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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: 1070210-HCBS (Home and Community-Based Services) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) made several Venmo transactions to a staff person (SP) for gas money the VA gave a television to the SP. The SP also smoked marijuana with the VA. Date of Incident(s): Ongoing, prior to December 17, 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 through five interviews conducted with a facility supervisory staff person (P), the SP, the VA, the VA’s friend (F), and the VA’s guardian (G). The VA enjoyed going to baseball games, watching movies, playing video games, going out to eat, swimming, and spending time with friends and family members. The VA’s diagnoses included cognitive disability, anxiety, and depression. The VA had a community job on weekday afternoons. The VA received individualized home supports with training from the facility. The VA’s Individual’s Abuse Prevention Plan stated that the VA earned money at his/her job and was able to make purchases and payments on his/her own. However, the VA needed support to manage his/her larger finances to ensure that s/he could pay all of his/her bills and afford all his/her expenses. The staff persons were to support the VA with his/her shopping needs. The VA sometimes made excessive purchases and was vulnerable to others taking advantage of him/her financially. The VA sometimes loaned money to others and trusted that they would repay him/her. The VA stated that the SP assisted the VA with grocery shopping. On two occasions the VA gave money to the SP to use to purchase gasoline because s/he “wanted to be a friend” to the SP. The SP repaid the money s/he borrowed from the VA. On one occasion, after the VA purchased a new television, the VA gave his/her old television to the SP. The VA offered to give the television to the SP and the SP did not ask for the television. The SP later returned the television to the VA. The VA never paid for the SP’s meals at restaurants and did not smoke marijuana with the SP. The G stated that when the VA began receiving services from the facility, the G told the staff persons that the VA had a problem with impulsive spending and asked that the staff persons “help [the VA] with that.” In December 2025, the VA asked the G for additional money because s/he needed money for transportation to his/her job. When the G checked the VA’s Venmo account, s/he saw four transfers of money, totaling $116, made to the SP. The VA also gave a television to the SP, but after the facility was notified about the VA giving the television to the SP, the SP returned the television to the VA. The F stated that s/he knew the VA for several years and approximately 1 ½ years previously the VA introduced the F to the SP, who was the VA’s IHS worker. The VA sometimes “hung out with” the SP outside of the hours the SP worked with the VA. On one occasion, the VA asked the F to tell the G that the F and the VA went to a restaurant where the VA spent $73 for their meal, even though the F did not go to the restaurant with the VA. The F believed that the VA paid for the SP’s meal. One of the VA’s other friends told the F that the VA was buying items for the SP and giving $50 gas station gift cards to the SP. The P stated that the SP received training on the VA’s vulnerability regarding financial situations and that the VA equated friendship with giving gifts. Once the P became aware that the VA gave money to the SP, the P talked to the SP, who told the P that s/he knew s/he should not borrow money from the VA. The VA told the P that s/he offered money to the SP. The SP did not provide proof to the P that s/he repaid the VA for the money s/he borrowed, but the P believed the G had proof that the money was repaid. The SP stated that s/he primarily provided transportation for the VA to go grocery shopping. The SP frequently used his/her personal car when taking the VA shopping, but s/he was reimbursed for the mileage by the facility in the following paycheck. The VA knew that the SP was in financial difficulty and “insisted” on helping the SP several times even though the SP told him/her not to. The SP always paid the VA back “as soon as [s/he] could” with either cash or Venmo. On one occasion, the VA asked the SP if s/he wanted the VA’s old television and the SP took it. The G later asked the VA for the television so the SP returned the television to the VA. The SP did not receive training on “the exchange of money” between the staff persons and clients. The VA sometimes asked the SP to “hang out” outside of the SP’s work hours and the SP occasionally spent extra time with the VA going to the mall, movies, or the state fair. The SP never smoked marijuana with the VA. The G’s review of the VA’s Venmo account provided the following information: · September 22, 2025 - $21 sent to the SP. · November 17, 2025 - $45 sent to the SP. · November 17, 2025 - $30 sent to the SP. · November 26, 2025 - $20 sent to the SP. Total: $116 The facility’s Personal Funds and Property policy stated that the staff persons could not borrow money or purchase personal items from the clients. The client funds were to be kept separate from the staff persons’ funds. The facility’s Conduct of Employees policy and procedure stated that theft, destruction, or inappropriate removal of a client’s property was unacceptable. Borrowing money or purchasing personal items from a client was also unacceptable. Facility documentation showed that the SP and the P 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: On four dates between September 22 and November 26, 2025, the VA sent money totaling $116 to the SP though Venmo. In December 2025, the G was able to see those transactions when s/he checked on the VA’s Venmo account after the VA told the G that s/he needed money for transportation to his/her job. The VA also told the G that s/he gave his/her old television to the SP after the VA purchased a new one. The G asked the VA to have the SP return the television and told the P that the VA gave money to the SP on several occasions. Although the SP and the VA each stated that the VA loaned the money to the SP and that the SP repaid the VA for the money s/he borrowed, the VA’s plans stated that the VA was vulnerable to others taking advantage of him/her financially. The VA needed support from the staff persons to manage his/her finances and to ensure that s/he could pay all of his/her bills and afford all his/her expenses. 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 that the VA’s Venmo account showed that the VA transferred money to the SP on multiple occasions that even if the SP paid the money back to the VA, the money was unavailable to the VA when s/he needed it prior to it being paid back, 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 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 the VA used Venmo to transfer money to the SP on four 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. The facility reimbursed the VA for $116. 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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