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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: 1076682- H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh Christine.Cavanaugh@state.mn.us 651-431-3444 Suspected Maltreatment Reported: It was reported that an administrative/supervisory staff person (SP) was responsible for managing a vulnerable adult’s (VA’s) funds and that there was over $1,000 of unaccounted for/undocumented transactions. Date of Incident(s): Ongoing prior to October 22, 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 information from law enforcement; and through nine interviews conducted with the SP, an administrative staff person (P1), two administrative/supervisory staff persons (P2 and P3), three facility staff persons (P4, P5, and P6), the VA’s guardian (G), and the VA’s case manager (CM). Attempts were made via phone and email to contact and interview a staff person (P7). Initially, P7 responded and left a voice mail message, but P7 then did not respond to subsequent requests. Information showed that the VA did not handle his/her finances and would be upset if his/her money was taken; therefore, the VA was not interviewed for this investigation. The VA was a very positive person and liked to be around people. The VA enjoyed watching TV and football, shopping, board games, listening to music, and playing basketball and swimming. The VA participated in Special Olympics. The VA was diagnosed with an intellectual disability and had “complex behavioral needs.” The VA’s file stated the VA moved into the facility in September 2023 and lived there with three other housemates. According to the VA’s Annual Consents from, the facility had financial authorization/consent to assist in the management and safekeeping of the VA’s funds and property including cash, checking account, savings account, and property. All receipts for purchases made while receiving services with the facility were to be retained and available for review. The facility’s Funds Management policy provided the following information: · Staff persons were to ensure the “safekeeping of program and individual’s funds and/or property.” Prior to handling any individual’s funds, the license provider secured a signed financial authorization/consent from the individual or guardian and was updated annually. The consent identified areas the program was authorized to assist the individual with any necessary limitations to the assistance. · Individuals’ money was to be kept separate from other individual’s money and program funds. · Receipts were to be secured for all transactions and in the event that a receipt was not available, staff were to indicate as such on a voucher form. Staff persons were to accurately record all financial transactions for each individual account. · Staff persons were not to borrow money from an individual, purchase personal items from an individual, sell items or services to, or require an individual to purchase items which the program was already paying for. · Pictures of major purchases over $100 were to be uploaded to Therap (electronic system). As appropriate, each individual had petty cash available at the facility for small purchases and was not to exceed $75. When additional money was needed, preapproval from a person in P2’s position was required. · Staff were to conduct an audit of petty cash prior to and after transactions, record the transaction on the Individual Petty Cash Balance Sheet (IPCBS), complete a voucher with attached receipt, and staple it onto the balance sheet. The petty cash was to be replenished per an individual’s budget, and a new petty cash balance sheet was started each time the petty cash was replenished. · All checking and savings account transactions were to be entered into Therap and a person in the SP’s position was to ensure the transactions were updated at least weekly. As available at sites, all transaction receipts were to be scanned and attached to each transaction in Therap. The G provided the following information: · Around September 2023, when the VA started services with the license provider, the G was “never” told how the VA’s funds “would be handled.” The G had access to the VA’s banking and statements and on an unknown date after the VA started receiving services, the G gave the VA’s debit card to the facility. The G did not request receipts, but thought that the facility was saving them and that a “second person” monitored the management. · On an unknown date prior to July 2025, the G saw some concerning transactions on the VA’s bank statements such as frequent automated teller machine (ATM) withdrawals and “large amounts” between $70-$80 of individual transactions from restaurants. When the transactions became “more excessive,” around late October 2025, the G told P1 about his/her concerns. The G also asked the SP about the restaurant charges and the SP said that s/he “sometimes” used the VA’s card to pay for other housemates because it was “easier” and then s/he repaid the VA. · The G said s/he did not give any staff persons permission to use the VA’s card for other clients/housemates. On an unknown date, the G told the SP that if “on occasion” staff took the VA out to eat, that the VA’s funds could pay for the staff’s meal; however, the G did not remember if there was a discussion about the frequency of that happening and did not think staff persons would do it more than “on occasion.” But “never” did the G “give any indication” that staff were to use the VA’s card to pay for another client’s food and did not “recall ever saying, Here, just use [the VA’s card] for whatever for everybody.” In October 2025, when the G talked to P1 about his/her concerns, P1 told the G that staff were not allowed to have clients pay for their food and that there was a business card for that. · On August 8, 2025, there was a charge for $24 at a local gas station but the G did not know what it was for and stated that it could be “nothing but gas” for a vehicle. (Note: A law enforcement officer [LEO] confirmed that the charge on the VA’s card was for two pizzas that totaled $24.67. Facility information showed two staff persons [P9] and the SP were working that date. There was no documentation of pizza purchased with the VA’s card.) On May 1, 2026, the G said s/he did not give staff persons permission to use the VA’s card to purchase pizza for “everybody.” · The VA typically used his/her funds for items such as body wash, shampoo, bowling, bingo, “special” grocery items, and eating out. P1, the Internal Review written by P1, facility documentation, the VA’s Individual Petty Cash Balance Sheet (IPCBS), receipts, the VA’s bank records, and bank video footage obtained by law enforcement provided the following information: · On October 22, 2025, the G and two other family members of the VA’s went to the licensed provider’s office with concerns regarding the VA’s funds. · After P1 learned about the G’s concerns, s/he and other supervisory staff persons “immediately” reviewed the VA’s financial records between January and October 2025, and then went back farther into 2024. Receipts and petty cash balance sheets were found in a cabinet downstairs at the facility but the SP had not uploaded any receipts to Therap (electronic system) since July 2024 and there were “all kinds” of receipts and petty cash balance sheets missing. The VA’s IPCBS, showed that as of October 30, 2025, the VA’s petty cash balance was $4.16. · The VA had a debit card and a petty cash zippered bag that was kept at the facility that all staff persons had access to. Staff persons primarily used the VA’s petty cash for purchases. The G managed the VA’s bank account, so the facility did not have access to the VA’s bank statements. · The SP worked for the license holder for many years. Since November 2023, the SP managed the VA’s petty cash, and it was the SP’s responsibility to ensure all receipts were accounted for. P2 was responsible for overseeing Therap, but P1 stated, “That’s where we dropped the ball.” P1, P2, and other supervisory staff persons were working “more than half time” at sites doing direct care. Additionally, P1 stated, “It would have been an easy thing to miss, unless you were looking directly for this.” · The following were the concerning transactions discovered during the review of the VA’s financial records: o ATM withdrawals that were on the VA’s bank statements. (Note: The bank had a drive-up ATM and teller window. There was only one camera from outside the bank that showed the front of vehicles driving up to the ATM/teller window. Because of the camera placement, it made it difficult to identify the person[s].): § October 16, 2024; 9:30 a.m. – a $300 ATM withdrawal. The VA’s IPCBS showed that on October 16, 2024, a deposit was for $14.57 was made which was documented with the SP’s initials. The SP and P3 were working. (Note: The LEO confirmed the identity being the SP driving the facility’s vehicle and the VA was present in the passenger seat.) § January 12, 2025; 12:24 p.m. – a $203.50 ATM withdrawal out of state while the VA was on vacation. The SP was on vacation with the VA. There was no entry on the VA’s IPCBS and no receipts for expenditures. § May 27, 2025; 3:37 p.m. – a $200 ATM withdrawal. There was no IPCBS found for the VA dated between May 11 and 29, 2025. (Note: The LEO confirmed the identity being the SP and driving the facility’s vehicle. The passenger seat was vacant.) § May 30, 2025; 9:50 a.m. – a $200 ATM withdrawal. The VA’s IPCBS showed a $100 deposit which was documented by the SP’s initials and no receipts for expenditures. (Note: Bank video footage showed the SP walking to the drive-up alone and withdrawing cash. The SP was holding a bag that looked similar to the VA’s petty cash bag and removed the check card from the bag to make the withdrawal. The SP put the card back in the bag and appeared to put some of the cash into the bag and some into his/her right pocket.) § July 21, 2025; 1:02 p.m. – a $200 ATM withdrawal. There was no deposit into the VA’s IPCBS. P4 and P7 were working; the SP was not scheduled to be working. (Note: Bank video footage showed a person in a black vehicle withdrawing money at the bank window. The passenger seat was vacant although there was a dog moving about in the vehicle. The LEO confirmed the person was the SP and that the vehicle belonged to the SP.) § August 31, 2025; 3:40 p.m. – a $200 ATM withdrawal. There was no deposit into the VA’s IPCBS and no receipts for expenditures. The SP and P3 were working. (Note: Bank video footage showed a person drive up to the bank teller window and withdraw cash. The LEO confirmed the person was the SP driving the facility’s vehicle. The passenger seat was vacant.) § October 6, 2025; 4:14 p.m. – a $200 ATM withdrawal. The VA’s IPCBS showed that between October 2 and 12, 2025, there was not a $200 deposit. (Note: Bank video footage showed a person driving up to the ATM with a person in the passenger seat. The LEO identified the persons as the SP and the VA in the facility’s vehicle.) § The seven undocumented ATM withdrawals totaled $1388.93. o Cash withdrawals that were on the VA’s bank statements: § October 4, 2024; 8:53 a.m. – a $50 cash withdrawal. The SP and a staff person (P11) were working. (Note: Bank video footage showed the facility vehicle in the drive-up first stopping at the ATM, and then at the teller window. The LEO confirmed it was the SP and the VA inside the vehicle.) $200 was withdrawn from the ATM and documented onto the VA’s IPCBS by the SP’s initials. The $50 cash withdrawal was not documented on the VA’s IPCBS. § October 18, 2024 – a $50 cash withdrawal which was not deposited on the VA’s IPCBS. The SP and P11 were working. (Note: There was no bank camera footage for this date.) § [Note: There were two cash withdrawals that the G was concerned about that occurred on June 20, 2025, at 12:35 p.m. for $150 and July 23, 2025, at 4:07 p.m. for $20. The LEO identified the G person who made the two withdrawals.) § The two undocumented cash withdrawals totaled $100. o Restaurant debit card transactions: § April 4, 2025 – a $42.93 debit card transaction for Domino’s Pizza. There was no receipt and T-Logs stated the VA attended a Fish Fry and $13 of petty cash was withdrawn for that. The SP and P4 were working. § May 24, 2025 – a $44.63 debit card transaction for Village Inn. A receipt showed two meals were purchased and no reimbursement was paid to the VA. There was no T-Log entry. The SP and P6 were working. § May 26, 2025 – a $58.84 debit card transaction for A&W. There was no receipt and T-Logs written by P6 stated that the VA spent the morning visiting with staff, assisting in planting the garden, went to a Memorial Day BBQ and enjoyed lunch with peers, ate dinner with housemates, and went for a ride with staff. P3 and P6 were working. § June 7, 2025 – a $43.31 debit card transaction for Village Inn. There was no receipt and T-logs written by P7 stated that the VA “ate dinner with staff” and then “went for an after dinner car ride with staff.” The SP and P7 were working. A June 6, 2025, T-Log written by a staff person (P13) stated the VA “went out to eat with housemates.” [Note: On June 6, 2025, the same charge for $43.31 was withdrawn from the VA’s petty cash for Village Inn and it was most likely the meal was on June 6, 2025, but did not post to the VA’s bank account until the next day.] § September 7, 2025 – a $79.37 debit card transaction at Grandma’s. There was no receipt and T-Logs written by P7 did not have any information regarding an outing for food. P3 and P7 were working. § September 20, 2025 – a $78.14 debit card transaction for Pizza Hut. A receipt for Pizza Hut in the same amount stated, “divided by 4., but there was no reimbursement documented on the PCBS for the VA. The SP and P7 were working. (Note: P1 saw this receipt and stated it was the SP’s handwriting.) [Note: On September 20, 2025, $19.53 withdrawn from the VA’s petty cash for Pizza Hut. There were no staff initials on the documentation.] § The six debit card purchases that were not all for the VA totaled $347.22. [Note: Although some portions of each restaurant purchase could have been for the VA, the amount of each receipt was more than a single meal, and therefore not all for the VA.] o Petty cash withdrawals: § February 22, 2025 -- $20 was documented by the SP’s initials as withdrawn from the VA’s petty cash for bowling. Two receipts for bowling showed $10 for the VA and $10 for another housemate. No reimbursement to the VA was documented for the housemates bowling. The SP and P4 were working. § June 6, 2025 -- $43.31 was documented by the SP’s initials as withdrawn from the VA’s petty cash for a meal at Village Inn. [Note: On June 7, 20245, the same charge for $43.31 was charged on the VA’s debit card.] § September 20, 2025 -- $19.53 was documented as withdrawn for Pizza Hut. There were no staff initials on the documentation. [Note: On September 20, 2025, $78.14 was charged on the VA’s debit card for Pizza Hut. The receipt said it was “divided by 4” which would be $19.53; however, there was no documentation that showed any money was deposited back into the VA’s petty cash.] The SP and P7 were working. § The three petty cash withdrawals above totaled $141.45. [Note: Although some of the $141.45 could have been for the VA, given that the amount of the two restaurant purchases was more than a single meal, that two of the withdrawals for purchases were also charged to the VA’s debit card, and that there was a $10 bowling receipt for another housemate, the purchases were not all for the VA.] · P1 talked to the SP about the concerns with the VA’s financials and the SP “acknowledged” that s/he had “not ensured staff provided receipts” and that s/he had not entered receipts into Therap (an electronic record keeping system) since July 2024. The SP told P1 that s/he was “overwhelmed” with his/her job responsibilities due to the behavioral needs of clients, staff turnover, training staff persons, and his/her personal health issues. · P1 did not have any prior concerns with the SP and did not hear of any concerns from other staff persons. The SP was a “trusted” and “dedicated” staff person whom P1 “never would have suspected malfeasance.” P1 had no concerns with other staff persons. · The other three clients who lived at the facility financials for 2024-2025 were reviewed and there were no concerns noted. · During the course of the investigation, additional invoices/cash payments for various items for the VA were found that the SP gave to a financial administrative person (P12). The total amount paid to the facility from the VA’s funds between October 16, 2024, and October 7, 2025, was approximately $696.14. Of the $696.14, only $96.28 was documented in the VA’s financial information leaving approximately $599.86unaccounted for. (Note: It was unknown whether any of the above amounts could have been on the missing documentation and/or whether any of the missing money from the ATM and/or cash withdrawals was used to pay the facility. In addition, the facility had documentation to support the VA’s payments to the facility that totaled $696.14.) P2 stated that on October 22 or 23, 2025, P1 told P2 about the concerns the G had regarding the VA’s finances. P1, P2, and P3 reviewed the VA’s financial information. By October 27, 2025, P1 “had everything already together” and a timeline “set up.” P2 then went into communication logs to see who was working at different times to “piece together” information. P2 found that there was a “lot of missing” and contradicting information. The VA’s debit card was to be used for purchases when items for the VA were needed such as a new mattress pad or for when the VA went out to eat. For “bigger purchases, staff persons were to contact the G for approval. P2 was concerned with the frequency of petty cash being replenished and missing receipts. P2 had no prior concerns with the SP and said s/he was a “veteran” staff person. P2 was “hoping” it was all “just mismanagement of receipts and documentation,” but “feared” funds were “misappropriated.” P3 said that on October 22, 2025, P1 called P3 and asked him/her to bring the VA’s financial information to the office. P1 and P3 then reviewed the VA’s financials and there were “so [many] loose receipts” and missing petty cash ledgers. Staff persons were to fill out a ledger for any expense and staple a receipt to it. P3 said that on an unknown date in spring 2025, P3 withdrew money for the VA at an ATM to replenish the VA’s petty cash fund. P3 did not think there was anything “malicious” regarding the SP’s handling of the VA’s fund and thought that the SP was just a “poor record keeper” and that there was an “explanation” for “everything.” P4 provided the following information: · After learning about the concerns, P4 spoke to the SP who told P4 that s/he “should have done the paperwork right instead of cutting corners” but that all the receipts were in the basement of the facility in a file cabinet and that that in January 2025, s/he told the G that s/he lost some receipts, and the G told the SP that s/he did not need to save them and that the G did not “need them.” The SP also told P4 that “sometimes” s/he had the VA pay for other housemates when they were out and then had the housemates pay the VA back. · All of the clients had money bags with $50 cash per month that the SP oversaw. P3 told P4 that the cash in the money bags needed to be balanced each shift even if the night staff did not go on any outings/use cash. However, that system “wasn’t working out real well” with the night and morning shifts because of “timing”— the night staff needed to get “paperwork” done so the money bags were not always counted before the day shift started. However, they were counted in between the different day staff, and that is where P4 found discrepancies such as missing receipts. · On an unknown date the beginning of summer 2025, P4 told the SP that the cash balance was off and the SP said just to “throw the receipts in the money bag,” that s/he would “take care of it,” and that staff persons did not have to balance the sheets anymore. · P4 thought the SP did not “know what [s/he] was doing” and a $50 cash bag should not be “that difficult” to balance. · The SP was usually the staff who withdrew money from the ATM for the VA; however, P4 remembered one instance when P5 withdrew $200 because P4 had reminded P5 to get a receipt. P4 did not remember using the VA’s card at an ATM but said it was “possible” and would have been maybe at the beginning of 2025 if s/he did. · On a “few occasions” when P4 worked with the SP, and they went out to eat with clients or ordered pizza, the SP told P4 that s/he put the orders on the VA’s card and then was going to “divvy” it up between everyone later and then pay the VA back. P4 thought the SP did that because it was “easier.” P5 stated that s/he was trained to make copies of receipts whenever financial transactions were made and write down in a “book” how much money was spent and how much money was left. Receipts were kept inside a folder which was inside the facility office. P5 had not handled the VA’s money/debit card within the last year. P5 stated s/he never withdrew money from an ATM with the VA’s card and that the SP was responsible for such. P5 had no concerns with the SP. P6 said that around November 2025, s/he heard from the SP that there were “misplaced” receipts and that the SP thought s/he put them in a filing cabinet, but now “they [were] gone.” On one unknown date in 2025, P6 used the VA’s debit card to get medication for him/her. P6 brought the receipt to the facility and gave it to the SP. For petty cash, staff were to fill out a voucher and attach the receipt to it as well as fill out the petty cash sheet with a new balance and count the money to verify. The CM said that the G handled the VA’s finances but that the facility had access to the VA’s spending money/card. The SP provided the following information to the LEO and this investigator: · When the VA moved into the facility, the G gave the SP the VA’s debit card, which was then kept at the facility along with the VA’s petty cash in a money bag. Around that time, the G told the SP that the VA could take other individuals out as a “treat” and pay for them without being reimbursed. Another staff person was with the SP when that conversation happened, but the SP did not remember who. The SP said “as far as [s/he] knew” other staff persons knew that was approved as well. There were not any limits on amounts spent, but the SP stated that they “never went to any major restaurants” and most of the meals out were at Village Inn or Grandma’s. The SP “never really fully documented” when those occasions occurred—the SP would put it in his/her work calendar, or text other staff persons, or “word of mouth” that if the VA “treated [a] peer,” then that peer would “treat” the VA “a couple weeks later.” · The SP did a “majority” of replenishing the VA’s petty cash via ATM withdrawals although all staff persons also had access/ability to. At the facility, there was a petty cash balance sheet that was used to track cash transactions. The facility did not have access to the VA’s bank statements; however, the account balance was shown on the receipt of each ATM withdrawal. The SP stated the VA did not have a “limit” on his/her funds and the G said that if the VA “wanted something [s/he] could have it.” The SP had “constant” communication with the G “about everything.” · Staff persons did not always document every outing such as eating out, grocery shopping, etc. However, if a client’s cash was spent or withdrawn from an ATM, it was to be written on the petty cash sheet. The VA’s funds were used for the VA’s personal items, eating out, weekly bingo, and bowling. On unknown dates, the SP tried to order something for the VA online but the VA’s card did not work. The SP told the G about it but did not get any information as to why. Therefore, on unknown dates, the SP used either his/her card or the company card to make purchases for the VA that included CD players, a mattress cover, and clothing items. When the SP used the company card to purchase something for the VA, the SP turned in the receipt/information to the facility billing manager (P12), and a bill was made for the VA. The SP then withdrew cash out of the ATM to pay the bill. The SP stated that s/he “thought [s/he] didn’t need to” document those transactions for the VA because there was already documentation of the bill written when given to P12. A “couple of times,” the SP used his/her personal card to pay for things for the VA and the VA paid the SP back with his/her petty cash. · The SP put the VA’s receipts in a clear plastic tote at the facility. Between 2024 and 2025, the facility office moved to the basement, and then back upstairs due to basement construction. After learning about the concerns regarding the VA’s funds from P1, the SP looked at the facility for the clear tote of receipts but could not find it and said that office items had gotten moved. The SP was to scan the VA’s financial transactions/information into Therap; however, the SP stated s/he did not “keep up” on the scanning due to lack of time from providing direct care and staff shortages. · The SP provided the following information regarding some of the unaccounted for transactions as listed above: o Regarding the January 12, 2025, $200 ATM withdrawal: The SP, P1, and P4 brought two clients and the VA to Alabama for a vacation. The VA used the cash while on vacation to gamble ($20 one night and $20 one morning), to pay for breakfast (approximately “at least” $15), and for the purchase of two T-shirts, a sweatshirt, and a cup. (Note: According to P1 and P4, they did not see the VA gamble while on vacation. P1 said that the VA did not purchase any breakfasts, that they “cooked in the condo” and breakfasts were “included” in the hotel stays. However, P4 said that one time s/he, the VA, the SP, and one other client went out for breakfast. Additionally, while on the trip P4 saw the SP asked the VA if s/he liked several t-shirts while they were shopping and remembered washing at least two t-shirts that the VA purchased on the trip after they were back. P1 heard that the SP purchased a $50 sweatshirt for a coworker on the trip and “never asked for reimbursement.” The coworker “assumed” it was purchased with the VA’s funds since the SP “would not have $50 of [his/her] own money.” o Regarding the April 4, 2025, $42.93 transaction for Domino’s Pizza: The SP used the VA’s card at Dominos when the G told him/her to get pizza for the VA and other clients. o Regarding the May 24, 2025, Village Inn purchase of $44.63: The VA was on a “date” and paid for another client. o Regarding May 30, 2025, $200 ATM withdrawal: The SP did not remember why s/he would have put the VA’s cash in his/her pocket, but stated that “unless I went to the office and paid a bill I don’t remember,” or if there was something else “going on” that day with the VA. o Regarding July 21, 2025, $200 ATM withdrawal while the SP was not working: The SP stated that s/he got a call from an unknown staff person that the VA needed to pay for camp, so s/he went and withdrew the money from the ATM and turned it into P12. [Note: According to P1, the facility did not write a check to the camp and the G told P1 that s/he also did not write a check. The camp did not contact the facility about any outstanding balances for the VA for camp. In April or May 2025, a $100 deposit would have been made and when the VA went to camp on July 27-July 29, 2025, a balance of $90 was due. “Somehow camp got paid.” P1 also stated that the SP was the “only person that handled payment to camp.”] o Regarding the August 8, 2025, gas station purchase of pizzas (according to LE it was for two pizzas that totaled $24.67): The SP stated that the G gave him/her “permission” to get the house pizza that day. (Note: The gas station sold pizza.) o On September 20, 2025, the SP used the VA’s card at Pizza Hut ($78.14) and paid for other clients with the VA’s funds because a client was having maladaptive behaviors at the time. The SP was planning to have the clients pay the VA back, but then the SP “got too busy” and “forgot about it.” The SP stated s/he used the VA’s card/cash paying for other clients “maybe three times,” but did not remember dates. · The SP denied taking the VA’s money and/or using the VA’s funds for him/herself. P1-P6 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adult’s Act. P2-P6 and the SP were trained on the facilities policies and procedures. There was no documentation of P1’s training on policies and procedures; however, P1 wrote and updated them annually. P2 and P4 were trained on the VA’s plans. P1’s position was not required to have training on the VA’s plans. P3, P5, P6, and the SP did not have documentation that they were trained on the VA’s plans which was a violation of Minnesota Statutes, section 245D.095, subdivision 5 which states in part that the license holder must maintain personnel record of each employee to document and verify staff qualifications, orientation, and training. Relevant Rules/Statues: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1) states that whenever the license holder assists a person served by the program with the safekeeping of funds or other property, the license holder must immediately document receipt and disbursement of the person's funds or other property at the time of receipt or disbursement, including the person's signature, or the signature of the conservator or payee. Conclusion: A. Maltreatment: The facility, including the SP, who was an administrative/supervisor staff person, were responsible for the safekeeping of the VA’s funds. Information obtained showed that the VA had funds that were undocumented, unaccounted for, and for which there were no receipts, which was a violation of Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c), clause (1). The undocumented/unaccounted for transactions between approximately October 2024 through October 2025 included: seven ATM withdrawals totaling $1388.93; two cash withdrawals totaling $100; six debit card purchases totaling $347.22; and three petty cash withdrawals totaling $141.45. All staff persons had access to the VA’s card and petty cash. In addition, although the SP stated that the G gave permission for the VA’s funds to be used to pay for other clients’ meals, the G denied such and stated that s/he told the SP that staff could use the VA’s debit card for themselves if they were taking the VA out to eat. Although it was likely that some of the unaccounted funds were used for the VA, that not all of the unaccounted funds could be determined whether they were misused or repaid to the VA from other clients’ accounts, that some of the funds were likely mismanaged, and that the SP denied using any of the VA’s funds for him/herself, given that the following there was a preponderance of the evidence that in the absence of legal authority a person willfully used, withheld, or disposed of funds of the VA: · The SP was seen on video making each of the seven ATM withdrawals, including an occasion when the SP was not working, that were not deposited into the VA’s petty cash. · On May 30, 2025, via video, after the SP withdrew $200 from the ATM s/he put some of the cash in a bag that was likely the VA’s petty cash bag and then also put some of the cash into his/her right pocket. · Although the amount of money that was withheld from and/or not repaid to the VA when s/he paid for others meals/activities, the SP was an administrative/supervisory staff person and told other staff persons that the VA’s card could be used to pay for other meals/activities and allowed the practice while failing to ensure the VA was repaid. · On June 6, 2025, the VA paid $43.31 for meals at Village Inn, yet the SP withdrew $43.41 from the VA’s petty cash for the same meal at Village Inn. 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 Reporting of Maltreatment of Vulnerable Adults Act and on the facilities policies and procedures but there was no documentation to show that the SP was trained on the VA’s plans which was a violation as stated above. Although all staff persons had access to the VA’s card and cash and more than one staff person worked on the dates in question, the SP was an administrative/supervisory staff person who was responsible for the oversite of the VA’s funds, was the person who primarily replenished VA’s petty cash funds with ATM withdrawals, and was responsible to scan the VA’s financial information into Therap, and ensuring the petty cash balanced. In addition, the SP was seen on video withdrawing cash at the ATM and did not deposit the cash into the VA’s petty case, was seen on video putting some of the VA’s cash into his/her own pocket, told and allowed other staff persons to use the VA’s card for other clients meals/activities, and had the VA pay twice for meals at Village Inn when s/he used the VA’s card at Village Inn for $43.41 and also withdrew cash from the VA’s petty cash in the same amount. The SP was responsible for the financial exploitation 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 was recurring maltreatment because the VA’s money was withheld and withdrawn on more than one date. Action Taken by Facility: The facility completed an internal review and stated that their policies and procedures were not adequate because it “did no provide for timely oversight” by management to determine if “appropriate money management” was being carried out by the SP and other supervisory staff persons. The SP was a “trusted and experienced” staff person and “verifying” that s/he was “following policies and procedures” was “less of a priority than constant struggle to ensure all sites were properly staffed.” The policies and procedures were not followed by the SP. The Funds Management Policy was updated with “new safeguards” for “oversight and assurance” that all receipts were present for all transactions and staff persons were trained on the policy. The VA was reimbursed by the facility for the 2025 transactions because the G did not request restitution prior to 2025. 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. On June 24, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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