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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: 1119990-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall Suspected Maltreatment Reported: It was reported that a staff person (SP) used a tetrahydrocannabinol (THC) vape pen multiple times that included when the SP drove two vulnerable adults (VA1, VA2) in the community. Date of Incident(s): Prior to May 19, 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 May 29, 2026; from documentation at the facility; and through seven interviews conducted with VA1, two facility supervisory staff persons (P1 and P2), two facility staff persons (P3 and P4), VA1’s guardian (G1), and VA2’s guardian (G2). VA2 declined to be interviewed but provided information for the facility’s internal review and that was included below. Attempts were made via telephone, text message, and certified and non-certified mail to contact and interview the SP, but the SP did not respond. VA1 enjoyed arts and crafts, spending time with friends, fishing, swimming, and attending various community events. VA1’s diagnoses included post-traumatic stress disorder, a mild intellectual disability, an unspecified impulse disorder, and persistent mood (affective) disorder. VA2 enjoyed playing basketball, swimming, volleyball, skating, reading, listening to music, and going for walks. VA2’s diagnoses included post-traumatic stress disorder, anxiety disorder, major depressive disorder, and substance use. The facility’s Substance Abuse/Drug and Alcohol Policy said that working under the influence was prohibited. the facility’s Safe Transportation Policy said that staff were to transport “persons served in a safe manner.” The facility was a split-level home with VA1’s and VA’2 bedrooms on the upper level. P1-P3 provided the following information in their interviews and for the facility’s internal review: · On an unknown date near the end of April 2026, around 6:30 p.m., P3 and the SP were on a break outside the front of the facility. The SP used a THC vape pen which P3 knew was THC because of the type of vape and smell of the vapor. P3 told the SP that it was “not okay” and that the SP should not use a THC vape at work. The SP seemed “frustrated” and after the conversation spent the rest of the shift coloring at a kitchen table. P3 did not tell a supervisor about the SP using the vape as s/he was afraid the SP would retaliate against P3. · On what P3 thought was May 14, 2026, P3 arrived at the facility for a shift at 3 p.m. and the SP, who was on a break, came back inside the facility. P3 thought the SP had an odor of THC vapor but was not sure. Later in the shift, the SP went outside to talk with a family member. When the SP came back inside, P3 smelled THC vapor on the SP. · On an unknown date, later determined to be May 19, 2026, P3 worked a shift with the SP. Around 3 p.m., the SP took a phone call outside and when s/he came back into the facility, P3 smelled THC vapor on the SP. P3 told P2, who was also at the facility, about the SP using a THC vape pen at the facility. P2 called P1 and asked for a call back. · Shortly after, P1 arrived at the facility and was met by P2 outside the facility. P2 told P1 what P3 said regarding the SP using a THC vape pen at the facility. P1 went into the facility and talked with P3, who repeated what s/he told P2. · P1 and P2 talked with the SP in the staff office and asked whether the SP had a THC vape pen at the facility. The SP said that s/he had a THC vape pen in his/her vehicle. The SP denied using the THC vape pen that day but did say that s/he had used the vape pen while on shift but “not in a while.” The SP was reminded of the facility’s policy regarding substance use and then the SP was directed to leave the facility. · P3 said that the SP was “fidgety” and would often tap his/her leg. One time when the SP drove, the SP “moved [his/her] legs rapidly” while driving and told P3 that s/he “always does that” when P3 asked. The SP was “not all over the road” when s/he drove but P3 was not sure if the SP drove after using THC. VA1 said that several times when the SP drove, s/he swerved in between lanes but that the other passengers in the vehicle, including P3 and P4, did not appear to notice. The SP vaped “a lot” and would frequently “tap” his/her leg but did not appear to be under the influence. For the internal review, VA2 said that the SP “sometimes acted crazy and had red eyes,” but did not know that the SP used THC. P4 did not have any concerns with the SP. P4 thought that the SP quit vaping and was not aware of the SP using a THC vape pen at the facility. G1 and G2 were aware of the allegation. G1 said VA1 would have told him/her if there was a “major issue.” Facility records showed that P1-P4 and the SP were trained on the VAs plans, the facility’s Substance Abuse/Drug and Alcohol Policy, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although the SP told P1 and P2 that s/he used a THC vape pen while s/he worked at the facility, that P3 saw the SP use a THC vape pen on one occasion and smelled THC vapor on the SP multiple times, and that VA1 said that the VA swerved while driving, given that it was unknown whether the SP passed medications and/or operated a vehicle while under the influence of THC and that the VAs did not suffer any injuries, there was not a preponderance of the evidence as to whether there was a failure to supply the VAs with care or services which were reasonable and necessary to maintain the VAs’ physical or mental health or safety. It was not determined whether neglect did not occur (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 and determined that policies and procedures were adequate but not followed when the SP violated the facility’s Substance Abuse/Drug and Alcohol Policy and when P3 did not “report concerns in a timely manner.” Staff were retrained on mandated reporting requirements and the facility’s Substance Abuse/Drug and Alcohol Policy. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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