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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: 1069663-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069668-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler jason.pehler@state.mn.us Suspected Maltreatment Reported: It was reported a staff person (SP) used two vulnerable adults’ (VA1-VA2) funds to make unauthorized purchases. Date of Incident(s): From October 2021 to May 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: This investigator was assigned DHS Maltreatment investigation, report #202504516. During the investigation the facility (F1) discovered the SP was potentially involved in an additional alleged maltreatment at a second facility (F2), and a second DHS Maltreatment investigation was assigned #202506049. Information regarding both were contained within this report. VA1 resided at F1 and VA2 resided at F2. Pertinent information for this investigation was obtained remotely, including documentation from two facilities (F1 and F2); and through four interviews conducted with a facility supervisor (P1), VA1’s guardian (G), and the SP. The G said VA1 was aware of the situation, and the facility reimbursed the funds. VA1 was not interviewed because persons who were familiar with VA1 thought it would cause emotional distress to VA1. LE was contacted, but did not complete an investigation. VA2’s guardian was contacted, but did not respond. VA2 was aware of the investigation, but did not complete an interview as s/he did not have any direct information related to the alleged maltreatment. Facility documentation showed VA1 was a very social person who enjoyed conversing with others. VA1 was described as caring, kind, and willing to help others. VA1 was musical and liked to sing, listen to polka, and go out of eat. VA1 was diagnosed with developmental disabilities, anxiety, and multiple physical health conditions. VA1 was gluten intolerant and “should not” eat food that contained gluten. VA1 was subject to guardianship and had a representative payee. Facility documentation showed VA2 needed staff persons to listen to him/her. VA2 enjoyed coloring, drawing, playing with cars, and watching television. VA2 was diagnosed with developmental disabilities, obsessive compulsive disorder, Alzheimer’s, and multiple physical health conditions. VA2 was subject to guardianship. VA1’s and VA2’s Individual Abuse Prevention Plan (IAPP) showed VA1 and VA2 did not understand the value of money and would not know who to speak with if his/her money was being mismanaged. Staff persons would assist VA1 with purchases. VA2 could be easily taken advantage of financially, and staff persons would make attempts to recovery the VA’s money or property if needed. VA1’s and VA2’s Funds Authorization forms showed VA1 and VA2 required “full assistance with managing/handling personal spending funds with receipts obtained by staff (persons) for all transactions.” This included fully assisting with managing/handling the personal spending funds and obtaining receipts for all transactions. The facility was responsible to secure the VAs cash, checks, and banking cards. It also stated staff persons should not borrow money from the VAs. VA1 required approval prior to purchases exceeding $100. An Internal Review (IR1) regarding the alleged maltreatment at F1 provided the following information: · On May 2, 2025, it was discovered there were several transactions that did not have corresponding receipts during an audit of VA1’s financial records. The facility investigated VA1’s bank account transactions from November 2021 to April 30, 2025, and found a pattern that VA1’s bank account was used to make unauthorized purchases. The facility’s audit showed the SP used VA1’s bank account from April 2024 to April 2025 to make unauthorized purchases of meals for the household that totaled $1,977.99. Additionally, the facility audit showed that between December 2021, and January 2025, there was an additional $1163.67 of transactions did not have sufficient documentation regarding receipts for purchases. During the dates audited the SP was the supervisor of the facility. · The G said s/he had been asked for approval for items that cost more than $100 and provided multiple examples. The G said s/he had not been asked for authorization for VA1 to purchase dinner for the household. · The SP started working in November 2021, and while employed at the facility the SP completed 32 trainings related to fraud, documentation, maltreatment and rights. The trainings included the following points of emphasize: o Fraud could include instances where a vulnerable adult’s money was borrowed or used for something for which it was not intended. It was never okay to borrow money from the vulnerable adults. o Financial exploitation included, willful use, withholding or disposal of a vulnerable adults’ funds or property. o Financial exploitation included acquiring possession or control of, or an interest in, a vulnerable adults funds or property through the use of undue influence, harassment, duress, deception, etc. · The facility completed a financial audit of VA1’s finances which showed the following: o On December 12, 2021, there were two cash withdrawals totaling $308 from VA1’s bank account. o On September 6, 2022, a transaction made at Target included $40 cash back. On October 11, 2022, there was a transaction made at Walmart which included $60 cash back. Both cash back transactions were made while the SP was on shift and VA1 was absent from the facility. o On March 28 and 29, 2023, the VA’s bank account was used to make two purchases on the SP’s Amazon account. The SP was able to produce receipts for the items, and the purchases were not identified as unauthorized purchases. o The SP used his/her Amazon account to make multiple transactions on Amazon totaling $129.17. Those transactions were charged to VA1’s bank account on the following dates.
§ April 7, 18, 19, and 28, 2023 § May 5, and 19, 2023 § April 22, and 27, 2024 · On May 12, 2023, VA1’s first transaction on his/her own Amazon account was completed for a standalone air conditioner. · There was an email from June 7, 2023, that a previous supervisor (P2) instructed the SP to remove VA1’s bank account information from the SP’s Amazon account. On May 8, 2024, an Amazon purchase of $16.10 was made on the SP’s account for VA1. The SP provided the receipt of the purchase during the investigation. · VA1’s bank account was used on the SP’s Amazon account on April 22 and 27, 2024. The SP confirmed s/he completed the transactions as they were his/her television subscriptions. The transactions were completed after the SP had reportedly removed VA1’s bank account information from his/her Amazon account. There were additional charges from the VA’s bank account: o Amazon Prime - April 21, 2024: $7.61 o Amazon.com - September 20, 2024: $18.99 o Amazon.com - October 16, 2024: $18.99 · On January 13, 2025, an ATM withdrawal of $85 was completed during a time the SP was on shift and VA1 was absent from the facility. An Internal Review (IR2) regarding the alleged maltreatment at F2 provided the following information: · VA2 did not have an Amazon account, and the SP purchased an item for VA2 from Amazon using the SP’s personal Amazon account. There was a receipt for the purchase that confirmed the details. · On March 11, 2025, the SP purchased personal care items for VA2. The account used was not an Amazon account that was VA2’s or in connection with the facility. VA2’s bank account was used to make the purchase. · VA2’s bank account showed there were multiple purchases from Amazon Prime Video Channels that were charged to his/her account. o April 21, 2025: $14.01 o April 21, 2025: $8.62. o May 19, 2025: $7.54 o May 20, 2025: $14.01 o May 21, 2025: $8.62 · The facility believed the SP demonstrated a pattern of behavior of using multiple vulnerable adults’ bank accounts to make personal purchases due to the above transactions, as well as the information from the facility’s internal investigation of 202504516. Based on the information it was believed the SP did not remove the payment method, VA2’s bank information, from the SP’s Amazon account prior to additional purchases being completed. VA2’s bank statement confirmed the information within IR2 regarding the Amazon Prime purchase on the above dates. · On April 21, 2025, two transactions from Amazon were stated on VA2’s bank statement as “Prime Video Channels” for the following amounts of $14.01, and $8.62. · On May 19, 20, and 21, 2025, there were transactions on VA2’s bank statement as “Prime Video Channels” for the following amounts of $7.54, $14.01, and $8.62. P1 provided the following information: · P1 said the facility found a lack of documentation and receipts that would explain the purchases that were made. Based on VA1’s bank statements the majority of the purchases were from a restaurant and the purchases were on an almost weekly basis. P1 said the SP informed the facility the G had approved the purchasing of the meals for the household. However, P1 said the G told the facility s/he was not aware those purchases were occurring on a weekly basis. · P1 said there were additional purchases where VA1’s bank account was used to make purchases on the SP’s Amazons account. P1 said the SP admitted to using VA1’s card for multiple purchases, but the SP said s/he removed VA1’s bank account information from the SP’s Amazon account. P1 said based on the timeframes of the purchases either the SP did not remove VA1’s bank account information from the SP’s account, or the SP re-added VA1’s bank account back onto the SP’s Amazon account. · P1 said the facility reimbursed VA1 around $3,700 due to the mismanagement of funds that was discovered. · P1 said prior to the investigation the facility did not have any concerns with the SP’s work performance. The G said s/he had almost daily communication with the facility and the SP. Those conversations were in-person or over the phone and including talking about the SP assisting VA1 with larger purchases. The G said s/he had approved the SP to order pizza once, but did not recall approving meals being ordered on a regular basis, or for the entire household. The G added that VA1 would be willing to purchase pizza or other meals as s/he was motivated by food, and VA1 would not care if his/her money was used to order the food. The SP provided the following information: · The SP created an Amazon account for VA1 in 2022 after there was an incident in which the SP used VA1’s bank account on the SP’s Amazon account to order items for VA1, but the SP spent some of VA1’s money on subscriptions/movies. A previous supervisor contacted the SP regarding the concern; however, the SP was on vacation at the time, thereafter the SP had a death in his/her family. The incident was not discussed with the SP when s/he returned to work. · The SP estimated that several purchases occurred before it was discovered, and the purchases totaled around $100. The SP said s/he informed P2 and removed the payment information from the Amazon account. · The SP stated s/he was the only person that shopped for VA1, and VA1 did not purchase any movies on Amazon. The SP said s/he was the only staff person who assisted VA1 with banking at the facility. · The SP said s/he would assist VA1 in getting cash and would usually take cash out while at Walmart, but that was only done when VA1 had something planned that required cash. The SP provided an example of getting Dairy Queen. The SP was unable to provide a reason to why the cash withdrawal would not have been documented · The SP said the G had approved meals being purchased from restaurants, and VA1’s money could be used to purchase pizza for the home 1-2 times per month. The facility informed the SP that the G was not aware that VA1’s bank account was used to purchase dinner for the household, and the SP said s/he owed the G an apology. · The SP denied any knowledge of VA2’s bank account being used to purchase subscriptions from Amazon. The SP said VA2’s bank account could have been accidently used to purchase the subscriptions, and the transaction were not on purpose. Based on information obtained the facility reimbursed VA1 a total of $3,761.83, and the SP reimbursed the facility a total of $620.17. The SP’s reimbursement amount was based on the amounts of cash withdrawals from VA1’s account that did not have corresponding documentation. As well as the purchases that were made on the SP’s Amazon account that used VA1’s bank account. The facility reimbursed VA2 $52.80 for the unauthorized transactions, however the SP was no longer employed at the time the facility discovered the alleged financial exploitation of VA2 P1 and the SP completed training on VA1’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. In addition, the SP completed trainings on client finances, petty cash, handling vulnerable adults’ funds, and the prohibition of borrowing or lending items between staff persons and vulnerable adults. Conclusion: A. Maltreatment: Regarding VA1: It was reported the SP used VA1’s funds to make unauthorized transactions. From December 2021 to April 2025, there was approximately $3,700 worth of suspicious transactions made with VA1’s bank account. The suspicious transactions included ordering delivery food, ATM withdrawals, Amazon purchases, and Amazon subscriptions. IR1 showed the SP said s/he used VA1’s bank account to order items from Amazon. There was additional information which showed the SP’s Amazon account utilized VA1’s bank account to make purchases on Amazon that were not for the VA’s benefit. The facility found the cash withdrawals were not documented in VA1’s Petty Cash Trackers and VA1’s petty cash balance did not reflect the cash withdrawals as there was not money deposited into VA1’s petty cash. The SP stated s/he was the only person that assisted VA1 with shopping and banking, and VA1 did not purchase any movies on Amazon. The SP provided a plausible explanation for the cash withdrawals, however, was unable to provide a reason to why the cash withdrawals would not have been documented. The SP believed the G had approved meals being purchased from restaurants, and VA1’s money could be used to make the purchases, however when the facility informed the SP that the G was not aware that VA1’s bank account was used to purchase dinner for the household, and the SP said s/he owed the G an apology. Given that the SP had VA1’s bank account information on the SP’s Amazon account and used it to make purchases that were not for VA1, there was a preponderance of the evidence that the SP used VA1’s funds in the absence of legal authority. Regarding VA2: It was reported the SP used VA2’s funds to make unauthorized transactions. The suspicious transactions included Amazon Prime Video Channels made on the SP’s Amazon account. A bank statement showed multiple Amazon purchases in which the VA’s bank account was used. There was no information the purchases were made on behalf of the VA, or the VA benefited from the purchases. The SP denied any knowledge of VA2’s bank account being used to purchase subscriptions from Amazon. However, given that the SP had VA2’s bank account information on his/her Amazon account and stated VA2’s account could have been used by mistake to make the SP’s Amazon purchases and that the SP stated s/he used VA1’s funds to make purchases on Amazon that were not for VA1, it was more likely than not that the SP also used VA2’s funds to make the Amazon purchases. Therefore, there was a preponderance of the evidence that the SP used VA2’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 received training on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1 and VA2. 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 used both VA1’s and VA2’s funds each on more than one occasion. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility took corrective action, and 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 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.
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