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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: 1126210-H_CRS (Home and Community-Based Services-Community Residential Setting) 1067880-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Samantha.Wueste@state.mn.us Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) used two vulnerable adults’ (VA1’s and VA2’s) bank account information to make purchases for his/her personal use. Date of Incident(s): May 27 and June 2 and 9, 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; from documentation at the facility and law enforcement records; and through six interviews conducted with the SP, an administrative staff person (P1), VA1’s guardian (G1), VA1’s case manager (CM1), VA2’s guardian (G2) who was also VA2’s family member, and VA2’s case manager (CM2). VA1 and VA2 were unable to provide information for this investigation due to their respective diagnoses. The facility was a single-family home in a residential area, where VA1 and VA2 lived with two additional clients (C1 and C2). VA1 enjoyed community outings, drawing, and outdoor activities. VA1 was diagnosed with autism spectrum disorder, disruptive mood dysregulation disorder, anxiety disorder, major depressive disorder, and intellectual disability. VA1 lived at the facility for supports and services relating to his/her diagnoses that included financial management. According to VA1’s Individual Abuse Prevention Plan (IAPP) and Risk Assessment (RA), VA1 had a limited understanding of money and its value and was vulnerable to financial exploitation. The facility was VA1’s financial representative (representative payee) and provided “all services” related to managing and safeguarding VA1’s finances. Staff persons assisted VA1 in paying bills, making purchases, “budgeting” his/her money, and obtaining receipts for all transactions. Staff then provided the receipts to supervisory staff who were responsible for reconciling VA1’s financial account on a monthly basis. VA2 enjoyed listening to music, watching TV, and spending time with his/her friends and family members. VA2 was diagnosed with cerebral palsy, major depressive disorder, anxiety disorder and moderate intellectual disability. According to VA2’s IAPP and RA, VA2 received monthly social security and personal needs checks that were directly deposited into a bank account that was accessed using a debit card and/or checks. The facility was responsible for overseeing VA2’s finances and had access to view/manage VA2’s account and finances through an online platform. VA2 was vulnerable to financial exploitation because s/he had limited understanding of money or banking concepts and would not be able to recognize if his/her money was “mismanaged” so staff persons were to assist VA2 in managing and safeguarding his/her finances. Staff persons assisted VA2 in making purchases, “budgeting” his/her money, and obtaining receipts for all transactions. Staff then provided the receipts to supervisory staff who kept a ledger that was used to reconcile VA2’s account. P1 and facility documentation (including the facility’s Incident Reports and Internal Review, VA1’s and VA2’s financial records, and the SP’s staff file) provided the following information: · On May 13, 2026, the SP was hired to work at the facility within a supervisory position. At that time, C1 and C2 did not receive support from the facility with financial management. P1 stated that “all” facility staff who worked on-site and provided direct care to clients (including the SP) “could have potentially” assisted VA1 and/or VA2 in making purchases within the community at some point, as directed by each client’s care plans. Therefore, “all” facility staff were expected to assist in managing and safeguarding VA1’s and VA2’s finances “at some level.” However, “only” supervisory staff (the SP) and administrative staff had access to VA1’s and VA2’s online banking accounts and financial information. · On May 27, 2026, P1 was reviewing VA2’s financial account and saw that an online transaction was made to Motlank Limited (an online, e-commerce beauty retailer also known as “Motlankk”) using VA2’s financial account information, totaling $45.86. Shortly thereafter, P1 called the SP to ask about the transaction since this was not a purchase that would “typically” be made for VA2 and there was not a receipt obtained to document the transaction. During the conversation, the SP told P1 that s/he was not aware of the transaction and denied helping VA2 make any similar purchases. After speaking with the SP, P1 notified the facility’s administrative team about the fraudulent charge that was made using VA2’s account and then contacted and notified VA2’s financial institution, CM2, and G2, respectively. · At that time, because it was a single incident and there were no similar concerns regarding VA2’s or any additional client’s finances, it was “presumed” by the facility’s administrative team that the “unauthorized charges” were “likely” made by an unknown person. The facility continued to monitor/manage VA2’s finances without further concerns of “fraudulent activity” showing on VA2’s financial account. P1 stated that there were not any purchases from Motlank delivered to the facility at a later date, further indicating that the items from this transaction were not purchased for VA2. · On July 1, 2026, P1 was reconciling VA1’s financial account and saw two transactions on VA1’s June bank statement for services/accounts that were not used by VA1 and that did not have any receipts for the transactions. The transactions totaled $459.02 and included a payment made to MIDCO (a regional cable, phone, and internet provider) for $231.64 on June 2, 2026; and a payment made to Imagine Visa for $227.38 on June 9, 2026. P1 “immediately” notified the facility’s administrative team about the fraudulent charges involving VA1’s financial account, which according to the dates, occurred less than one week after P1 discovered the unauthorized transaction to Motlank on VA2’s financial account as outlined above. P1 also contacted and notified VA1’s financial institution, CM1, and G1, respectively. · Because these incidents occurred shortly after the SP was hired and that the SP was the “only” on-site staff person at the facility who had access to VA1’s and VA2’s online financial accounts at that time, the facility’s administrative team “suspected” that the SP “most likely” made the unauthorized charges using VA1’s and VA2’s finances. However, the SP told administrative staff that s/he was unaware of the transactions and denied using VA1’s and/or VA2’s finances for personal use. · The next day (July 2, 2026), an employee (E) from VA1’s financial institution called the facility and spoke to P1 regarding the two unauthorized transactions that were made using VA1’s account information. During the call, the E said that the financial institution reviewed the transactions and determined that the financial institution’s routing number and VA1’s financial account number were used to make an online payment for each transaction. In addition, the Imagine Visa account used in one of the transactions belonged to the SP. · After speaking with the E, P1 contacted local law enforcement (LE) to report the fraudulent charges made with VA1’s and VA2’s financial accounts. LE records provided the following information: · On July 8, 2026, a law enforcement officer (LEO) received a report of financial fraud involving VA1’s and VA2’s financial account information and contacted the facility to obtain additional information. The facility’s administrative team provided information that was consistent to the information that P1 and facility documentation provided to this investigator. · On July 27, 2026, the LEO spoke with VA1’s financial institution which confirmed that the transactions were determined to be “external withdrawals,” which meant that a person used VA1’s financial account number and routing number to make each transaction. The financial institution also confirmed that it was able to verify that the $227.38 transaction made using VA1’s financial account to Imagine Visa on June 9, 2026, was a Visa account belonging to the SP. · The LEO submitted administrative subpoena’s to Motlank Limited, MIDCO, and Imagine Visa requesting additional information relating to the unauthorized charges made with each VA1’s and VA2’s financial accounts, respectively. On July 29, 2026, MIDCO provided electronic records to the LEO showing that the SP had a personal account with the company, which serviced the same home address that the SP listed on his/her MN Driver’s License. [Note: This was also the same home/mailing address that the SP used to complete the MN DHS background study requirements.] MIDCO records also showed that on June 1, 2026, the SP made a payment of $231.64 which was the exact amount that was then withdrawn for payment to MIDCO from VA1’s financial account the next day. · At the completion of this report, the law enforcement investigation was ongoing while waiting to receive the subpoenaed records from Motlank Limited and Imagine Visa. The SP stated that s/he was aware of the allegations but denied making any unauthorized purchases using VA1’s and/or VA2’s financial account information. The SP said that in his/her role s/he had online access to VA1’s and VA’2 financial accounts. The SP then declined to further speak with this investigator and did not provide any additional information. According to G1, G2, CM1, and CM2, each was aware of the fraudulent charge(s) and the facility’s response to resolving the situation. G1, G2, CM1, and CM2 did not provide any additional information related to the allegations. According to the facility’s policy on Management of an Individual’s Monetary Resources, the facility provided the clients assistance with managing and safeguarding their financials. Staff persons were to obtain and save a receipt for all transactions or document a purchase if a receipt could not be obtained. Supervisory and administrative staff persons were to maintain a financial leger for each resident that was used to reconcile a resident’s financial account in accordance with their support plans. Additionally, staff persons were not permitted to “borrow” money from a resident or use a resident’s funds for personal use. The SP’s position description stated that s/he was responsible for ensuring the overall financial management of assigned area and services and proper management of the clients’ finances. Facility documentation showed that the SP and P1 were trained on VA1’s and VA2’s care plans, the facility’s Management of an Individual’s Monetary Resources policy, and the Reporting of Maltreatment of Vulnerable Adults. The SP was also trained on his/her job position. Conclusion: A. Maltreatment: VA1’s and VA2’s plans stated that each was susceptible to financial exploitation, had a limited understanding of money or banking concepts, and required the assistance of the facility and staff persons in managing their money. Information was consistent that two online payments for services were made using VA1’s account and were not authorized or used by VA1, totaling $459.02. On June 2, 2026, a payment was made to MIDCO (a regional cable, phone, and internet provider), for $231.64; and on June 9, 2026, a payment was made to Imagine Visa, for $227.38. LE obtained information which showed that the MIDCO account and the Imagine Visa account each belonged to the SP.
Information was consistent that VA2’s account was used to make an online purchase to Motlank Limited (an online beauty retailer) on May 27, 2026, for unknown items that were not authorized or used by VA2, totaling $45.86. P1 stated that VA2 did not receive any items or package(s) delivered to the facility from this online order/purchase from Motlank Limited (Motlankk). Given that only staff persons had access to VA1’s and VA2’s accounts and online account information and that neither VA1, VA2, nor their teams authorized these purchases, there was a preponderance of the evidence that in the absence of legal authority a person willfully used the funds of VA1 and VA2. 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 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP received training on VA1’s and VA2’s care plans, the facility’s Management of an Individual’s Monetary Resources policy, and the Reporting of Maltreatment of Vulnerable Adults. The SP denied to facility administrative staff and to this investigator that s/he made purchases using VA1’s and/or VA2’s accounts. However, the SP was the account holder for the MIDCO and Imagine Visa transactions that used VA1’s account information; P1 said that “only” supervisory staff, including the SP had access to VA1’s and VA2’s online banking information; and the online purchase using VA2’s account for Montlak was made less than one week prior. Therefore, the SP was responsible for maltreatment of VA1 and VA2. 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, 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 recurring maltreatment because the SP took money from VA1 two times (June 2 and 9, 2026,) and VA2 one time (May 27, 2026). However, the financial exploitation did not meet the definition of serious maltreatment because the amount taken from VA1 and VA2 was under $1000 respectively. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by the SP. The facility contacted VA1 and VA2’s financial institution to report and dispute the fraudulent charges and to update any account information or reissue new cards as necessary to VA1 and VA2, respectively. 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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