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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: 1070934-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that funds totaling around $1,400 were taken from a vulnerable adult (VA). Date of Incident(s): Prior to May 1, 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 for this investigation was obtained remotely, including documentation from the facility and through four interviews conducted with two management staff persons (P1 and P2), a facility staff person (P3), and the VA’s guardian (G). The VA was unable to provide information in an interview due to his/her abilities. The facility had a locked closet that contained a locked cabinet. The keys to the cabinet were stored inside the closet. Keys to the closet were maintained by staff on duty. The keys to the closet and cabinet were accessible to all staff. The VA had cash stored in two pouches in the cabinet. One was for typical petty cash purchases, and the other was cash from a spend down account. Although staff had access to the cabinet where cash was secured, clients and visitors did not have access. The VA’s Personal Focus Worksheet showed that the VA enjoyed spending time with his/her family members, watching television, and playing volleyball. The VA was diagnosed with a mild developmental disability. The VA had a Financial Authorization form that stated staff assisted the VA with “completing transactions” and “storage of cash.” The frequency of statements that itemized income and disbursement of the VA’s funds and property to the G was marked as “not applicable” and to the VA’s case manager as “as requested.” P1 provided the following information: · On April 5, 2026, P3 took the VA to Walmart to return an item that the VA previously purchased. After the return was made, P3 put $59.30 into the spend down pouch and the balance was $1,425.10. · On May 1, 2026, P2 called P1 and was “freaking out” because P2 was unable to locate the money from the VA’s spend down pouch. P1 told P2 to thoroughly look for the money, which s/he did but it was not located. · Between April 5, and May 1, 2026, there were no known purchases from the spend down account. · Based on what P1 knew, the money from the spend down pouch was not used between April 5, and May 1, 2026. Although a ledger was maintained for the spend down account, the ledger was also missing when it was determined that the cash was missing. · P1 denied taking the VA’s money. On unspecified dates, P1 talked to two facility staff persons and P2 talked to the remaining staff who worked at the facility and all staff denied taking the money or using the money for purchases for the VA. · On an unspecified date, the facility reimbursed the VA a total of $1,425.10. P2 provided information that was consistent with the information provided by P1 but added that s/he went to count the VA’s money on May 1, 2026, because the VA expressed interest in purchasing new furniture for his/her bedroom, but the money was gone. P2 denied taking the VA’s money. P3 stated that when s/he and the VA returned from Walmart on April 5, 2026, P3 deposited money in the spend down pouch and then counted the total amount of the money. At the time, the spend down pouch contained $1,425.10. P3 denied taking the VA’s money. The facility’s training records showed that all staff interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to April 5, 2026. Conclusion: A. Maltreatment: On April 5, 2026, P3 took the VA to Walmart to return a previous purchase made by the VA. When P3 and the VA returned to the facility, P3 put the cash, totaling $59.30, into the VA’s spend down pouch, which left the total at $1,425.10. On May 1, 2026, P2 went to count the money, but the money and ledger were missing and not found. P1 and P2 interviewed all facility staff and each staff interviewed denied taking the VA’s money. Facility clients and visitors did not have access to where the money was kept but all staff persons did via a key that was kept on staff who were on duty. Given that only staff had access to the VA’s money and the VA was missing money, and that there were no purchases made between the time it was last seen and was missing, there was a preponderance of the evidence that a staff person willfully used, withheld, or disposed of the VA’s funds 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. Given that all staff had access to the money and all staff denied taking the money, responsibility for the financial exploitation of the VA was inconclusive. Action Taken by Facility: The facility completed an Internal Review, which stated that policies and procedures were adequate, followed, and that moving forward, client cash would be counted daily. The facility reimbursed the VA a total of $1,425.10. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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