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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: 1117984-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072182-HCBS (Home and Community-Based Services) Investigator(s): Lindsay Arth/Lisa Shock 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) took a vulnerable adult’s (VA’s) funds for his/her personal use. Date of Incident(s): Multiple dates between March 2023 and August 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 law enforcement records; and through four interviews conducted with two facility supervisory staff persons (P1 and P2), a staff person (P3), and the VA’s guardian (G). Attempts were made via text, phone, email, and U.S. mail to contact and interview a staff person (SP) but the attempts were not successful. The VA was interviewed by law enforcement and that information is below. The VA was diagnosed with a developmental disability, spinocerebellar atrophy, major depressive disorder, and oppositional defiance disorder. The VA enjoyed going to work, playing with dogs, and playing video games. The VA had a rep payee who managed the VA’s finances and was responsible for paying the VA’s bills. The VA had a checking account where his/her paychecks were deposited into. The rep payee did not manage this checking account. The facility stored clients’ money, including checkbooks, in a locked safe at the facility that all staff persons had access to. Staff persons were to record transactions on a cash resource log any time there was money coming in or being spent, as well as keep receipts for money spent. P1, P2, P3, the Vulnerable Adult Internal Reporting Form, and the Vulnerable Adult Internal Investigation, provided the following information: · On August 26, 2025, P3 told P1 and P2 that s/he had “concerns” and “suspicions” regarding the SP and the VA’s money which included: o In April or May 2025, the SP asked P3 to take the VA to the bank to withdraw $1000 from the VA’s checking account for a new bed, which the VA wanted. Once P3 and the VA withdrew the $1000 cash from the bank, P3 gave the money to the SP and then P3 “never saw it again.” Additionally, the VA never received a new bed and when P3 asked the SP about the bed, the SP told P3 it was on “back order.” o In August 2025, the SP asked P3 and the VA to withdraw $350 from the VA’s checking account for a down payment for a tattoo the VA wanted. Once the VA and P3 returned home from the bank, P3 gave the SP the $350 but did not see what the SP did with it after. Additionally, P3 said that the VA never received the tattoo. o On a “few” unknown dates the past couple years, the SP asked P3 to take the VA to the bank to withdraw money and when the VA and P3 returned from the bank, P3 would give the SP the money and the SP would put the cash into a drawer. Despite this, P3 said that the VA “never” had money to “do anything.” The SP “rarely” added the money to the VA’s cash resource log, which staff persons were trained to do. · After talking to P3, P1 and P2 went to the facility and saw that there was no receipt for a tattoo. P1 then spoke to the SP who said that s/he withdrew money for a down payment for the tattoo from the VA’s account but that the tattoo shop did not give him/her a receipt. When P1 asked the SP for additional information such as the name of the tattoo shop, the SP “refused” to provide the information. P1 told the SP that s/he needed to “produce” a receipt by August 27, 2025, but the SP did not do so and stopped communication with the facility and “did not respond to anyone.” · P1 then conducted an “audit” of the VA’s account, which included reviewing the VA’s bank statements and noticed that the SP withdrew “large sums” of money from the VA’s account and that those withdrawals were never documented on the VA’s cash resource log and there were no receipts, which staff persons were trained to do. The SP also “forged” a “few checks.” Upon completing the audit, P3 determined that the VA was missing $6758. P1’s audit of the VA’s bank statement, including checks, and VA’s Cash Resource Log (log) provided the following information: · On August 15, 2025, $100 was withdrawn via check #1066 and on August 20, 2025, $350 was withdrawn via check #1067 from VA’s bank account and the log stated that the SP put the money as a down payment towards a tattoo for the VA. There were no receipts to show expenditures for the $450.
· On April 29, 2025, $1000 was withdrawn via check #1063 from the VA’s bank account and $200 was entered into the log. There were no receipts to show expenditures for the remaining $800. · On January 23, 2025, $800 was withdrawn via check #1060 from the VA’s bank account and $100 entered in the log. There were no receipts to show expenditures for the remaining $700. · On April 30, 2024, $300 was withdrawn from the VA’s bank account and $80 entered in the log. There were no receipts to show expenditures for the remaining $220. · On February 20, 2024, $500 was withdrawn from the VA’s bank account, and there was no deposit in the cash resource log. There were no receipts to show expenditures for the $500. · On November 9, 2023, $400 was withdrawn from the VA’s bank account, and $200 was deposited in the log. There were no receipts to show expenditures for the remaining $200. · On October 9, 2023, $1000 was withdrawn from the VA’s bank account, and $100 deposited into the log. There were no receipts to show expenditures for the remaining $900. · On September 25, 2023, $800 was withdrawn from the VA’s bank account via check #1144 and nothing deposited in the log. There were no receipts to show expenditures for the $800. The back of the check was signed by the SP. · On May 8, 2023, $600 was withdrawn via check #1137 and on May 10, 2023, $600 was withdrawn via check #1138, and $111.69 deposited into the log. There were no receipts to show expenditures for the remaining $1088.31. The VA’s name was signed on the front and back of the checks in notably different handwriting than the other checks. · On April 10, 2023, $600 was withdrawn from the VA’s bank account, and no deposit recorded on the log. There were no receipts to show expenditures for the $600. · On March 1, 2023, $600 was withdrawn via check #1133 from the VA’s bank account and nothing deposited in the log. There were no receipts to show expenditures for the $600. The back of the check was signed by both the VA and the SP. · The VA was missing $6,758.31. [Note: The total amount determined based on the information above was $6858.31.] Records from law enforcement (LE) provided the following information: · P1, P2, and P3 provided information to the LE that was consistent with the information each provided during their respective interview. P1 also told the LE that the clients were not “permitted” to have more than $300 cash on hand and that the large amounts of cash withdrawn were “not normal.” · Law enforcement called a tattoo parlor who said that they were “familiar” with the VA’s tattoo appointment but just prior to the appointment, the SP notified them that s/he was not able to bring the VA to the appointment and would reschedule. The tattoo parlor stated they had not received a down payment for the tattoo and did not hear from the SP after that. P2 told law enforcement that if the cash for the VA’s tattoo had not been spent, then it should have been returned to the VA’s possession, which had not been done by the SP. · The VA told the LE that s/he was supposed to be with staff persons when checks were cashed. The VA also said that s/he did not recognize the signature on two of the checks, and s/he would not sign a check in the manner that was done. The SP was not supposed to sign the VA’s checks. · The VA said that they withdrew money for a new bed but s/he never received the new bed. The VA also stated that cash was withdrawn from his/her account for a tattoo but s/he had got the tattoo, and the VA did not have the money. · The SP did not respond to law enforcement. · Law enforcement sent the report to the county attorney for a review of charges for “theft by check” and “financial exploitation” of a vulnerable adult including taking or using property for the “benefit of someone else,” which was pending at the time of the investigation. The G said that the facility notified him/her of the incident. The G did not "handle" the VA's money and said it was "all handled" through the facility and the rep payee. The G met the SP "several times" and did not have any concerns with the SP relating to the incident. The G did not have any concerns with the facility and said that they were "great." Facility documentation showed that the SP, P1, P2 and P3 were trained on the VA’s plans, facility’s policies and procedures, including client rights, and the Policy and Procedure Client Funds and Personal Items Policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information from all sources showed that the SP wrote out checks from the VA’s account without authority, failed to document cash transactions into the VA’s cash resource log, and did not deposit all the VA’s cash into the VA’s cash account. The VA said that s/he and the SP took out money for a bed and a tattoo and that the VA did not receive a bed or a tattoo and did not get the money from the SP. The VA was missing $6858.31. Given that only staff persons had access to the VA’s account and that the facility stored clients’ money, including checkbooks, in a locked safe at the facility that all staff persons had access to and that staff persons were to record transactions on a cash resource log any time there was money coming in or being spent, as well as keep receipts for money spent, there was a preponderance of the evidence that in the absence of legal authority a person willfully used, withheld, or disposed of funds of the VA. 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 facility’s policies and procedures, including client rights and Policy and Procedure Client Funds and Personal Items Policy, and on the Reporting of Maltreatment of Vulnerable Adults Act. All staff persons had access to the VA’s funds and the SP did not provide information for this report. However, P1’s audit of the VA’s account showed that the SP withdrew “large sums” of money from the VA’s account and that those withdrawals were never documented on the VA’s cash resource log and there were no receipts for expenditures, which staff persons were trained to do. In addition, the SP’s name was signed on more than one of the VA’s checks for cash, and the SP was responsible for the bed purchase for which the VA did not receive and tattoo downpayment for which when P1 asked the SP for additional information such as the name of the tattoo shop, the SP “refused” to provide the information or a receipt for the down payment. 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 took money from the VA on multiple dates but it 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, as there was “significant evidence” to show financial exploitation against the VA. There were no prior similar concerns with the SP. 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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