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 MALTREATMENT INVESTIGATION MEMORANDUM Office of Inspector General, Licensing Division Public Information 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: 1126823-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Carla Harvieux Minnesota Department of Human Services Office of Inspector General Licensing Division PO Box 64242 Saint Paul, Minnesota 55164-0242 carla.harvieux@state.mn.us 651-431-6616 Suspected Maltreatment Reported: It was reported that on the evening of January 15, 2026, a vulnerable adult (VA) left the facility without the supervision of a staff person (SP). The next day, the VA was found deceased in the community. Date of Incident(s): January 15, 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 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on February 20, 2026; from documentation at the facility, law enforcement records, and records from a medical examiner’s office; and through interviews conducted with facility staff persons (P1, P2, and the SP), and the VA’s family member (FM). According to the facility’s website, the facility provided Intensive Residential Treatment Services (IRTS) to individuals with severe and persistent mental illnesses, persons with co-occurring disorders, those in high-risk populations, people transitioning from psychiatric hospitals, correctional facilities, homelessness, or from inpatient care to community-based living. The facility worked to provide a path to stability for its residents who were ready to engage in therapeutic programming and supportive services to achieve mental health recovery and stability. The facility customized programs to meet diverse needs and used evidence-based practices for sustainable progress. The core of the facility’s program was “Enhanced Illness Management Recovery” that focused on empowering individuals, collaborating with partners, and offering medication management and administration. The facility provided individuals with information about mental illnesses and substance use disorders, helped them identify and modify unhelpful thought patterns and behaviors, and assisted them to recognize triggers. The facility also helped individuals develop coping mechanisms to maintain recovery, encouraged them to work toward intrinsically motivated change, and helped them set and pursue recovery goals. The facility was not a locked/secured facility. Facility documentation showed that the VA was diagnosed with schizoaffective disorder bipolar type and that s/he had a history of engaging in self-harm with the possible intention of dying by suicide. The VA was not subject to guardianship. Referral information from the facility showed that prior to residing at the facility, the VA was evaluated in the emergency department of a hospital and placed on an involuntary 72-hour hold because s/he had attempted to harm him/herself in early November of 2025. The VA was admitted to a program that provided care to individuals with mental illnesses and discharged to the facility in late November of 2025. Progress Notes for the VA showed that on November 21, 2025, the VA electronically signed the facility Client Handbook Orientation which included an explanation of the facility’s policies, procedures, and rules, and the VA’s rights. The facility outlined specific measures to minimize risk to individuals including assessing client needs and vulnerabilities during admission, completing initial diagnostic assessments, and assessing individuals throughout their stay at the facility to meet their needs and ensure that appropriate staffing levels were maintained. All shifts were awake shifts and on-call supervisors were available. Facility nurses reviewed and monitored the facility’s ongoing implementation of its Health Services and Medication Policy. The VA’s Diagnostic Assessment showed that the VA isolated him/herself over the years which weakened his/her support system. Primary difficulties for the VA included mood instability, anxiety, and periods of depression leading to low motivation and difficulty following through. The VA had a history of using substances including methamphetamines, marijuana, and alcohol, and might sometimes have auditory hallucinations. When the Diagnostic Assessment was completed on November 25, 2025, the VA denied that s/he had current thoughts of self-harm and said that s/he did not feel that s/he would “ever try to again,” but wanted to work on getting better. The VA’s Crisis Plan showed that s/he was referred to the facility due to an attempt to die by suicide. The VA felt that s/he was in crisis when s/he was unable to explain things, when s/he was unable to find the right words, or when someone was argumentative. Coping strategies that worked for the VA included breathing, meditation, taking walks, listening to music, and talking with someone to calm. The VA wanted staff persons to give him/her space when s/he felt stressed and time to “process.” The VA enjoyed going fishing and playing video games. The VA’s Individual Abuse Prevention Plan (IAPP) showed that the VA was vulnerable to “self-abuse” because the VA disregarded his/her personal safety. However, the facility documented that the VA told staff persons that s/he would not attempt self-harm at the facility, but there were concerns that the VA might attempt to harm him/herself after s/he was discharged or if s/he went on a “pass.” Updates to the IAPP on January 6, 2026, showed that staff persons worked with the VA to identify triggers and increase coping skills, provided distractions as needed, and would give the VA a referral for therapy in the community if the VA permitted it. The VA’s Functional Assessment was updated on January 15, 2026, to show that the VA consistently attended all scheduled groups and on-site therapy appointments and took his/her medications as prescribed. The VA was open, cooperative, and reflective during sessions, and seemed to benefit from structured therapeutic support. No information showed whether staff persons thought the VA was using substances at the time of the incident. However, it was noted that the VA had difficulty with interpersonal stress related to feelings of guilt, regret, and family relationships. The VA remained in contact with some of his/her family members but did not want to involve them in the treatment process. The VA’s Progress Notes for the week before s/he passed away documented that the VA engaged in group activities, but voiced concerns that s/he was not sleeping well at times and had some loss of appetite. Staff persons encouraged the VA to eat regular meals and provided feedback about the importance of sleep. On January 11, 2026, the VA felt “good” but was a little sad because it was an unspecified staff person’s last day of work at the facility. The VA was usually engaged in peer group interactions and staff persons assisted the VA and other individuals to use coping skills to process their thoughts and feelings. No information showed that the VA voiced self-harm thoughts to staff persons. The Program abuse Prevention Plan (PAPP) described the facility as a two-level residential residence with several bedrooms, two bathrooms, a kitchen, living area, dining room, and recreation room. There was a two-car-attached garage, a laundry area, and an administrative office area. The stairway that connected the upper and lower-level limited staff persons’ visibility of individuals on the stairway and the bathrooms were not within direct line of sight. Staff persons were to conduct and document “safety rounds” every four hours for individuals and every two hours for those identified as high risk. Checks were to include stairwells, bathrooms, the laundry area, and limited visibility areas. A site visit on February 20, 2026, showed that the facility had a video recording system with cameras inside and outside the facility that recorded anyone who left or entered the facility. The system did not have audio. Interviews with this investigator, facility documentation, the facility’s Internal Review, records from the law enforcement agency, and records from a medical examiner’s office provided the following: · P1, a facility supervisory/administrative staff person, said that at about 9:50 p.m., on January 15, 2026, the VA left the facility without supervision from a staff person. P1 thought that the SP attempted to prevent the VA from leaving the facility, and the VA said that s/he needed to go for a walk to clear his/her head and left the facility. The VA did not return, but P1 did not call a law enforcement agency right away because the local law enforcement agencies did not want the facility to call them unless it was an emergency. In addition, on January 17, 2026, P1 knew the VA was found deceased in the community, and law enforcement agencies were aware that the VA had left the facility and was deceased. · The facility’s schedule showed that on January 15, 2026, the SP worked from 9 p.m. to 7:30 a.m. the next morning. No other staff persons worked the overnight shift with the SP on January 15, 2026. · Recordings from the facility’s video recording system showed that there was a camera which recorded activities inside the facility at a main door. At 9:49:20 p.m. on January 15, 2026, the VA exited the facility. A camera which showed activities outside the door showed that at 9:49:28 p.m., the VA went onto the facility porch and over the porch railing into the yard, then walked out of the range of the camera. At 9:49:36 p.m., the SP walked toward the door that the VA had just passed through then exited the facility behind the VA. The camera that showed activity outside the facility showed that at 9:49:41 p.m., the SP exited the facility and looked in the direction in which the VA had walked. At 9:49:51 p.m., the SP left the porch and walked in the same direction as the VA had taken. The SP was then out of the camera’s range, and the camera did not show his/her subsequent actions. · The SP said that at about 9:45 p.m. on the date of the incident, s/he was sitting at a table in the living area in the facility’s upper level, when the VA exited his/her bedroom, walked past the SP, and went to the lower level of the facility. The SP heard a facility exit door open, so s/he immediately put on his/her coat and went downstairs but did not see the VA. The SP opened the exit door and went onto the open porch, where s/he observed the VA walking away from the facility to the SP’s left. The SP asked the VA where s/he was going, and said that the VA replied that, “My mind told me to leave,” and added that s/he needed to go for a walk to clear his/her head. According to the SP, the VA told him/her that s/he would return to the facility in about 15 minutes. · The SP asked the VA not to leave because it was dark and cold, and redirected the VA to stay at the facility several times, but the VA walked away from the facility and said that s/he would return in about 15 minutes. The VA sometimes left the facility after dark, and it was not uncommon for the VA or other individuals who received services at the facility to take walks after dark. The VA did not take his/her personal items like s/he might if s/he were leaving the facility without planning to return, and was dressed warmly for the weather, so the SP thought that the VA would return as s/he said s/he would. The SP provided electronic confirmation that at 9:52 p.m., on the date of the incident s/he notified P1 that the VA left the facility but said that s/he would be back. At 2:12 a.m., on January 16, 2026, the SP electronically updated P1 that the VA had not returned to the facility. · P1 confirmed that the SP immediately notified him/her that the VA left the facility but said that s/he would return. P1 asked the SP to keep him/her updated and said that the facility would follow its Missing Client policy. · The facility’s Missing Client policy showed that the facility would immediately investigate any missing client to ensure that if a client was found to be missing, the appropriate authorities were notified. Any client found to be absent from the facility for 24 hours without prior arrangement would be treated as missing and the facility and its immediate vicinity were to be searched. If the client was not located, the staff persons were to immediately contact the Program Director (PD), Treatment Director (TD), and/or facility health care professional (HCP) regarding the missing client, who would then notify a law enforcement agency, the client representative and/or emergency contact, and/or the client’s case manager. The facility was to provide law enforcement with the client’s name, age, description, mental status, mobility equipment information, and any other pertinent information. The PD, TD, or HCP was to complete an Incident Report, and make a report to the Minnesota Adult Abuse Reporting Center (MAARC). · Staff persons following the Missing Client policy would wait 24 hours to treat anyone missing from the facility as a missing person, which meant that the VA would not have been considered missing until about 9:50 p.m., on January 16, 2026, then staff persons were to notify P1, search the facility and its immediate vicinity, and the PD, TD, or HCP would notify a law enforcement agency, the client’s representative or emergency contact, and the client’s case manager and make a report to MAARC. · Records from a law enforcement agency showed that just after 9:30 a.m., on January 16, 2026, the agency received a call from a community person regarding an individual who was found deceased in the community. Law enforcement officers (LEOs) went to the community location and located the deceased individual, who was later determined to be the VA. When LEOs arrived, they assessed the VA and requested assistance from a medical examiner’s office. The VA was wearing multiple layers of clothing including a t-shirt, sweatshirt, several jackets, black sweatpants, and tennis shoes. A medical examiner (ME) came to the location and took the VA’s body to the ME’s office with him/her. LEOs identified the VA, notified the VA’s family members (FMs) that s/he was deceased, contacted the facility, and began an investigation into the VA’s death. · Records from the ME’s office showed that on January 16, 2026, the VA was found to have died by suicide in the community. A toxicology report showed that there were no substances in the VA’s blood at the time s/he passed away. · At 2:06 p.m., on January 17, 2026, P1 received a phone call from the FM who told P1 that s/he wanted to come get the VA’s personal items. P1 thought that the VA left the facility, decided not to return, or moved in with the FM, but the FM told P1 that the VA had died by suicide in the community after leaving the facility. At 2:40 p.m., on January 17, 2026, P1 completed a Critical Incident Reporting Form and sent it to DHS Licensing, and on January 24, 2026, the facility submitted a MAARC report regarding the incident and the VA’s death. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: The VA’s diagnoses included schizoaffective disorder bipolar type, and s/he had a history of engaging in self-harm. Prior to residing at the facility, the VA was placed on an involuntary hold because s/he attempted to harm him/herself in early November of 2025. Facility documentation showed that the VA had a history of using substances and sometimes had auditory hallucinations. The VA’s November 25, 2025, Diagnostic Assessment showed that the VA said that s/he did not have thoughts of self-harm and wanted to work on getting better. Documentation showed that on January 15, 2026, the VA attended groups and therapy appointments and took his/her medications as prescribed. The VA was described as open, cooperative, and reflective, and no information showed whether the VA was using substances at the time of the incident or that the VA voiced thoughts of self-harm to staff persons. Information was consistent that at about 9:50 p.m. on January 15, 2026, the VA left the facility and was found deceased in the community on January 16, 2026. The SP said that on January 15, 2026, s/he heard the VA exit the facility through a door on the lower level and quickly went to check on him/her. The SP redirected the VA to stay at the facility because it was after dark and cold outside. According to the SP, the VA said that s/he needed to take a walk to clear his/her mind and told the SP that s/he would return to the facility in about 15 minutes. The SP notified P1 shortly after the VA left the facility and later updated him/her that the VA had not returned. Video recordings from the facility showed that at 9:49:20 p.m. on January 15, 2026, the VA exited the facility. At 9:49:36 p.m., the SP walked toward the door that the VA had just passed through then exited the facility after the VA. The camera that showed activity outside the facility showed that the VA hopped over the porch rail and at 9:49:41 p.m., the SP exited the facility and looked in the direction in which the VA walked, then at 9:49:51 p.m., the SP left the porch and walked in the direction the VA took. The SP and the VA were out of the camera’s range, and their subsequent actions were not recorded. P1 confirmed the notification from the SP and instructed the SP to follow the facility’s Missing Client policy which showed that individuals were considered missing if they were absent from the facility for more than 24 hours. When a client was determined to be missing, staff persons were to search the facility and its vicinity, notify the PD, TD, or HCP, who would then notify a law enforcement agency, the client’s representative, emergency contact, or case manager, and then complete an Incident Report and make a report to MAARC. On January 17, 2026, the FM told P1 that the VA died by suicide in the community and P1 completed a Critical Incident Reporting Form that day, then made a report to MAARC on January 24, 2026. Records from the law enforcement agency and the medical examiner’s office determined that the VA died by suicide and there were no substances in his/her system when s/he passed away. Although the VA passed away in the community after leaving the facility, given that the facility was not a secure or locked facility, that the SP followed the VA within seconds of the VA exiting the facility, that the SP said s/he redirected the VA to return to the facility, and that no documentation showed that staff persons were aware that the VA might engage in self-harm on the date of the incident, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and services that were reasonable and necessary to obtain or maintain the VA’s health. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate and were followed regarding the incident. The facility reviewed its policies and procedures and considered additional staff training on early identification of “elopement risk” and reassessed its afterhours monitoring procedures. Action Taken by Department of Human Services, Office of Inspector General: On March 11, 2026, the facility was issued a correction order because it was determined that facility supervisory and administrative staff persons had knowledge that the VA passed away on January 17, 2026, and sent a Critical Incident Reporting form to DHS, but did not make a MAARC report until January 24, 2026.
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