrier in order to “change something” on the VA’s cell phone. The cell phone carrier password gave access to the VA’s account information. The VA stated that s/he used the same password for various accounts. The SP’s demeanor then changed and s/he began to text on his/her own cell phone and became “short” with the VA. The SP then left. · The VA said that s/he initially thought his/her wallet was lost but later as s/he thought about it, s/he believed the SP took the wallet his/her first day of work, when the SP took his/her personal items off the boxes. At the time, s/he had at least $220 cash in his/her wallet, gift cards totaling approximately $100, his/her driver’s license, a debit card, a Sam’s Club card, an EBT card, an ATM card, his/her insurance card, the FM’s insurance card, the FM’s debit card, and possibly checks with account numbers on them. On an unknown date after, the VA began receiving emails of new accounts being opened in his/her name which the VA did not open or have knowledge of. Four accounts were opened, including accounts with Amazon, Samsung, Door Dash, and Walmart, but no purchases were made. There was also a new email account with Gmail. The SP’s telephone number was listed on the newly opened accounts. · Charges were made on the FM’s bank card for Lyft, restaurants, and Roku television. [Note: Although the VA was an authorized user on the FM’s account, the FM was not receiving services from the facility and therefore, the focus of the investigation was solely focused on the VA’s funds/accounts.] The VA also discovered that the SP opened a new Gmail account and opened a new account on Door Dash, which cost $9.99 per month and was tied to either the VA’s or the FM’s account. When the VA checked into the account, the VA’s name was incorrect, a different address was listed, and the SP’s telephone number was on the account. The VA emailed the information to the P and the CM. The P provided information that the address on the account was that of the SP’s family member. The VA contacted his/her banks and told them the ATM cards and checks had been stolen. The VA then discovered that his/her old cell phone was missing and the VA believed that the SP took the cell phone on his/her second visit to the VA’s home, after transferring information between the VA’s new cell phone and the old one. The SP had gotten the log-in information for the old cell phone from the VA. After the incidents, one of the VA’s banks provided him/her with a statement of transactions on his/her account and reimbursed the VA for the disputed charges. The VA was unable to obtain a bank statement or reimbursement information from a second bank. · One of the VA’s bank statements showed that the VA was reimbursed by his/her bank for $806.09 for 33 disputed transactions made on the VA’s bank account between July 25 and August 2, 2024. · At some point, the P talked to the SP and asked about the accounts and unauthorized purchases and after that the VA received notifications from Amazon and Walmart that there were attempts to close and delete account information. After discovering unauthorized purchases on his/her accounts, the VA believed the opening and closing of accounts and unauthorized purchases were done by the SP. The CM provided the following information: · The VA needed assistance with organization, technology, paperwork, deadlines, meal preparation, cleaning, and setting schedules for daily tasks. The SP only worked with the VA twice and no other persons went to the VA’s home. · The VA initially believed that s/he had misplaced his/her wallet and was “very slow” to assume that anything was wrong with his/her financial accounts until s/he found the SP’s contact information on one of the “false sites” that had been set up. The VA was “embarrassed” that money was taken from him/her. The VA contacted the CM and asked if it was “okay” for the SP to create accounts using the VA’s personal information. The VA told the CM that when the SP helped the VA with his/her online accounts, the SP had the VA set the sign-in screens so that his/her passwords were visible. · The VA sent emails to the CM regarding notifications s/he received about new online Amazon accounts that were set up, but which were not created by the VA. The browsing history for one account showed searches for infant items and gaming systems. A DoorDash account had a name other than the VA’s and some accounts had addresses that were close to where the VA dropped the SP off when s/he drove the SP home. Other accounts listed the SP’s cell phone number. A DoorDash subscription was set up for a cost of $9.99 each month (from the FM’s account). Four new Walmart accounts had been opened using the VA’s name and email address. The VA told the CM that over $1,000 had been charged to his/her bank debit card, including charges for a laundry service. The CM contacted the P and told him/her about the issues the VA was experiencing and the P told the CM that s/he planned to talk to the SP. The VA then began to receive notifications from Walmart and other vendors about accounts that were deleted. The VA and the CM believed that the SP “was trying to get rid of the evidence.” Charges were made on the VA’s accounts between July 26 and August 2, 2024. The VA had cash in his/her wallet when it was taken, as well as gift cards, insurance cards, and driver’s license. The P provided the following information: · The SP worked for the facility for three or four months, and prior to the incident, s/he was a good worker, and was good at updating the P on client activities. The VA’s main goal was to have assistance with organization and setting up apps on his/her cell phone so that s/he would know when payments were due. The facility staff persons were not to provide assistance to the clients with banking or financial transactions. · On August 1, 2024, the FM contacted the P and told him/her that there was an incident between the VA and the SP and that the VA was unable to find his/her wallet after the SP was at his/her home. The VA had also learned that financial transactions were made on the VA’s accounts at locations near the SP’s address as well as orders being placed at Amazon and Door Dash. The VA did not use Door Dash. Orders were sent to the SP’s address from various restaurants and a tobacco store. At least some of the orders were placed on August 1, 2024. It was unclear how much money the VA was missing. The CM also told the P that the VA drove the SP to his/her home, which was against the facility’s policies. · The following day, the P asked the SP what occurred between the SP and the VA. The SP told the P that “nothing occurred” and denied knowing anything about the VA’s finances. The P gave the SP a letter that stated that s/he was being “let go” and the SP signed the letter and did not deny or confirm that s/he did anything wrong. The SP provided the following information: · The SP worked with the VA on two occasions and helped the VA learn how to use his/her new cell phone. The SP helped the VA enter his/her contacts and email account into the new cell phone. The first day, the P drove the SP to the VA’s home and the SP worked with the VA for two hours. [Note: The P stated that s/he did not drive the SP.] The SP took the bus home and the VA did not drive the SP home. The next day from 1 to 3 p.m., the SP went to the VA’s home and helped the VA with his/her cell phone. After working with the VA for a short time, the SP took the bus home. On the following day, the P asked the SP to come to the office to talk to the P. · The SP stated that s/he helped the VA transfer data and apps from his/her old cell phone to a new one, but s/he never touched the VA’s cell phone and told the VA what to do. The SP used his/her cell phone to show the VA how to create a Gmail account on his/her cell phone. The VA’s old cell phone “had nothing on it” because it had all been transferred to the VA’s new cell phone. The VA tried to make his/her email account go to his/her cell phone and the SP “walked [the VA] through it,” but did not do it for the VA. The VA did not know his/her password to his/her email account, but finally got it to work. The SP saw the VA’s password when s/he first entered it because the VA had it set to show the passwords as s/he typed them. · The SP stated that s/he did not use the VA’s Amazon account or the other apps on the VA’s cell phone. The SP did not enter any information into his/her shift notes that s/he helped the VA with his/her online and Amazon accounts. The SP did not know why there were charges on the VA’s account from stores near the SP’s home. The SP stated that it would be “dumb” for him/her to order things from Amazon to be sent to his/her home address. The SP also stated that “there were cameras everywhere” so s/he would not make purchases near his/her home. The SP did not use a laundry service and did not know why the VA was charged by the laundry service. The SP did not shop at Walmart and did not have an account with Walmart. The SP did not know why his/her name was on a Walmart account connected to the VA’s bank card. · When asked why the telephone number attached to an Amazon account with the VA’s information was the same telephone number as the one the SP gave to the facility, the SP denied ever having that telephone number. The SP did not know anything about a Roku membership, Lyft charges, or a Door Dash account. The SP denied taking the VA’s old cell phone and/or wallet. · When the SP met with the P and told the SP that there was an investigation, but did not tell the SP what it was about. The SP signed a piece of paper given to him/her by the P, but did not read it. The SP was unaware that the VA’s wallet was missing or that the VA was missing money. The VA provided a list of costs connected to items that were taken by the SP that included the following: · Old cell phone: $200 · Wallet: $90 · Cash: $400 · Gift cards: $250 · Medical insurance cards replacements: $160 · Late fees: $80 · Driver’s license replacement: $40 · Total: $1,220 A laundry company provided an invoice for four transactions made on the VA’s debit card between July 25 and 28, 2024, totaling $65. According to the facility’s Timecard Report, on July 25, 2024, the SP worked with the VA for 2.25 hours. On July 31, 2024, the SP worked with the VA for 5 hours. Facility documentation showed that the SP and the P 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: On July 25 and 31, 2024, the SP worked with the VA at the VA’s home and assisted the VA with updating his/her cell phone and reviewing the VA’s online accounts. The SP also transferred information from the VA’s old cell phone to his/her new cell phone. The VA said that the SP looked at several of the VA’s online accounts and saw the VA’s passwords for his/her current accounts. The VA stated that s/he and the FM had no other visitors other than the SP at their home during that time frame. After the SP worked with the VA, the VA discovered that his/her wallet and old cell phone were missing. The VA also discovered that many purchases were made on his/her bank accounts and new online accounts were opened in his/her name with the SP’s phone number that the SP had given the facility. The VA’s bank statement showed that the bank reimbursed the VA for $806.09 for 33 disputed transactions made on the VA’s bank account between July 25 and August 2, 2024. A laundry service’s invoice stated that there were four transactions made on the VA’s debit card totaling $65. The VA stated that s/he did not make any of the purchases. The VA provided information that the total amount lost because of the stolen wallet and cell phone was $1,220. The SP denied having the phone number used and stated that s/he did not take the VA’s wallet or cell phone, obtain the VA’s online account information and passwords, make purchases with the VA’s debit card, or use the laundry service that later billed the VA. Although the SP denied taking the VA’s wallet and cell phone, using the VA’s debit card, setting up online accounts using the VA’s personal information, or having the phone number used, given that the phone number used to open accounts was the same one the SP gave the facility; that charges were also made on the FM’s bank card for Lyft, restaurants, and Roku television; and that no other person was in the VA’s home during that time, it was more likely than not that the SP took the items from the VA and used the VA’s account information and passwords to create new accounts. Given that the VA stated that s/he did not make the purchases or open the accounts, that many of the purchases were made near the SP’s home, and that the SP was the only person other than the VA who had access to the VA’s online accounts and passwords, 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 for purchases that were not made for the VA. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but not followed. Program’s policies strictly prohibit staff from accessing or handling client property or financial accounts without authorization. The staff member allegedly accessed a client’s wallet and financial information without permission, violating these policies. This was immediately reported and responded to. The facility retrained staff persons and the SP no longer worked at the facility. 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.
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