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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: 1069222-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) took checks from a vulnerable adult (VA) in the amount of $3,225. It was also reported that the SP took money from the VA’s bank account totally $2,650. Date of Incident(s): Ongoing, prior to July 16, 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 August 6, 2025; from documentation at the facility; and through five interviews conducted with three facility supervisory staff persons (P1 – P3), the VA, and the VA’s guardian (G). Attempts were made by telephone and mail to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed traveling, going on community outings, and spending time with his/her family members. The VA’s diagnoses included Down syndrome, mild developmental disability, mild cerebral palsy, and major depressive disorder. The VA worked at a community job or went to a day program four days each week. The VA’s Individual Abuse Prevention Plan stated that the VA was eager to please others and might be easily persuaded into situations that could place him/her at risk. The VA had limited understanding of the value of money. While the VA understood that s/he needed money to purchase items, s/he had significant limitations in financial concepts and was unable to manage his/her finances independently. The VA’s petty cash was locked in a cupboard at the facility. Once a week, the VA was provided $40 to spend without the need to collect receipts. The staff persons maintained a monthly financial ledger for the VA listing his/her expenses. The VA had two hours of unsupervised time at the facility and up to two hours unsupervised time in the community for taking walks, riding his/her bicycle, or going to a movie. The VA stated that the SP sometimes took the VA to the bank and to stores such as Walmart. The SP helped the VA purchase pop and clothing. The VA did not recall if the SP ever asked the VA to purchase anything for the SP. P1, P2, and P3 provided the following information: · P3 stated that in 2021 the SP began working at the facility. P2 stated that in December 2020 the VA opened a checking account. When the VA received a check, a supervisory staff person deposited the check into the VA’s bank account. If cash was withdrawn for the VA to use, that amount was documented on the VA’s petty cash ledger and the cash was placed in the VA’s petty cash fund. As the VA spent the money, the staff persons documented the withdrawals on the petty cash ledger and kept the receipts with the ledger. Each month the petty cash ledger was reviewed by an administrative staff person. P2 learned that there were three authorized signers on the VA’s checking account. Two of the signers were former supervisory staff persons who no longer worked at the facility and the third was the SP, who was added after s/he began working at the facility. After the discrepancies were found in the VA’s financial records, all of the signers were removed from the VA’s checking account. · P1 stated that on one occasion s/he planned to take the VA shopping and while at the facility saw that the VA had “a couple” of unpaid bills. P1 called the VA’s employer to ask how the VA was paid and was told that the VA had automatic deposit of his/her paychecks into a checking account. P1 called P3 and asked whether the VA had a checkbook for his/her checking account. P3 told P1 that there was a “check holder” in the main office that contained one voided check, but all of the other checks were “torn out.” P1 had no information as to what happened to the other checks. P1 then took the VA to the bank to order checks and get a bank statement. The bank statement showed that there were several withdrawals from the VA’s checking account. P1 also learned that not all of the VA’s employment checks were deposited into the VA’s bank account and the bank statement did not match the facility’s petty cash ledger. P1 gave the VA’s financial information to an administrative staff person (P4). P2 stated that on July 16, 2025, P4 told P2 that there appeared to be money missing from the VA’s checking account. · P1 stated that every month the VA received two checks in the mail from social security and from his/her rep payee. When P1 reviewed the VA’s bank statements, s/he found that in some months, only one check was deposited into the VA’s checking account. P3 believed that on numerous occasions beginning in December 2024, the SP took the VA to his/her bank to cash some of the checks the VA received in the mail. The SP then kept the money from the checks so nothing was documented as being deposited or withdrawn from either the VA’s checking account or petty cash fund. The SP ensured that “some” of the VA’s employment paychecks were deposited in the VA’s bank account so that money could be placed in the VA’s petty cash fund for his/her personal needs. · P2 stated that the VA’s bank statements showed that items were purchased at JCPenney, but P2 did not find any clothing or other items at the facility that appeared to be purchased at JCPenney. The VA liked to shop for his/her clothing at thrift stores, Walmart, and garage sales. P1 stated that when s/he recently took the VA shopping for clothing, the VA’s clothing was “pretty worn” and P1 did not believe the VA’s money had been spent on clothing. Not all of the purchases documented in the VA’s petty cash fund had corresponding receipts. Other receipts were “found” elsewhere in the facility and did not have any identifying information as to what businesses they were from or who made the purchases. · P3 stated that when s/he looked in the facility for information about the VA’s financial records, s/he found some of the SP’s banking information which showed money going into the SP’s bank account and a receipt for a PlayStation that corresponded to dates when money was taken from the VA’s bank account. · P1 stated that although the SP had access to the other clients’ funds, no money was missing from their financial accounts. P2 stated that another client’s (C’s) guardian reported to P2 that “someone” was attempting to use the C’s debit card, but that the bank stopped the card from being used. No information was provided as to who attempted to use the C’s debit card and no money was taken from the C’s bank account. The G stated that the SP sometimes scheduled the VA to take trips without informing the G about the trip plans. The facility did not provide the G with receipts for the VA’s purchases even though the G wanted to know what the VA’s money was spent on. The VA did not often purchase new clothing for him/herself. The facility’s Internal Review provided the following information: · P4 reviewed the VA’s financial records and found that each month, the VA received a check for approximately $460 from his/her rep payee for his/her personal needs. That money did not show up in the VA’s petty cash ledger. In addition, there were multiple amounts ranging from $250 to $500 that were withdrawn at the bank using bank withdrawal forms. Whenever the VA went to his/her bank s/he was accompanied by a staff person. The facility requested surveillance video footage from the bank to identify who accompanied the VA, but had not received any video footage from the bank. · The VA told P2 that s/he typically spent his/her money on soda, food, and clothing and did not have many additional expenses. The VA usually went shopping with the SP, but s/he was unable to recall how often s/he went shopping. The VA told P2 that s/he did not give his/her money to any staff person. · P2 estimated that the final restitution amount owed to the VA by the facility would be approximately $5,200. P2’s review of the VA’s bank statements and petty cash ledger provided the following information: · December 24, 2024 – Cash withdrawal of $110 from the VA’s bank account with no corresponding deposit to the VA’s petty cash fund. · January 22, 2025 – Cash withdrawal of $110 with no corresponding deposit to the VA’s petty cash fund. · January 29, 2025 – A deposit of $105 was made to the VA’s petty cash fund. · February 24, 2025 – Cash withdrawal of $110 with no corresponding deposit to the VA’s petty cash fund. · April 22, 2025 – Cash withdrawal of $110 with no corresponding deposit to the VA’s petty cash fund. · April 30, 2025 – A $425 check was cashed and recorded in the VA’s petty cash ledger. A separate ledger entry for a withdrawal of $435 was marked “Fargo.” · May 17, 2025 – The VA’s petty cash ledger had an entry for $284.75 marked “Fargo” which had no corresponding entry on the VA’s bank statements. · May 22, 2025 – Cash withdrawal of $110 with no corresponding deposit to the VA’s petty cash fund. · June 24, 2025 – Cash withdrawal of $110 with no corresponding deposit to the VA’s petty cash fund. · July 16, 2025 – The VA’s petty cash ledger showed a deposit of $650, which had no corresponding entry on the VA’s bank statements. · Between December 23, 2024, and June 12, 2025, eight cash withdrawals totaling $2,650 were taken from the VA’s checking account. All of the withdrawals were associated with the SP’s initials and the SP worked at the facility on each of the dates. Two of the withdrawals totaling $540 corresponded to entries in the VA’s petty cash ledger. One $200 withdrawal corresponded to a deposit to the VA’s petty cash fund three days after the withdrawal. The remaining $1,910 in cash withdrawals had no corresponding same-day entries in the petty cash ledger. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: A. Maltreatment: There were three authorized signers on the VA’s bank account. Two of the signers no longer worked at the facility and the SP was the third authorized signer. Between December 23, 2024, and June 12, 2025, eight cash withdrawals totaling $2,650 were taken from the VA’s checking account. All of the withdrawals were associated with the SP’s initials and the SP worked at the facility on each of the dates. In addition, not all of the VA’s paychecks were deposited into his/her bank account and not all withdrawals from the VA’s bank account had corresponding deposits shown on the VA’s petty cash ledger. There were no receipts to show that the VA made purchases with the money. After reviewing the VA’s bank account information and his/her petty cash ledger, P2 estimated that the final restitution amount owed to the VA by the facility would be approximately $5,200. Given that that the VA was at risk of financial exploitation and did not have a good understanding of his/her finances, including budgeting and banking, and would not recognize mismanagement of his/her finances; and that only staff persons had access to the VA’s accounts and funds, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used, withheld, or disposed of 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. The SP was the only staff person working at the facility that was an authorized signer on the VA’s checking account and several withdrawal forms used to withdraw money from the VA’s bank account included the SP’s initials. 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 money was taken from the VA’s bank account on numerous occasions. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incidents, the staff persons received additional training on client financial safeguards and it was ensured that the client financial records were checked each month. 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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