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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: 1072533-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh Christine.Cavanaugh@state.mn.us 651-431-3444 Suspected Maltreatment Reported: It was alleged that a staff person (SP) used a vulnerable adult’s (VA’s) debit card for the SP’s personal use. Date of Incident(s): Ongoing Prior to May 30, 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 was obtained during a site visit conducted on June 30, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with two supervisory staff persons (P1 and P2), the VA’s case manager (CM), the VA’s rep payee (RP), the VA, the SP, a DoorDash customer service representative, and a hotel manager. The VA’s file stated that the VA was diagnosed with schizophrenia, bipolar disorder, generalized anxiety disorder, depression, and post-traumatic stress disorder. The VA was able to advocate for him/herself and preferred to be included in discussions regarding his/her care. The VA preferred staff persons to attend outings and appointments with him/her. The VA was able to verbalize financial needs for assistance and managed his/her own funds. According to the VA’s Individual Abuse Prevention Plan, the VA was not susceptible to financial exploitation and there was no reported history of it. The VA had unlimited unsupervised time in the community and was not subject to guardianship. Facility documentation including the General Event Reports and Internal Review provided the following information: · On April 3, 2025, the VA gave his/her Serve card to the SP for “safekeeping.” (Note: According to www.serve.com, a Serve card is a “reloadable” debit card.) April 29, 2025, was the last shift the SP worked with the VA. (Note: The VA told this investigator that s/he got his/her card back around May 3, 2025, after asking the SP for it.) · On May 28, 2025, the VA told P1 and P2 that s/he attempted to use his/her Serve card and it was denied due to lack of funds. · On May 30, 2025, Serve statements were reviewed and the transactions “seemed to match” the VA’s personal reported outings; however, the VA “still believed” there was fraudulent activity on the card. According to the Internal Review, the VA believed the following charges were unauthorized: nine charges at Speedway gas station; eight charges at Walmart; two charges at Door Dash; two charges at Subway; and eight charges at Dollar Tree. Additionally, the statement showed that on April 5, 2025, there was an Expedia.com purchase of $211.58. · The VA disputed the charges s/he believed were unauthorized, but on June 10, 2025, Serve notified the VA that the disputed charges were declined due to the consistency with the VA’s transaction history. The VA provided the following information during a joint interview with law enforcement (LE): · On April 3, 2025, the VA gave his/her Serve card to the SP to hold so that the VA “wouldn’t spend it” and would have enough money to pay for his/her medical expenses. · The VA stated that between April 3 and May 3, 2025, s/he used the card for pop and cigarettes, but did not remember if s/he used it for other purchases. The VA said s/he did not have possession of the card during that timeframe, so s/he could have used cash for the pop and cigarette purchases instead of the card. · The VA denied making the Expedia charge, but knew the SP went to local hotels. The VA denied using DoorDash and said that the SP did not order anything for the VA via DoorDash. The VA “always” went to Speedway and Holiday and the SP brought the VA to those places. The VA stated, “The only thing I really do is get pop and cigarettes.” The VA also “loved” Walmart, “always” went there, and said it was his/her “home.” The VA liked to buy jeans, food, makeup and “everything” at Walmart. The VA did not have any receipts. P2 said that on May 28, 2025, the VA told P2 that s/he “had no money” and that the SP “took” all his/her money, so P2 told P1 to look at the VA’s statements with the VA. The VA told P2 that the SP used his/her Serve card at the places that the VA typically went to; however, the VA said s/he never used Door Dash. On an unknown date, P2 saw that the SP had McDonalds delivered to the facility. Because the VA managed his/her own funds, the facility did not document or track the VA’s spending or cash. P1 said that around the end of May 2025, the VA told P1 about concerns with purchases on his/her debit card and that s/he thought the SP used his/her card. When P1 reviewed the VA’s statements, there were purchases from places the VA normally went to; however, not at the frequency on the statements. P1 said that the only person who had access to the office during that time, where the card was kept, was the SP. Serve statements; information from LE including Expedia and DoorDash transaction details, a DoorDash customer service representative, Walmart, and a local hotel; and the facility’s T-Logs provided the following information: · The Serve statements dated February 4 through April 2, 2025, showed there were transactions at Aldi, Walmart, Burger King, White Castle, McDonalds, and gas stations. · The Serve statements dated April 3 through May 3, 2025, when the VA stated that the SP had the VA’s card, showed twenty-six transactions/charges which including the following: o On April 4, 2025, the Serve statement showed three DoorDash purchases ($5.64, $23.70, and $7.75 respectively). The DoorDash customer service representative provided information that the three DoorDash charges were associated with the SP’s DoorDash account. According to the representative, there was a DoorDash account in the VA’s name, but there was no purchase history for the VA’s account. LE obtained information from DoorDash and confirmed the SP’s name, email, and phone number were associated with the account that made the DoorDash purchases. Delivery details showed that the orders were delivered to the SP at a local hotel that was the same hotel as the Expedia purchase discussed in the next bullet. o On April 5, 2025, the Serve statement showed one Expedia purchase for $211.58. According to Expedia transaction details obtained by LE, on April 4, 2025, at 8:12 p.m. the SP’s first and last name, phone number, and email address were used to make a purchase using the VA’s card with Expedia.com via a mobile app for $211.58. The booking was for a two-night stay at a local hotel for April 5-7, 2025. § According to the SP’s timecard, the SP worked at the facility on Friday, April 4, 2025, from 6:45 a.m. until 8:30 p.m. The SP did not work at the facility on April 5 or 6, 2025, and returned to work on April 7, 2025, at 8:45 a.m. § T-Logs showed that the VA was at the facility April 5 and 6, 2025. § A law enforcement officer followed up with the VA who stated s/he never gave the SP permission to use his/her card to purchase a hotel stay and the VA never stayed with the SP at hotel. § A manager at the hotel stated that the SP had a history of staying at that hotel location and that hotel staff were to verify a guest’s ID upon check-in. o On April 9, 2025, the Serve statement showed one purchase at T.J. Maxx for $70.59. The VA provided information that s/he did not make this purchase. However, LE obtained video footage from T.J. Maxx which showed the VA at the checkout making a purchase and exiting the store alone. o There were multiple other purchases at Holiday Stations, Walmart, Speedway, Super Gas USA, and the Dollar Tree. There was no information or video obtained to show who made these purchases. · LE submitted their report to the county attorney for possible charges. The SP provided the following information: · Historically the VA overspent and “always” asked to borrow money from the SP or others for soda or cigarettes. On unknown dates between late February and April 2025, the SP lent money to the VA totaling between approximately $200-$300 and the VA did not repay the SP. · The SP took the VA on outings to several stores including Home Goods, Burger King, Arby’s, KFC, Walmart, Dollar Tree, and gas stations. The VA’s card got declined multiple times while they were at stores, so sometimes the SP paid for the VA’s items. · The VA was responsible for his/her own finances and used cash and/or his/her card. The VA “mostly” kept his/her card; however, at some point between February and April 2025, for an unknown amount of time, the card was stored in the facility office on a desk because the VA wanted to “budget” due to overspending. One time the VA called the SP to see if a staff person could get his/her card from the office. Because the office required a code to enter, only supervisory persons and maintenance persons had the code. However, the SP said s/he gave the code to staff persons if needed when s/he was not at the facility. · Around March 2025, the SP borrowed $100 or $120 from the VA and the SP repaid the VA the “next day.” [Note: The SP borrowing money from the VA was a violation of Minnesota Statutes, section 245A.04, subdivision 13, paragraph (d), clause, (1) states in part that program staff must not borrow money from a person served by the program.] · The SP denied using the VA’s card for him/herself and denied using it for DoorDash or Expedia. The SP had his/her own DoorDash account and used that if s/he wanted food delivered to the facility. The CM said that sometime during spring 2025, the CM and the VA agreed to have the VA’s Serve card kept in the office at the facility to keep the card “safe” so the VA did not lose it. The VA liked to go to gas stations and had a history of sometimes overspending on pop and cigarettes. The VA had his/her own cell phone with internet access. The CM was not aware of the VA doing any online shopping, but knew the VA shopped at Walmart. The RP was the VA’s “social security” rep payee, and the VA’s check came to the RP monthly. The RP paid the VA’s bills and the VA’s personal needs money was put onto the Serve card. The RP was only able to put money onto the card but the VA was able to use the card for purchases and/or cash withdrawals. P1, P2, and the SP were trained on the Reporting of Maltreatment of Vulnerable Adult’s Act, the VA’s plans, and the facility’s policies and procedures. Conclusion: A. Maltreatment: Information obtained showed that there were purchases on the VA’s Serve card for which the VA stated s/he did not make. The VA said that on April 3, 2025, s/he gave his/her Serve card to the SP so that s/he would not overspend. The SP stated that the card was kept in the staff office. The VA received his/her card back on approximately May 3, 2025. Between April 3 and May 3, 2025, the VA was unsure if s/he used his/her card or not, but LE obtained camera footage of the VA using it at TJ Maxx during that timeframe, which also was reflected on the VA’s Serve statement. There were multiple other purchases at Holiday Stations, Walmart, Speedway, Super Gas USA, and the Dollar Tree that the VA stated s/he did not authorize or do, but there was no information or video obtained to show who made these purchases. Information obtained showed that on April 4, 2025, at 8:12 p.m., an Expedia.com purchase for $211.38 was made using the VA’s Serve card for a local hotel and on April 5, 2025, the purchased was reflected on the VA’s Serve statement. The booking was under the SP’s name, email, and phone number. Additionally, the three DoorDash purchases that totaled $37.09 on the VA’s Serve statement were associated with the SP’s DoorDash account and delivered to the SP at the local hotel. Although the SP denied using the VA’s debit card for him/herself, given that records showed that the SP’s identifying information was linked to the Expedia.com booking using the VA’s Serve card, that the SP was working at the facility at the time of the booking purchase, that T-Logs showed the VA was at the facility during the time of the hotel stay, that the DoorDash charges on the VA’s card were associated with the SP’s Door Dash account and delivered to the local hotel that was the same hotel as the Expedia purchase, and that the VA stated that the SP did not order him/her DoorDash and that s/he did not authorize the Expedia and/or Door Dash purchases, there was a preponderance of the evidence that in the absence of legal authority a person willfully used the VA’s funds. 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 VA’s plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP denied using the VA’s card for him/herself. However, given that information obtained showed that the SP’s identifying information was associated with the Expedia.com booking and the three DoorDash charges which were delivered to the same hotel booked by the Expedia purchase, that the SP was responsible for the 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 Serve card taking money from the VA more than one time. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate and followed; however, there was a need for additional staff training. Person specific training was conducted for all staff persons who worked with the VA. The VA’s plans were updated with risk of abuse under financial exploitation. Additionally, the funds and property authorization was updated to reflect the “provider’s responsibility” for the VA. 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. Given that the facility took immediate correction action, a Correction Order was not issued for the violation outlined above.
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