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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: 1071922-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden Thomas.C.Nixon@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA) debit card to purchase gas for the SP’s car, and a beverage and a camping chair for the SP. Date of Incident(s): July 20, 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 VA’s guardian (G), the VA’s case manager (CM), and facility supervisory staff persons (P1 and P2). Attempts were made by telephone and mail to contact and interview a staff person (SP), but the SP did not respond by the completion of this investigation. The VA’s support plans, including Risk Assessment Detail, stated the following: · In 2013, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included intellectual disability. The VA enjoyed bowling and going out to eat. The facility provided at least one staff person 24-hours a day for the VA’s supervision and care, including medical needs, transportation, and community safety. Staff always accompanied the VA when in the community. [Note: Information was provided through P1, P2, and store surveillance footage that the SP left the VA unsupervised in a car when the SP went into at least two stores on July 20, 2025, which was a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), which states, in part, the license holder must provide services in response to the person's identified needs as specified in the coordinated service and support plan and the coordinated service and support plan addendum.] · The VA did not understand money and might not recognize mismanagement of his/her funds. Staff carried the VA’s money when out in the community, gave money to the VA for his/her transactions, ensured proper change, and kept receipts. Staff reported any concerns on the VA’s behalf. The G and the CM each said that the VA had limited communication skills and would not be able to recall recent events. The VA would not recognize or report if someone misused his/her money. P1, P1’s text messages, and P2 provided the following information: · P1 and P2 each said that the VA did not understand money or how to purchase items. Staff persons carried the VA’s money on outings, processed transactions, and gave the receipts to P1, who then completed routine monthly audits. P1 said that the VA could “easily be taken advantage of” and had “zero concept of money.” P1 and P2 each said that the SP routinely worked with the VA at the facility and took the VA into the community on various outings while also completing various transactions. P1 and P2 each had no prior concerns the SP’s conduct. · P1 said that on August 7, 2025, s/he completed a monthly audit and noticed that on July 20, 2025, the VA’s debit card was used to purchase $30 worth of gas at Kwik Trip and two beverages, a Diet Dr. Pepper and a Poppi prebiotic drink. The VA did not drive or own a car and although s/he routinely drank Diet Dr. Pepper, s/he did not drink Poppi prebiotic. Then, shortly after, the VA’s debit card was used again at a Walmart to purchase two camping chairs. P1 recalled that on July 20, 2025, the SP drove the VA to a local bocce ball tournament and prior to leaving for the tournament, P1 told the SP to help the VA buy a camping chair so that s/he had a place to sit at the tournament. P1 did not tell the SP to buy two chairs. The SP should have taken a patio chair from the facility or brought his/her own chair to use. P1 texted the SP asking about the transactions. · P1’s text messages showed that the SP’s response included: It had slipped my mind my phone was dead and I wasn’t carrying my wallet that day and we needed to hit the road so I had used [the VA’s] card and hit the road. I got [the VA’s] $30 (for the gas) and second chair in [my] car I just didn’t get the chance to let you know since I was absent from [the facility] for awhile [SIC] now. My apologies! · P1 said that although the SP said that his/her phone was “dead,” P1 had additional text messages, which showed the SP texting P1 immediately following the bocce ball tournament, indicating the SP’s phone was not “dead.” P1 said that although the SP said that s/he had been “absent” and that was why s/he had not told P1 about the transactions, the SP had worked at least three shifts since the bocce ball tournament and did not say anything to P1 or P2. The VA had one camping chair at the facility, but not two camping chairs. · About one week after August 7, 2025, the SP delivered $30 to the VA and brought the VA’s second camping chair. The SP said that s/he mistakenly left the second chair in the SP’s car trunk. The chair no longer had any sales tags attached and so could not be returned to the store. The facility planned to reimburse the VA for the second chair and the SP’s beverage at the gas station. The facility’s financial policies stated that staff were prohibited from borrowing money from a client or requiring a client to purchase items that the facility was eligible for reimbursement. The facility’s maltreatment policies stated that staff were prohibited from willfully using a client’s funds without legal authority and from using a client’s financial resources for means that were a detriment to the client. Facility documentation stated that the SP, P1, and P2 received training on the facility’s financial policies and the Reporting of Maltreatment of Vulnerable Adults Act. P1 and P2 received training on the VA’s support plans, including Risk Assessment Detail. The SP received training on some of the VA’s support plans, but there was no documentation s/he received training on the VA’s Risk Assessment Detail which was a violation of Minnesota Statutes section 245D.095, subdivision 5, paragraph (a), clause (2), which states, in part, the license holder must maintain documentation of staff qualifications, orientation, and training. Conclusion: A. Maltreatment: Although the SP did not provide information for this report, consistent information was provided by P1, P2, and the SP’s texts to P1 that on July 20, 2025, the SP used the VA’s debit card to purchase gas for the SP’s car and while the SP did not comment on other purchases that same day, including a beverage and a camping chair, these purchases were made during the same outing with the VA and the SP, and the camping chair was in the SP’s car trunk. The G, the CM, P1, and P2 each said that the VA would not recognize or report if someone misused his/her money. P1 said that the VA could “easily be taken advantage of” and had “zero concept of money.” The SP text P1 that s/he “just didn’t get the chance to let you know since I was absent from [the facility] for awhile,” however, P1 stated that s/he had worked at least three shifts with the SP since the SP used the VA’s funds and never attempted to tell P1. In addition, P1 stated that s/he told the SP to purchase one chair the VA and did not give permission to purchase two chairs and the VA only had one chair at the facility. Given that the SP used the VA’s money to purchase him/herself gas, a drink, and a chair, there was a preponderance of the evidence that the SP willfully used the VA’s funds for purchases for the SP’s use and benefit. 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 responsible for the VA’s care and supervision. Although the SP did not acknowledge receiving training on all the VA’s support plans, this did not minimize the SP’s responsibility to care for the VA. The SP received training on the facility’s financial policies, which stated that the SP was prohibited from borrowing money from the VA or using the VA’s money for means that were a detriment to the VA; and the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act. 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. The SP was responsible for using the VA’s debit card at two different stores on July 20, 2025. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The facility reimbursed the VA for the misused funds. 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 and serious 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. The SP began working in a position allowing direct contact with persons served by the program in June 2021; however, at that time the license holder did verify the spelling of the SP’s name before initiating a background study request to DHS. In December 2022, the license holder self-corrected the spelling error and initiated a second background study request to DHS with the correct spelling. Because the license holder self-corrected the background study violation involving the SP before the Commissioner discovered the violation, the license holder is not being fined or cited for the background study violation. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. On December 11, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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