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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: 1102760-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) took money from three vulnerable adults (VA1-VA3) in the amounts of $6273.25, $1075.61, and $5958.42 respectively. Date of Incident(s): Ongoing between April 20 and July 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 was obtained during a site visit conducted on July 31, 2026; from documentation at the facility and law enforcement records; and through seven interviews conducted with VA1, VA2, VA3, two facility supervisory staff persons (P1 and P2), and two staff persons (P3 and the SP). VA1, VA2, and VA3 were not subject to guardianship. VA1 was diagnosed with moderate intellectual disabilities and enjoyed puzzles and traveling. VA1’s Risk Assessment Detail stated that VA1 was his/her own rep payee but VA1’s family members assisted VA1 with his/her finances. At times, VA1 did not remember if s/he used cash or his/her debit card. VA1 was aware of “amounts” but if s/he “spends [s/he] loses track.” VA1 had a limited concept of money and would not recognize mismanagement so staff persons were to report any mismanagement of VA1’s finances. VA2 was diagnosed with mild intellectual disabilities and was visually impaired. VA2 enjoyed sports and spending time with friends. VA2’s Risk Assessment Detail stated that VA2 understood the value of money but needed assistance managing his/her finances. Staff persons were to “prep” money as needed whenever VA2 wanted it. Due to VA2’s diagnoses of being visually impaired, VA2 may not recognize mismanagement of his/her finances. VA3 was diagnosed with a traumatic brain injury and an intellectual disability. VA3 enjoyed sports and being outside. VA3’s Risk Assessment Detail stated that due to VA3’s diagnoses, VA3 had difficulty understanding money amounts and had difficulty recognizing mismanagement of his/her finances. VA3 required assistance managing his/her finances and the facility assisted VA3 with all his/her financial matters. P1 and P2, law enforcement records, and the Internal Investigation and Incident Reports for VA1, VA2, and VA3 provided the following information: · On July 3, 2026, P1 was doing the facility financials and received an email from VA1’s family member, who typically emailed P1 VA1’s financials each month. The email said that there were some “large” withdrawals on VA1’s bank statement and money taken from VA1’s savings account. · P1 then began looking into the concerns and saw that there were “bigger withdrawals” than were typical for VA1. P1 also looked at VA2’s and VA3’s financials and saw that there was also a “large amount of cash” withdrawn from VA2’s and VA3’s checking account on “more than one occasion.” · The concerns also included May 19, 2026, when there was $1704.99 in “fraudulent” charges at the Mall of America for VA3 for shoes in three different sizes, duplicate items, and clothing for a gender different than VA3. VA3 also did not have all these items in his/her possession. · On June 8, 2026, the SP withdrew $700 from an ATM for VA1 for VA1’s birthday but nothing was purchased so P2 went to the store and purchased items for VA1’s birthday.
· P1 said there was also a handwritten receipt dated June 10, 2026, for VA3 which showed $1600 for a tattoo which P1 thought seemed like “a lot” and “a lot” of ATM “charges” on the same date. P1 called the tattoo shop and was told that VA3 paid $500 for a tattoo and left a $100 tip. The tattoo artist said that the staff person with VA3 asked for a handwritten receipt instead of a printed one. The tattoo artist verified it was a staff person who matched the SP’s physical description. P1 thought that the SP added a “one” to the receipt from the tattoo place, making it look like $1600 instead of $600. · There was also a handwritten receipt for $1500 for VA3 stating that it was a “deposit” for another tattoo shop scheduled for August 7, 2026. P1 called that tattoo shop who said that VA3 did not have an upcoming appointment and they had not received a down payment for a tattoo. VA3 also denied planning and/or scheduling another tattoo appointment. · On June 13, 2026, the SP went on medical leave. Then there were transactions made for VA1, VA2, and VA3 after the SP was on leave including on June 19, 25, 26, and July 1, 2026, and some were in the SP’s hometown. (Note: The SP lived in a different town from the facility that was approximately 30 miles away and there was no information that VA1, VA2, or VA3 visited that town on those dates.) P2, P3, and two staff persons (P4 and P5) said that although the SP was on leave, on June 19, 25, 26 and July 1, 2026, the SP came to the facility. P4 told P2 that on July 1, 2026, when the SP came to the facility, s/he was “going through” the facility desk where financials were kept. P2 said that one time the SP came to the facility, the SP wanted to send an email and asked to use P2’s computer but P2 told the SP, “No.” P2 thought it was “odd” that the SP came to the facility to send an email because s/he was on leave and lived in another town. · On June 17, 2026, VA2 purchased a gift for the SP totaling $36.66, which was a violation of the facility policy of accepting gifts from clients. P1 said that VA2 liked to buy gifts but P2 did not think that VA2 would have purchased a gift for the SP because VA2 did not purchase gifts even for his/her significant other. · VA1’s, VA2’s, and VA3’s bank cards and cash were kept in an unlocked desk drawer in the main area of the facility that all staff had access to. However, the missing money was “narrowed” to the SP because the SP took VA3 to the tattoo shop and “all” the “questionable” ATM transactions occurred during the SP’s shift or when the SP returned to the facility during his/her leave. The SP also turned in the ATM receipts but provided “no reason” for the withdrawals or they were “invalid” reasons including one for $400 that appeared to have a “forged” signature for VA1 who “denied” the signature or that s/he gave $400 to his/her family member who also denied that s/he got money from VA1. Also, on June 19, 2026, there was a handwritten note for VA3 that said that VA3 also gave $400 to a family member who also denied that s/he got money from VA3. · P2 said that the facility always used debit cards for the clients so it was “traceable.” The only exception was when VA1 went to the casino and then P2 took out cash but it was never more than $60. Additionally, the SP’s role never went to the ATM. · P2 said that no money had been missing since the SP stopped coming to the facility while on leave. · Neither VA1, VA2, nor VA3 gave the SP or any other staff person “permission” to take their money or “willingly” gave the SP or any other staff person money. VA1 was missing $6273.25, VA2 was missing $1075.61, and VA3 was missing $5958.42. · For the Internal Review additional staff persons and clients were spoken to about the allegations. A supervisory staff person (P6) said that the SP notified him/her about going to the ATM while on leave but that P2 had asked the SP to do so, so an unidentified housemate, could get a tattoo. At that time, P6 told the SP that s/he should not be doing work tasks while on leave. P6 also said that typically, the clients did not use the ATM except when they went to places that did not accept debit cards, such as the fair. VA2 also asked P6 to purchase a gift for the SP and P6 said that s/he told VA2 that staff persons could not accept gifts and that it was “against policy.” However, VA2 said that s/he “wanted to do it anyways.” P6 said that when the clients returned from the Mall of America, P6 went through the purchases and receipts and “all purchases were present” and the clients had the items in their rooms. P6 said s/he did not see duplicate items purchased, including two identical jerseys for $169.99 and two identical sweatshirts for $130 each. P6 said that unknown/unidentified staff persons told him/her that VA3 “insisted” on purchasing clothing of the opposite gender. (Note: The SP was the opposite gender as VA3.) · VA1 told the facility that s/he preferred to use his/her bank card instead of cash. [Note: The SP said s/he took out cash for VA1 because VA1 preferred cash.] P2 also said that s/he had worked with VA1 for approximately one year and that VA1 only used his/her card, never cash. · For the Internal Review the SP said s/he returned to the facility during his/her leave “a few times” because s/he could not access a “leave of absence site” through his/her cell phone. One time, the SP came to the facility because VA2 bought him/her a gift. The SP was not aware that s/he could not accept gifts and said that P6 ordered the gift with VA2. Regarding VA3’s tattoo, the SP said that the tattoo place had “electrical problems” and that s/he had to pay cash instead of a card and that the total cost for the tattoo was $1600. The SP also said that the original tattoo was $500 with a $100 tip but that VA3 wanted to add “colors” to it so “it was more” and that VA3 had to return on a later date for the color. The SP also said that VA3 wanted another tattoo and that P2 asked the SP to schedule it when the SP was at the facility on leave, “visiting.” (Note: P2 denied this, denied asking the SP to withdraw money, and denied asking the SP to work while s/he was on leave.) · The SP said that on July 1, 2026, s/he withdrew $600 from the ATM for VA2, because a staff person (P7) asked him/her to do so but did not say why. However, P7 denied this. · The SP further said that while at the Mall of America, VA3 spent close to $5000. When asked about the missing items for VA3, the SP said that s/he had “no sports things” in his/her possession but then said “what [s/he] did” have, law enforcement now had in their possession. VA1 said that s/he worked and that his/her paycheck was deposited into his/her bank account via direct deposit. If VA1 wanted to go shopping, staff persons took him/her. Staff persons held onto VA1’s money and VA1 also had money in a bank. VA1 did not know where staff persons kept his/her money and did not know how much money s/he had. VA1 was not aware of any staff person taking his/her money. VA2 said that s/he used a “card” that was kept “somewhere” at the facility. VA2 “did not know” if any staff person took his/her money but also said that s/he “heard” that “someone” took approximately $600 from his/her bank account. VA2 “always” had money available to him/her to buy things. VA2 purchased a gift for the SP which included a “blanket and other stuff.” When VA2 gave it to the SP, the SP said that s/he “liked it” and then the SP took the gift home. VA2 did not know how much the gift cost. VA3 said that someone took his/her money but that s/he did not know who did so. VA3 did not know how much money was taken. Staff persons held onto VA3’s money and VA3 used a debit card. There were no times that VA3 did not have money to buy something s/he needed. A couple days prior to July 31, 2026, an unknown staff person took VA3 to get a tattoo. VA3 did not know how much the tattoo cost. P3 provided the following information: · P3 did not recall the date but on that date, at some point after 4 p.m., P3 was in the office when s/he saw the SP walking up to the front door of the facility. P3 was “confused” because the SP was supposed to be on leave. The SP then came inside. P3 thought that the SP would say, “Hi,” but the SP did not do so. P3 then heard “rummaging” and saw the SP sitting at the desk with a cabinet open where the clients check cards, receipts, and cash, if any was on hand, were stored. After five to ten minutes, the SP left. P3 said that it was not common for staff to come to the facility when they were not working. · P3 never took a client to the ATM and was told that s/he should not and that purchases should be done via check card so it was “documented.” If cash was needed, staff persons were trained to take out no more than $100. Staff persons were to get receipts for all purchase for the clients and then put the receipts in the binder at the desk. The SP provided the following information during his/her interview done in conjunction with law enforcement: · The initially denied that s/he took VA1’s, VA2’s, or VA3’s money. However, the SP then said that s/he purchased items for him/herself and/or his/her significant other using VA3’s card while at the Mall of America and showed those items to this investigator and law enforcement. The items included clothing and a pair of shoes. The SP also said that s/he withdrew $500 from VA1’s account via ATM on two occasions for his/her personal use. The SP denied taking any other money. · The SP said that VA1 preferred cash because it was “easier [for VA1] to keep track” so staff persons took cash out of the ATM for VA1. (Note: VA1 told the facility that s/he preferred to use his/her bank card instead of cash.) P2 also asked the SP to “pull money” for VA1, VA2, and VA3 from the ATM. · At some point, the SP also took VA3 to get a tattoo and went to a nearby gas station to use their ATM to get $1600 cash, which included “everything” that VA3 wanted, including color for his/her tattoo. The tattoo place did not have a receipt printed so they wrote it down and then provided a date to come back to finish the tattoo. · The SP also came to the facility while on leave between five and six times to pick up a gift that VA2 got him/her, to work on paperwork for his/her leave, and to “visit” the clients. On an unknown date after June 13, 2026, while the SP was on leave, the SP came to the facility and P2 asked the VA to go to the ATM to take out $1500 for VA3 for another new tattoo which the SP thought s/he could do since s/he was still an employee. The SP withdrew the money and once s/he returned to the facility, s/he gave the money to P2. (Note: P2 denied this, denied asking the SP to withdraw money, and denied asking the SP to work while s/he was on leave.) The Management of an Individual’s Monetary Resources said that money belonging to clients was to be kept secure and “accountability ensured.” Access to a client’s funds was to be limited to designated supervisory staff persons, the primary money manager, and other authorized staff persons. There was to be no co-mingling of funds between clients and staff persons. Transactions were to be recorded on a transaction register and receipts were to be collected. Law enforcement also investigated this report, which was submitted to the county attorney for charges which were pending at the completion of this report. P1, P2, P3, and the SP were trained on VA1’s-VA3’s plans, the facility policies and procedures including the Management of an Individual’s Monetary Resources, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On July 3, 2026, P1 discovered that VA1, VA2, and VA3 were missing funds. VA1 was missing $6273.25, VA2 was missing $1075.61, and VA3 was missing $5958.42. Consistent information was provided that VA1, VA2, and VA3 each required staff person assistance with money management and were all susceptible to financial exploitation. Information was consistent that only staff persons have access to VA1’s, VA2’s, and VA3’s funds and that neither VA1, VA2, nor VA3 gave any staff person permission to use or their funds. Therefore, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used, withheld, or disposed of VA1’s, VA2’s, and VA3’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. Although the SP initially denied taking VA1’s, VA2’s, or VA3’s money, the SP then stated that s/he used VA3’s card at the Mall of America to make personal purchases and twice withdrawing $500 from VA1’s account via ATM for his/her personal use but denied taking any other money. However, the SP worked or was at the facility on each of the dates of the transactions; some of the transactions took place in the SP’s hometown where VA1, VA2, VA3 did not visit during that time; the tattoo artist said s/he was given $600 for VA3’s tattoo which was $1000 less than what the SP said and wrote on the receipt; and the SP had reason to minimize his/her actions for fear of repercussions. Therefore, it was more likely than not that the SP also took the additional funds from VA1’s, VA2’s, and VA3’s for his/her personal use. The SP received training on the Reporting of the Maltreatment of Vulnerable Adults Act, the facility policies and procedures including the Management of an Individual’s Monetary Resources, and VA1’s, VA2’s, and VA3’s plans. The SP was responsible for the 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, abuse resulting in serious injury, or financial exploitation of a vulnerable adult if the value of the funds or property is $1,000 or greater. 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 serious and recurring maltreatment because the SP took over $1000 from three vulnerable adults on multiple occasions. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined the policies and procedures were adequate but not followed. 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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