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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: 1097394-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069248-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a staff person (SP) used a vulnerable adult’s (VA) bank account to make multiple transactions on Cash App. Date of Incident(s): May 12 to July 2, 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 two interviews conducted with a facility supervisor (P), and the VA. The SP was contacted to request an interview, but s/he did not respond. Facility documentation showed the VA enjoyed watching television shows. The VA was diagnosed with developmental disabilities, anxiety, and had a history of alcohol use disorder. The VA had significant short-term memory loss and confusion. The VA did not have a representative payee, but struggled to understand paperwork and how to complete documents. The VA was not subject to guardianship. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to financial exploitation. The facility trained staff persons on financial exploitation upon hire and on an annual basis. The VA’s Funds and Property Authorization stated the facility was authorized to assist the VA with the safekeeping of funds or other property, and staff persons were not to borrow money from the VA. Cash App was a mobile payment application available on mobile devices. Cash App allowed users to send and receive money to other persons, make purchases, and invest money. LE records provided the following information: · On July 1, 2025, the VA’s bank account was discovered to have a balance of $0 after multiple Cash App withdrawals. · The VA’s bank statements showed s/he did not have Cash App transactions prior to May 12, 2025. From May 12 to July 2, 2025, there were 61 Cash App transactions, which totaled $1923. Within the description of the Cash App transactions was a portion of the SP’s name, which was spelled uniquely. · The VA denied having Cash App, but said s/he provided his/her debit card to the SP to order Domino’s Pizza. The VA did not remember any other time s/he provided his/her debit card to another staff person. A Domino’s purchase was located in the bank statement at the same time as the Cash App transactions started. · The facility scheduled confirmed the SP was scheduled on May 12, 2025. · The SP denied s/he used the VA’s debit card, but said s/he did order pizza with the debit card. The SP said s/he used Cash App in the past, but his/her account was hacked. The SP estimated the last time s/he used Cash App was approximately a month and a half ago. The SP attempted to login to Cash App while interacting with LE, however LE observed the name of the person did not match the SP’s name, but rather it was a community person’s name. · LE had prior contacts with the community person. The community person was contacted and said s/he had known the SP in the past, but had no contact for a few years. · The P informed LE that the P heard that the SP had changed his/her Cash App name to that of the community person. · LE obtained information from Cash App which showed the SP’s account had a name change on July 2, 2025. The name change was renamed to that of the community person’s name. Additionally, previous names matched that of the SP’s Cash App names, and the SP’s phone number was on record of the Cash App account. The SP’s Cash App account name was changed on July 2, 2025, the same date in which the P contacted the SP about the suspicious Cash App transactions observed on the VA’s account. · LE found the SP’s Cash App account had the VA’s debit card as the payment source for transactions from May 2 to July 2, 2025. Additionally, there were GPS coordinates of the SP’s phone to the facility address, as well as other nearby areas. Based on GPS, and transaction record there were indications that the Cash App account was opened while at the facility, as well as the SP’s residence. Furthermore, there were attempted transactions to a PayPal account using the VA’s name, and transactions made to a second community person, whom was a known associate with the SP’s. The transactions also showed the address of the second community persons. · LE believed it was more likely than not the SP attempted to use the community person’s name to cover up a link to the transactions that were completed. LE determined there did not appear to be any indications that the SP’s Cash App account was hacked based the consistency of transactions. · LE sent his/her report to Polk County Attorney's Office for review for charging the SP. The facility completed an Internal Review (IR) which provided the following information: · It was discovered the VA’s bank account had multiple unauthorized transactions totaling $1923. · The P reviewed the VA’s phone applications, and the VA did not have a Cash App account on his/her phone. · The VA was responsible for his/her own money, without the assistance of staff persons. · The VA said s/he gave the SP his/her “card” to order pizza, but the SP stated the VA used his/her cell phone to make the order, and the VA gave his/her debit card information over the phone. The SP said the VA used the cell phone instead of the facility landline because it was “easier at the time.” · The SP denied using Cash App to make a purchase for the VA, and denied using the VA’s debit card on his/her phone. The SP said s/he had been “locked out” of his/her Cash App, and his/her email and phone number changed so s/he no longer had access to his/her Cash App. The P and SP completed training on the VA’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: It was reported that from May 12 to June 2, 2025, the SP completed 61 Cash App transactions, totaling $1923 using the VA’s bank account. The SP denied using the VA’s debit card to make Cash App transactions. The VA’s bank statement showed the Cash App transfers were sent to a person with a portion of same first name as the SP. LE records showed it was more likely than not the SP changed his/her account name on Cash App, and although the name on the Cash App appeared to a community person, there was no other information that person had contact with the VA, and therefore was unlikely to have access to the VA’s debit card. LE records also indicated there were also transactions to a known associate of the SP’s, transaction attempts to the SP’s PayPal account, and GPS that showed location of the transactions, which were in direct connection of the SP’s known addresses. Given the information from LE and that the SP’s first name, which had a unique spelling, was on the VA’s bank statement description of the Cash App transactions, there was a preponderance of the evidence that in the absence of legal authority the SP 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 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 as the SP completed multiple transactions using the VA’s debit card. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility did not complete additional staff training, and there was no similar past events. The facility took corrective action and added information to facility policies regarding financial applications such as, but not limited to Venmo, Cash App, and PayPal. 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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