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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: 1109259-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP) had taken $80 from a vulnerable adult’s (VA) cash box that was located in an office in the facility. Date of Incident(s): July 24, 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 through four interviews conducted with the SP, a supervisory staff person (P1), and the VA’s guardians (G1, G2). Attempts were made to contact another supervisory staff person (P2) via phone and certified mail to request an interview with P2, but P2 did not respond. The VA enjoyed doing puzzles, watching TV, and engaging with the staff persons that supported him/her at the facility. The VA was diagnosed with autism and moderate intellectual disability. Due to the VA’s diagnoses, the VA was not able to provide information related to this investigation. The VA’s Individual Abuse Prevention Plan stated that the VA did not understand financial matters, would not be aware if money was missing, and would not know who to report missing money to. The VA would not hold or be responsible for any cash, debit/credit cards, or checks. The VA had a representative payee to manage his/her benefits. Staff would safely store the VA’s cash, debit/credit cards, and checks. Staff would obtain receipts and document all transactions. The Program Manager would monitor the VA’s bank account and paid bills as needed for the VA. The SP provided the following information: · The SP worked at the facility for one year and five months. During that time, the facility had stored the cash in a lock box, but the lock box was not locked. The lock box was typically located in the staff office in a closet next to a desk. The closet was not locked and usually was left open. · The SP had asked the Program Administrator multiple times for a different lock box for cash funds and debit/credit cards since there was a separate lock box for insurance cards, but a lock box was not purchased or provided. · On an unknown date in May 2025, the SP observed that the cash box had not moved, and the ledgers had not been checked. The SP counted the VA’s money and observed that the VA had $160 in the cash box. The SP placed books and a hole puncher on top of the cash box. From May until July 24, 2025, the books and the hole puncher had not moved from where the SP had placed them. · On July 24, 2025, the SP counted the VA’s cash that was in the cash box. The VA had $160. The SP took $80 from the VA’s cash box to pay for two $40 apartment application fees for the SP. The SP intended to pay the money back before anyone noticed that the money had gone missing. · The SP received a text on July 28, 2025, from the Program Manager that an all-staff meeting needed to occur regarding missing money. The SP texted the Program Manager directly and admitted that s/he took money from the VA. The SP was told that if s/he had paid back the money that day, it would be considered “borrowed” money but, if they paid back the money the next day, it would be considered “stolen” money. · The SP paid back the VA $80 on July 29, 2025, and resigned from his/her position with the facility on August 4, 2025. · The SP understood that s/he “made a mistake” by taking the money and was “open and honest” about when and why s/he had taken the money but, had also paid the money back. Since the SP observed that the lock box had not moved for over two months, s/he did not think s/he would get caught and did intend to pay the money back before anyone found that the money was missing. P1 provided the following information: · P1 did not recall the date that s/he observed the VA had missing money but P1 observed that one of the two envelopes were not sealed. The envelope that was open contained the VA’s cash and receipts. · P1 counted the VA’s money and initially determined that $150 was missing and P1 notified his/her supervisor. P1 sent a text message out to all staff who worked at the facility regarding a staff meeting to discuss the missing money. The SP texted P1 admitting that s/he had taken the money. · After talking to the SP who said that s/he had only taken $80, P1 recalled that s/he had purchased blood sugar test strips and “other things” and did not add the receipts to the VA’s ledger. After recounting the money, P1 determined that the VA was only missing $80 instead of $150. · The money was stored in a lock box in the staff office in the corner near the wall and “stuff” was on top of the lock box. The lid to the lock was “pretty heavy” but, it was unknown where the key to the lock box was, and it had been that way throughout the duration that P1 had worked at the facility (approximately one year). · The SP put $80 cash back into the VA’s cash envelope but P1 did not recall when that occurred. On that same day, P1 purchased a new lock box with a key and did not have spare keys made. P1 was the only person with a key to the new lock box that was relocated to a cabinet in the staff office. Prior to the incident occurring, P1 was not concerned with how the VA’s funds were stored. · P1 would check and count the VA’s money “maybe once a week” or when s/he made purchases. When purchases were made, P1 would keep the receipts in an envelope and note the amount spent on the VA’s paper ledger that was kept at the facility. G1 and G2 provided the following information: G1 did not have concerns regarding the VA’s care. G1 was also the VA’s rep payee and did not have concerns with the facility and how they handled the VA’s funds. G1 was notified that the VA was reimbursed the funds shortly after the facility had found that the money was missing. G2 did not have concerns regarding the VA’s care. G2 was not concerned with the facility and how they handled the VA’s funds. The facility’s policy and procedure regarding Safeguarding Funds of Individuals Served stated that staff must not borrow money from an individual served by the program. Cash resources of $60 or less would be available (in locked storage) to the individual served/staff. Larger amounts of cash on hand for individuals served would be kept in a safe located at the facility. The Program Manager, Program Directors, and Program Administrators would be the only staff with access to the site safe. Receipts would be documented on the individual’s monthly expenditure form. On a weekly basis, the Program Manager was responsible for counting all cash on hand, reviewing receipts, and comparing the monthly expenditure form for cash to ensure accuracy. At the end of each month, the Program Manager was responsible for balancing the cash on hand with the monthly expenditure form for cash. Forms would be submitted to the Program Director for review on a monthly basis. The Program Director or the Program Administrator would count the cash on hand and cash in the safe each month when reviewing the monthly expenditure forms for cash and sign the monthly expenditure forms verifying the amount of cash on hand/in the safe. The VA’s Monthly Expenditure Form was dated for 2024-2025. Eight Transactions were listed from October 6, 2024, through July 27, 2025, with a deposit on October 6, 2024, and April 12, 2025. The Monthly Expenditure Form had not been signed off on by the Program Manager or the Program Director for transactions dated from October 6 through July 24, 2025. The Program Manager did not count the VA’s cash on hand on a weekly basis and the Program Director did not balance the VA’s cash on hand on a monthly basis. All staff person’s interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults, the facility’s policies, and were trained on the VA’s handling of funds. Relevant Rules and or Statutes: Minnesota Statutes, section 245D.10, subdivision 1, stated that the license holder must establish, enforce, and maintain policies and procedures as required in this chapter. Conclusion: A. Maltreatment: On an unknown date in May 2025, the SP observed that the cash box had not moved, and the ledgers had not been checked. The SP counted the VA’s money and observed that the VA had $160 in the cash box. On July 24, 2025, the SP counted the VA’s cash that was in the cash box. The VA had $160. The SP took $80 from the VA’s cash box to pay for two $40 apartment application fees for the SP. The SP received a text on July 28, 2025, from the Program Manager that an all-staff meeting needed to occur regarding missing money. The SP texted the Program Manager directly and admitted that s/he took the VA’s money. The SP paid back the VA $80 on July 29, 2025, and resigned from his/her position with the facility on August 4, 2025. According to facility documentation on the VA’s Monthly Expenditure Form, the facility’s policy and procedure regarding Safeguarding Funds of Individuals Served was not followed which was a violation of Minnesota Statutes, section 245D.10, subdivision 1. Although the SP understood that s/he “made a mistake” by taking the VA’s money and was “open and honest” about when and why s/he had taken the money and paid the money back, given that the SP took $80 from the VA for the SP’s use and that the VA did not have that money to spend if s/he chose to, there was a preponderance of the evidence that the SP used and withheld 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. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. 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 maltreatment for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and did not meet the statutory definition for serious maltreatment. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed by the SP. Staff persons at the facility were retrained on the policy and procedure regarding Maltreatment of Vulnerable Adults and Safeguarding Funds for Individuals Served. Monthly financial documents would be sent to the finance department each month for transactions and receipts to be entered and tracked electronically. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On December 8, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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