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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: 1071956-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall Suspected Maltreatment Reported: It was reported that three vulnerable adults (VA1, VA2, and VA3) had questionable ATM withdrawals and purchases that were made by a staff person (SP). Date of Incident(s): Multiple dates prior to March 5, 2026. 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 visits conducted on March 26, 2026 and April 3, 2026; from documentation at the facility and law enforcement records; and through eleven interviews conducted with three vulnerable adults (VA1, VA2, VA3), three facility supervisory staff persons (P1, P2, the SP), two facility staff persons (P3, P4), VA1’s guardian (G1), VA2’s and VA3’s guardian (G2), and a law enforcement officer (LEO). VA1 enjoyed watching movies, gaming, sports, camping, and fishing. VA1’s diagnoses included a mild/moderate intellectual disability, attention-deficit hyperactivity disorder, and anxiety. VA1 was susceptible to financial exploitation and may not recognize mismanagement of his/her finances. Staff were to keep VA1’s checkbook balanced and retain receipts when purchases were made. VA2 enjoyed watching tv, listening to music, and going out to eat. VA2’s diagnoses included a severe intellectual disability and conduct disturbance. VA2 was legally blind. VA2 was susceptible to financial exploitation and would not know if his/her funds were mismanaged. Staff were to physically assist VA2 with all purchases which included keeping receipts and maintaining and balancing VA2’s accounts. VA3 enjoyed basketball, bowling, softball, playing video games, and going out to eat. VA3’s diagnoses included a mild intellectual disability, anxiety disorder, and unspecified mood (affective) disorder. VA3 was susceptible to financial exploitation and had limited understanding of financial management. Staff were to keep VA3’s checkbook balanced and retain receipts when purchases were made. The facility’s Management of an Individual’s Monetary Resources Policy said that “money belonging to people served” was to be “kept secure and accountability ensured.” “Cash on hand per person should not exceed $50 or as otherwise indicated on the person’s financial transaction consent.” Any amount kept on hand that exceeded $50 required approval from a supervisory staff person. If a receipt could not be obtained, “a voucher will be completed with detailed information and a confirmation signature.” Receipts and vouchers were to be dated with the name of the vendor, what items were purchased, and the total expenditure. If a staff person assisted with the transaction, that staff person was to write their name on the receipt. If an individual supported received cash, the individual supported was to sign a “voucher confirming they received the cash.” If an individual supported was “unable to sign and whenever possible, another person will co-sign the voucher as a witness.” The facility was two levels with a basement. VA1’s and VA3’s bedrooms were on the basement level and VA2’s bedroom was on the main level. A staff office was on the main level. The VAs funds were kept in a binder on a bookshelf in the staff office. The facility’s internal review, the VAs’ bank statements, the VAs’ ledgers, and the VAs’ progress notes provided the following information: · From August 2, 2024, through March 5, 2026, VA1 had $5,205.40 in questionable ATM transactions and purchases that were completed by the SP. From January 12, 2024, though March 4, 2026, VA2 had $1,247.25 in questionable ATM transactions and purchases that were completed by the SP. From January 6, 2024, through February 28, 2026, VA3 had $5,371.77 in questionable ATM transactions and purchases that were completed by the SP. · On March 25, 2026, the SP provided P1 with three ATM receipts for VA2. The ATM receipts were one from March 2, 2026, for $143 and two for March 3, 2026, for $83 and $81. The SP also gave P1 a $320 gift card for VA2 and said that the gift card was for VA2’s “TV subscriptions.” · There were numerous transactions that the SP entered for the VAs where progress notes did not indicate the respective VA went out in the community when or where the transaction happened. The SP entered casino transactions for VA1 on February 22 and 28, 2026, VA2 on February 22, 2026, and VA3 on February 28, 2026. For both days, progress notes did not indicate that the VAs went out in the community. For the internal review, P4 and two other staff persons who worked on those days were asked whether the VAs went to the casino and all said that the VAs had not. P4 and another staff person added that if a casino outing would have occurred, they would have put it in that VAs progress note. At 8:47 p.m. on February 28, 2026, VA3 had a transaction at a local convenience store for $20 in cash back and pizza and soda. P4 worked the evening shift on February 28, 2026, and said that VA3 did not go to the convenience store. · The SP made numerous ATM transactions for VA1, VA2, and VA3 that were late at night or early in the morning where progress notes indicated that the VAs were at the facility. The late night and/or early morning ATM transactions were made mostly at bars. · There were numerous cash transactions for the VAs entered by the SP where a missing receipt voucher was created by the SP, and the amount did not include any change from the transaction. Several of the missing receipt vouchers did not include a signature from the respective VA and only included the SP’s signature. P1 provided the following information: · By the 15th of each month, the SP would create a monthly cash resource record (MCRR) for each of the VAs for the previous month and provide it to P1. The MCRR included information for all the respective VAs accounts. P1 would go to the facility and complete an audit of the VAs financials once per month after the MCRR was completed. P1 would go through the VAs bank account statements, ledgers, and receipts to ensure that “everything matches up.” · On February 26, 2026, the SP provided P1 with the VAs MCRR for January 2026. P1 reviewed the MCRR for VA1 and noticed that there was a cash transaction for $81 with “cash camp” listed as the purchase. P1 was confused as to why VA1 would need cash collected for camp in January as VA1 attended camp in July and for which VA1 had not paid a camp fee yet. P1 asked the SP why VA1 got cash for camp and the SP said that it was for the “camp canteen” and that the cash was in VA1’s pouch in the financial book. For VA2, P1 noticed that there was a $120 cash transaction for the casino. P1 had previous conversations with the SP with $20 being the limit when taking individuals to the casino and asked the SP why more than $20 was taken out. The SP said that s/he “forgot” with a “chuckle.” · On March 5, 2026, P1 trained P2 at the facility. In the internal review, P1 said that P2 provided P1 with three missing receipt vouchers that the SP had given P2. Two receipts were for the casino, and one receipt was for money sent to a family member. P2 said that VA1 refused to sign them and told P2 that s/he did not send money to a family member nor had s/he been to the casino. P1 told this investigator that s/he reviewed the financial book and saw that VA1 and VA3 had a “few cents” in their cash pouches while VA2 did not have any cash. VA1’s checking card was missing from the financial book and was not found in the staff office. P1 looked at the receipts “closer” and noticed that there was a pattern of missing casino receipts for the VAs where a missing receipt voucher was created by the SP. · P1 went back to the facility around 5:30 p.m. and when s/he entered the facility, the staff person working said, “You just missed [the SP].” P1 went to the staff office to check the medical folder for appointments and found VA1’s checking card “shoved in the little front sleeve” of the medical folder. P1 did not see the checking card in the medical book earlier in the day when s/he looked through it. · The VAs’ cards and cash were kept in the financial book in the staff office. Staff would hold onto the VAs cards and cash when out in the community. When making purchases, the VAs would be given their card/cash and would buy the item and collect a receipt. The receipt and card/cash would be given back to the staff after the purchase was made. · P1 thought that the purchases for the VAs were “actually true” and did not question them until s/he saw the $81 ATM transaction for VA1 and the $120 casino transaction for VA3 when s/he reviewed the January and February 2026, ledgers. P3 provided the following information: · P3 said that s/he took the VAs out for purchases but could not remember the last time s/he used cash for a purchase. The VAs would use their debit cards and the only places that they used cash would have been for a fair or rodeo the past summer. P3 took an individual served to the bank to get cash a week or two prior to speaking with this investigator (Investigator’s note: P3 was interviewed on March 26, 2026) and that was the only time s/he assisted an individual supported to get cash in 2026. · Over the two years that P3 worked with the SP, a VA’s debit card was not at the facility a “handful of times” but P3 “wasn’t counting” (Investigator’s note: P3 did not say which of the VAs’ cards were not at the facility). P3 would contact the SP, and the SP would drop off the card at the facility. The SP “sometimes” would say that s/he “forgot it in my pocket” or that “they went somewhere the night before.” · P3 said that the VAs’ debit cards and cash were kept in a binder in the staff office. Each VA had his/her own money pouch and ledgers in the binder. When a purchase was made, a receipt was to be collected and when back at the facility, the transaction was entered into the respective ledger in the financial book. On the receipt, staff would circle the date of the transaction and sign the receipt. P3 said that the ledgers were not always replaced at the beginning of each month, so s/he would circle the date on the receipt, sign the receipt and put it in the respective VAs’ money pouch. The SP would enter the transaction when a new ledger was put in the financial book. · If an individual wanted to make a purchase that was larger than $50, P3 would contact the SP who would contact the individual’s guardian for approval. The SP would then tell P3 whether it was okay to complete the purchase. P2 provided the following information: · On March 5, 2026, P2 worked the morning shift. P1 came to the facility to help organize the staff office. At an unknown time during the day, P1 told P2 to lock up the VAs’ financials in a cabinet in the staff office. P1 said that s/he could not provide further information to P2 about why the VAs’ financials had to be locked up. The SP did not come to the facility on March 5, 2026, when P2 was there. · On an unknown date after March 5, 2026, P1 notified P2 that VA2’s bank account had a negative balance. P2 checked VA2’s ledgers and receipts and VA2’s bank account balance should have been $126 or $124 but the bank statement showed that VA2’s account balance was negative “$200 something.” The bank statement had ATM withdrawals from the “beginning of March [2026],” for which there were no receipts at the facility. VA1 said that his/her debit card and cash were kept in VA1’s pouch in the financial folder which was kept in the staff office. VA1 said that s/he would go to the casino “once a month” and would spend $40 in slot machines. VA1 denied asking anyone to make purchases for him/her and denied asking anyone to get cash for him/her. VA1 said that s/he was present when purchases were made for VA1. For the internal review, VA1 said that s/he used an ATM at a local gas station and denied that other people helped VA1 get cash. VA2 did not know where his/her money was kept and said, “Yes” when asked if staff kept his/her money. VA2 said that s/he was present when purchases were made for VA2 and said, “No” when asked if s/he told anyone that they could spend his/her money without VA2 present. VA3 pointed to a cabinet in the staff office when asked where his/her debit card was kept and said, “In the bank,” when asked where his/her cash was kept. VA3 said that s/he would go to the casino “sometimes” but “not in a while.” VA3 said, “No” when asked if anyone could make purchases for VA3 without him/her present and shook his/her head no when asked if anyone could get cash for him/her without VA3 present. P4 said that the SP assisted the VAs with purchases and “sometimes” P3 assisted. P4 said that s/he “used to” take the VAs out to make purchases but in the “last couple years,” it was the SP or P3. The SP took VA3 to the casino in what P4 thought was January 2026 but was not sure. G2 said that VA2 would require staff assistance with making purchases. VA3 needed assistance with balancing funds to make sure VA3 had enough for purchases. VA2’s and VA3’s debit cards were kept in the staff office at the facility. VA3 may have “a little bit of money” in his/her wallet but typically did not have much unless VA3 was shopping with staff. VA2 typically did not have cash at the facility and did not keep money on him/herself. VA2 would be able to provide “minimal” information. VA3 may not give an “exact” answer and might struggle with “time perception.” G1 was newer to working with VA1 and was not sure where VA1’s funds were kept at the facility. VA1 may not remember exact dates when recalling events. The SP provided the following information to this investigator and the LEO, and for the facility’s internal review: · The SP said that each of the VAs had their own money pouch that was kept in the financial binder in the staff office. Purchases made with the VAs fund without the individual present happened “once in a while” and that after the transaction happened, the SP would “tell” the respective VA and “show them.” For the internal review, the SP said that the VAs used cash to “go to the casino” and that there was “no other reason they need cash.” · The LEO asked the SP why there were numerous times that receipts were not handed in for the VAs’ transactions and the SP said, “We make our receipts” if they did not have one. The LEO clarified that the SP was talking about a missing receipt voucher and asked who signed the missing receipt vouchers. The SP said that the staff person and the respective VA would sign the missing receipt voucher and put them in the respective VA’s money pouch. VA1 and VA3 signed themselves where VA2 had a stamper that staff would use with VA2 present. The SP was asked why there were several missing receipt vouchers for VA2 where only the SP signed, and the SP said that VA2 did not always have a stamp. This investigator clarified that there were missing stamps from VA2 on 2026 missing receipt vouchers, and the SP said, “I can’t remember those.” When asked why signatures were missing for multiple missing receipt vouchers for VA1 and VA3, the SP said that s/he would create them at the “end of the month” and if s/he forgot to create one or get a signature from the VAs, P1 would tell him/her. · The SP was asked about a cash transaction on June 27, 2025, where VA3 spent $100 on “ticket, food, shirts,” where there was no change added back to the ledger and a missing receipt voucher was created as there was no receipt. The SP said that VA3 “spent it all.” The SP was asked why there was a pattern of cash transactions for the VAs where there was no change added back to the ledger and the SP said again that the VAs “spend it all.” · On February 14, 2026, VA2 had an ATM transaction at a local bar with a receipt time stamped at 12:57 a.m. The SP said that s/he “went home” and worked the next day. The SP was asked if s/he took VA2’s debit card home and the SP said, “No, well we’d purchased stuff before that.” This investigator clarified that the transaction happened at 12:57 a.m., and the SP said, “Yeah, because I forgot it,” and added that “they were going to go get stuff for snacks and stuff.” The SP then said that s/he took VA2’s card home “on accident.” The SP was asked if it was a normal practice to get cash for the VAs without the VAs present and the SP said, “Once in a blue moon,” if a VA wanted to “do something the next day.” The LEO clarified that there were multiple ATM transactions in a short amount of time and the SP said, “Yeah, I can’t remember what those are for.” · On February 20, 2026, VA1 had an ATM transaction at 9:47 p.m. for $84 and on February 21, 2026, at 12:14 a.m. for $63 that were at a local bar. The SP said that the cash was for the casino (Investigator’s note: VA1’s ledger did show a cash transaction on February 22, 2026, for $220 with “casino” listed as the description). When asked why the ATM was used twice, the SP said, “Two different ones. Not sure offhand why I did that.” · On February 22, 2026, VA1 and VA2 had casino cash transactions. The SP told this investigator and the LEO that VA1 and VA2 went to the casino on February 22, 2026, but for the facility’s internal review said that only VA1 went to the casino. There were also casino cash transactions for VA1 and VA3 on February 28, 2026. The SP was asked why progress notes for the VAs did not include that the VAs went out in the community, the SP said, “I don’t know,” and that the other staff persons working “knew” where the SP and the VAs were going. The LEO clarified that there were no progress notes in February 2026 for the VAs that mentioned going to the casino and the SP said, “I know we should have.” · The SP denied taking VA1’s, VA2’s, and VA3’s funds. Facility records showed that P1-P4 and the SP were trained on the VAs plans, the facility’s Management of an Individual’s Monetary Resources policy, and the Reporting of Maltreatment of Vulnerable Adults Act. At the completion of the DHS investigation, law enforcement sent the case to the county attorney to review for charges. Conclusion: A. Maltreatment: VA1, VA2, and VA3 had questionable ATM withdrawals and cash purchases that were made between January 2024 and March 2026. On more than one occasion, the SP took VA1’s, VA2’s, and VA3’s debit cards with him/her after the SP finished his/her shift and on more than one occasion, took money out of ATMs without the VAs present. While the ATM transactions were added to the corresponding VA’s cash ledger, the cash transactions, on numerous occasions, were made where there was no receipt collected, and all the funds would be used with no change added back to the ledger. When asked why there was no change added back for purchases made with cash, the SP said that s/he would let the VAs “spend it all.” On more than one occasion, the progress note written for the respective VA on the dates of transactions entered by the SP did not indicate that the respective VA went out in the community where the transaction occurred and on more than one occasion, the respective VA’s progress note indicated that the VA did not leave the facility during the shift. When asked why the progress notes did not indicate that the respective VA went out in the community, the SP said, “I know we should have.” Although the SP denied taking VA1’s, VA2’s, and VA3’s funds, given that the SP made numerous ATM withdrawals with VA1’s, VA2’s, and VA3’s debit cards when the VAs were not present some of which were made at a bar, that cash transactions were made where there was no change on numerous occasions, that the VAs’ progress notes did not indicate that the respective VA went out in the community where or when numerous transactions happened, that the SP made several missing receipt vouchers for the VAs’ money, and that the SP had VAs’ cards in his/her possession when not working on more than one occasion, there was a preponderance of the evidence that the VAs’ funds were used in the absence of legal authority. 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 trained on the VAs’ plans, the facility’s Management of an Individual’s Monetary Resources policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP was responsible for maltreatment of the VAs. 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 did not meet the statutory definition of “serious” maltreatment but was “recurring” maltreatment because the SP made withdrawals and transactions with VA1’s, VA2’s, and VA3’s funds on more than one occasion. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. All staff were to be retrained in assisting individuals supported with finances and the facility’s Management of an Individual’s Monetary Resources policy. P1 was to be retrained on the facility’s Management of an Individual’s Monetary Resources policy, the Reporting of Maltreatment of Vulnerable Adults Act and was given a corrective action plan for “failing to notice financial exploitation” when monthly audits were completed. VA1, VA2, and VA3 were to be reimbursed “funds that through investigation are suspicious.” The SP 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 and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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