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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: 1070880-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Samantha Wueste/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) used money belonging to three vulnerable adults (VA1, VA2, and VA3) for the SP’s personal use. Date of Incident(s): August and September 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 Facility A and Facility B; and through five interviews conducted with VA1’s, VA2’s, and VA3’s guardians (G1, G2, and G3, respectively), a supervisory staff person (SP), and an administrative staff person (P2). A supervisory staff person (P1) provided information at the outset which was included in this report. The DHS investigator met VA3, and s/he declined to be interviewed. VA1 and VA2 were not interviewed due to their limited communication skills. VA1’s, VA2’s, and VA3’s support plans, including Self-Management Assessments, provided the following information: · VA1-VA3 lived at either Facility A or Facility B, which were owned and operated by the same license holder, and each provided at least one staff person 24 hours a day for the clients who lived there. Staff helped the clients, as needed, manage medications and appointments, prepare meals, facilitate community outings, and complete daily living activities. · VA1 and VA2 were each “non-verbal” and might use gestures or signs to communicate. VA1 liked staying active and going to the zoo; and VA2 liked listening to music and going for walks with staff. VA1 and VA2 each did not understand the value of money. Facility A managed VA1’s and VA2’s finances by keeping their credit cards and receipts in a lockbox and maintaining receipts for purchases. A supervisory staff person completed “routine” financial audits, and all staff were required to report any concerns. · VA3 communicated verbally and enjoyed shopping and socializing with peers. VA3 had a limited understanding of budgeting and might make “impulsive” purchases. Facility B helped VA3 with budgeting and creating shopping lists. VA3 might carry his/her own credit card or cash when in the community but afterward, staff secured the items in a lockbox for VA3 to “reduce the risk of financial exploitation.” · VA1’s, VA2’s, and VA3’s diagnoses included intellectual disabilities. G1-G3 each said that they did not have concerns with Facility A’s and/or B’s overall care and supervision. P1 and P2 provided the following information: · P1 said that on February 10, 2026, s/he completed a financial audit of the clients’ funds at Facility A and Facility B. P2 said that the audit was in response to concerns about the SP’s use of the facilities’ household credit cards. · The SP was responsible for completing monthly audits of the clients’ funds at Facility A and Facility B. However, during P1’s audit on February 10, s/he discovered that these were not always happening. There was no documentation that the SP audited VA3’s funds for July, August, and September 2025. The SP did audit VA1’s and VA2’s funds during that timeframe and marked them as having no concerns. · However, when P1 and P2 looked at VA1’s, VA2’s, and VA3’s ledgers and statements, there were unexplained purchases. On August 5, 2025, VA1, VA2, and VA3 each had a “large” purchase at the same discount furniture store without any saved receipts. VA1 spent $800 at the furniture store, VA2 spent $900, and VA3 spent $1000. When P2 obtained a receipt from the store, s/he saw that the clients’ credit cards were pooled together to purchase a sectional couch, which was delivered to the SP’s home address. · VA3 told P1 and P2 that s/he had never been to the discount furniture store and had no awareness of his/her money being used at a furniture store. · P1 and P2 each said that they asked the SP about the furniture store purchase and the SP said that the couch was purchased for the SP’s personal use but that s/he must have “accidentally” used VA1’s and VA2’s (sans VA3) credit cards. All the clients’ credit card information was stored on the SP’s laptop, and the SP had electronically selected various cards when s/he purchased the couch online and did not verify if the cards belonged to the SP. Regarding VA3’s furniture store purchase, the SP said that this was for a bed that VA3 wanted to use when s/he visited G3’s house. However, VA3 and G3 each told P1 and P2 that they were not aware of a bed purchase, and no furniture was delivered to G3’s house. · VA1’s financial records showed that on September 8, 2025, his/her credit card was used to make a $287.60 purchase at Walmart.com for fall décor (e.g., stacked yarn pumpkins and oak leaf garland), vanilla candles, and a 50-inch TCL TV, all of which VA1 did not have in his/her possession. P2 obtained a receipt, which showed that the order was placed online by the SP and picked up by the SP the following day. P1 and P2 each said that they checked Facility A and did not find a TV, vanilla candles, or fall décor for VA1. VA1 had/has never owned a TV. · P2 said that there was no information that any other clients had concerning purchases or misused funds. The SP provided the following information: · Since 2023 or 2024, the SP provided some level of supervisory help at Facility A and Facility B. The SP trained employees, wrote the clients’ support plans, and took the clients to medical appointments. · The SP frequently helped the clients with online shopping and had several of the clients’ credit card information saved in the SP’s online accounts, like Walmart.com. The SP did not have the clients’ physical credit cards. The SP was not aware of concerns with the clients’ credit cards or unexplained charges until s/he was informed through this investigation. The SP said that if a client’s credit card was used by the SP for the SP’s personal purchase, it was an “accident” and “not intentional.” “I just put it on the wrong card” when making the purchase online. The SP did not typically look at receipts after making a purchase for him/herself. The SP said that s/he was “more than happy to rectify” any unexplained charges or missing money. · Regarding VA1’s purchase of fall décor and vanilla candles, the SP said that G1 had asked the SP to “spruce things up” in VA1’s bedroom and so the décor was purchased for that purpose and should be in VA1’s bedroom. · Regarding VA1’s purchase of a 50” TV, VA1’s TV had previously broken and so VA1 ordered a new one online. The TV was delivered to Facility A and was waiting in its original box for maintenance to hang it in VA1’s bedroom. · Regarding VA3’s purchase of a bed, the SP said that VA3 had cancelled the order and so the bed was never delivered. VA3 should have been refunded the cost of the bed from the store. The SP added that VA3 was not a reliable reporter of information and might say that s/he did not purchase something, when s/he did make the purchase. [Note: There was no information that VA3 received a refund from the furniture store.] Facility A’s and B’s financial policies and procedures stated that staff were prohibited from borrowing money from a client. The supervisory staff person (e.g., the SP) was to conduct regular spot checks and a monthly formal audit of the finances of each client. The supervisory staff person (e.g., the SP) was to ensure that each expenditure was appropriate, documented with a corresponding receipt. An administrative staff was to complete a financial audit each time they “formally” visited the facility. Facility A and B documentation stated that the SP received training on the Facility A’s and B’s financial policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was listed on VA1’s, VA2’s, and VA3’s support plans as being the creator or a reviewer of the document(s). The SP’s position description stated that s/he was responsible for ensuring the overall financial management of assigned area and services and proper management of the clients’ finances. Conclusion: A. Maltreatment: Information was provided by receipts and P1, P2, VA3, and G3 that showed the funds belonging to VA1, VA2, and VA3 were used for purchases that were not in their possession and did not benefit them. The SP said that s/he “accidentally” charged his/her personal expenditures to the clients’ credit cards. However, the SP was a supervisory staff person, who was responsible for ensuring the overall financial management of assigned area and services and proper management of VA1’s, VA2’s, and VA3’s finances. The SP was aware that each client’s credit card information was stored on the SP’s laptop; however, s/he did not verify which credit cards s/he was using for his/her personal expenditures. Instead, the SP used the clients’ money to purchase such things as a couch, which was delivered to the SP’s house; and then the SP did not discover the “accident” during his/her monthly audits of the clients’ funds. The SP’s conduct was in violation of Facility A’s and B’s financial policies and procedures and with the SP’s role as a supervisory staff person, and it was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP described the incidents as “accidents,” the SP was responsible for ensuring this did not happen and/or catching it and correcting it during his/her monthly audits, which did not happen. The SP also stated that some of the items were at the facility, yet the items, including the 50” TV, vanilla candles, and fall décor, were not located at the facility. Therefore, there was a preponderance of the evidence that in the absence of legal authority the funds of VA1, VA2, and VA3 were willfully used. 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 and was listed on VA1’s, VA2’s, and VA3’s support plans as being the creator or a reviewer of the document(s). The SP’s position description stated that s/he was responsible for ensuring the overall financial management of assigned area and services and proper management of individual served finances. The SP was responsible for maltreatment of VA1, VA2, and VA3. 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. The maltreatment did not meet the definition of being serious maltreatment, but the SP was responsible for the financial exploitation of VA1, VA2, and VA3, which made it recurring maltreatment. 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: Facility A and B completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at Facility A or B, and all clients were reimbursed by the facility for their misused funds. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified by the Office of Inspector General that s/he was responsible for recurring maltreatment and would be disqualified if not licensed by a health-related board. 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 that the SP 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 were s/he not regulated by the board.
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