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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: 1070742-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Beth Virden Gessner.Rivas@state.mn.us Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) used the VA’s cash-on-hand, savings account, and trust fund to purchase items that were not for the VA’s use or benefit. Date of Incident(s): Ongoing prior to June 3, 3025 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 three interviews conducted with the VA’s guardian (G), the VA’s trust manager (TM), and a facility supervisory staff person (P1). Attempts were made by telephone, mail, and email to contact and interview the SP. The SP provided a written statement about the allegations to the DHS investigator, which was included in this report, but the SP did not respond to the interview request and was not interviewed. The VA’s support plans, including Funds and Property Authorization, stated the following: · In 2010, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disabilities and bipolar affective disorder. The VA had kidney failure and was on a special diet consisting of “a lot of water” and monitored sodium and potassium intake. · The VA was “very friendly and compassionate” and liked to listen to oldies rock music and go for walks and scenic drives. · The VA communicated using some words and non-verbal signals, like grabbing a staff person’s hand when s/he wanted to leave. The VA could not read or write or recognize letters or numbers. · The facility stored and/or managed the VA’s debit card, savings account, and cash-on-hand for monthly needs. The TM managed the VA’s trust fund. The VA and his/her two housemates lived at the facility, which was a single-family home. The facility provided at least one staff person 24-hours a day. The TM said that the VA’s day-to-day purchases were handled by the SP using the VA’s cash-on-hand and savings account. Periodically, when the VA had a larger purchase, the SP reached out to the TM via email about using the VA’s trust fund money. At the time, the TM did not believe any of the purchases were “suspicious;” however, the TM was not familiar with the VA’s abilities and so did not know what purchases the VA might want or make. The facility’s incident report, dated June 2, 2025, stated: In reviewing receipts and emails, [P1] discovered that [the SP] was making purchases with [the VA’s debit card] and falsely reporting to the trust. The majority of items and meals purchased were never received by [the VA], would not be appropriate for [the VA], and would be detrimental to [the VA’s] health due to [his/her] kidney disease, fluid restriction, and low sodium diet. Records have been found as far back as 2022. P1 provided the following information: · In February 2025, there were concerns regarding the SP’s personal time entries, which prompted P1 to review the facility’s financials and then discovered concerns with the VA’s financials. · The SP was responsible for completing weekly audits of the VA’s financials and another supervisory staff person (P2) was then responsible for monthly audits. In February 2025, when concerns were discovered, P2 told P1 that s/he had not been auditing the VA’s financials like s/he should have and instead was “taking [the SP’s] word for it.” [Note: The conduct of not reconciling the VA’s accounts monthly was inconsistent with the facility’s Funds and Property Policy and a violation of Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3), which states that the license holder shall monitor implementation of policies and procedures by program staff.] · P1 discovered multiple withdrawals from the VA’s cash-on-hand and savings account, which were not logged or accounted for on the VA’s ledger. P1 asked staff about these expenditures; however, the staff told P1 that the SP handled all the VA’s transactions, cash-on-hand, and savings account. · The VA was in end-stage renal failure and required foods with low-sodium and -potassium. More than once, the VA’s money was used to buy foods, which were not low-sodium and -potassium including a $13.15 purchase at Holiday gas station for three hashbrowns on December 12, 2024, and a $26.60 purchase at Stir Fry Express for “buffet by the pound” on December 18, 2024. · There were times when food was purchased using the VA’s money, but staff documented the VA ate food served at the facility; this included a $13.31 purchase at Panera Bread on August 2, 2022, for two bacon egg and cheese sandwiches when staff documented the VA was at the facility eating pancakes. On August 4, 2022, the VA’s money was used for a $24.36 purchase at TK Sushi when staff documented the VA was at the facility eating a turkey taco salad. · Between December 21 and 23, 2024, the VA’s money was used to reserve a two-night stay at a waterpark hotel and have pizza and a breakfast delivered, totaling $716.79. Staff documented the VA was at the facility and did not order food delivery between December 21 and 23, 2024. · On June 5, 2024, VA’s money was used for two Xbox gaming controllers and an Xbox headset for $591.65. The VA did not own or possess an Xbox gaming console. P1 said, “[The VA] would not cognitively be able to use and understand” an Xbox gaming console. · P1 also discovered “massive spending on the [VA’s] trust.” · The SP placed more than one online Amazon order using the VA’s trust fund and had it shipped to the facility’s main office. A receptionist at the main office told P1 that the SP had “an excessive amount of packages” delivered under the VA’s name and that the SP would then pick up the packages. However, the packages were not brought to the VA, including a dresser with a closet organizer for $152.90, a Nintendo Switch Mario Deluxe Bundle for $378.24, and a remote Christmas tree for $109.36 on December 9, 2024. · The facility determined the time span of these concerning purchases was from July 2022 to February 2025 and that over $11,000 was missing or misused from the VA’s trust fund and about $1,400 was missing or misused from the VA’s cash-on-hand and savings account. The facility planned to reimburse the VA. · P1 said that the VA had limited communication skills and “wouldn’t be aware of any” financial matters. The SP’s written statement included the following: · The SP worked with the VA for ten years and oversaw the VA’s “trust fund communication” for eight years. During that time, facility administrators routinely audited the VA’s finances and never had concerns. · The VA had a prepaid debit card, which was stored in a drawer in a locked staff office with the key hanging in the living room and accessible to all staff. Staff used the debit card to take the VA to the zoo, local attractions, waterparks, etc. Receipts were saved and given to the TM at the end of each quarter when the TM typically reloaded the debit card with $1,000. · For Amazon orders, the SP compiled a list of things the VA needed and then emailed the list to the TM, who placed the order and had it shipped to the facility’s main office. The SP then brought the items to the VA at the facility. The Amazon orders included clothing, electronics, bedding, furniture, puzzles, etc. · “I believe [the facility] is attempting to shift blame for systemic failures, particularly in oversight, documentation, and staff support, onto me. I followed the procedures I was trained in, communicated transparently, and acted in good faith.” · The SP said that s/he could have done better with the financial documentation piece but that s/he never misused the VA’s money. “I categorically deny any financial exploitation or maltreatment.” The G said that s/he did not manage the VA’s money and was not aware of overall concerns. The facility’s Funds and Property Policy stated that staff were prohibited from borrowing, using, withholding, or disposing of money belonging to a housemate. Facility documentation stated that the SP received training on the facility’s Funds and Property Policy and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was listed as a creator/drafter of the VA’s support plans and the main contact for direction or assistance regarding the VA’s support plans. Conclusion: A. Maltreatment: The VA’s financial records showed the VA’s money was used for multiple purchases between July 2022 and February 2025, which were not for the VA or consistent with the VA’s prescribed diet. Over $11,000 was missing or misused from the VA’s trust fund and about $1,400 from the VA’s cash-on-hand and savings account. Information was provided that the SP was responsible for handling all the VA’s transactions, cash-on-hand, and savings account. The SP provided a written statement regarding the allegations, in which s/he denied misusing the VA’s money and said that all staff had access to the VA’s debit card. However, the SP did not explain or give context to all the purchases using the VA’s money including times when the SP emailed the TM requesting the VA’s trust fund be used to purchase items on Amazon, which were never delivered to the VA (e.g. a dresser with a closet organizer) and/or not for the VA’s benefit (e.g. Xbox and Nintendo Switch accessories). Given that only staff persons had access to the VA’s funds, there was a preponderance of the evidence that in the absence of legal authority the VA’s funds were willfully used, withheld, or disposed. 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. The SP received training on the VA’s support plans and 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 in this report was “recurring” maltreatment because the SP misused the VA’s funds more than once from 2022 to 2025. In addition, information obtained by the Department of Human Services, showed that the SP was previously determined to be responsible for recurring financial exploitation. D. Person Regulated by Health-Related Licensing Boards Pursuant to Minnesota Statutes, section 245C.31, subdivision 1, when individuals regulated by a health-related licensing board are determined to be responsible for substantiated maltreatment under Minnesota Statutes, section 260E or 626.557, instead of the Commissioner of the Department of Human Services making a decision regarding disqualification, the licensing board makes a determination whether to impose disciplinary or corrective action under Minnesota Statutes, chapter 214. The SP is regulated by a health-related licensing board. The health-related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for recurring maltreatment and would be disqualified from direct contact if s/he were not regulated by the board. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility reviewed and updated the VA’s support plans and trained staff on the updates. The facility reimbursed the VA for his/her missing or unaccounted for funds. The SP and P2 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 by financial exploitation. The maltreatment determination is subject to appeal.
The health related board that the SP was regulated by was notified that the SP was determined to be responsible for recurring maltreatment and if not regulated by the board would be 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. On January 8, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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