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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: 1116669-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden beth.virden@state.mn.us 651-431-6572 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) supplied THC (marijuana) products to a vulnerable adult (VA), who was receiving services and support at the facility and had a history of “addiction issues.” Date of Incident(s): Unknown; Ongoing prior to April 28, 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 July 20, 2026; from documentation at the facility; and through nine interviews conducted with the VA’s guardian (G) who was also the VA’s family member, the VA’s case managers (CM1 and CM2), facility staff persons (SP1, SP2, P1, and P2), a supervisory staff person (P3), and the VA’s housemate (H). This investigator met the VA, but s/he declined to be interviewed. The VA’s support plans, including Support Plan Addendum-Intensive Services, provided the following information: · The VA liked hanging out with friends and going to stores. · In 2024, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included major depressive disorder, fetal alcohol syndrome, borderline intellectual functioning, impulse control disorder, and stimulant use disorder. The facility provided at least one staff person 24 hours a day to help with the VA’s behavior management, medication administration, community integration, meal preparation, and transportation. Staff were to provide “verbal directives” to the VA if s/he was engaging in potentially dangerous behavior and/or entering potentially dangerous situations. · The VA wanted to stay sober from drugs and alcohol. “[The VA] is working on staying clean from drugs but does vape marijuana. [The VA] feels it helps [him/her] manage [his/her] moods.” As of March 2026, the VA acknowledged that s/he was “currently struggling with [his/her] sobriety” and that s/he was “smoking weed and vaping regularly.” · The VA did not have restrictions on his/her rights, which were determined to be necessary for his/her health, safety, and well-being. While living at the facility, the VA was over 21 years old. · [Note: There was no mention in the VA’s support plans reviewed for this investigation regarding what staff should do if the VA sought or obtained THC products, alcohol, or illegal substances.] According to mn.gov, Minnesota’s cannabis (THC) law was passed in 2023, which legalized cannabis-use by people ages 21 and older. The facility was a single-family house where the VA lived with the H and two other housemates. The facility’s Professional Conduct Policy stated that staff were prohibited from giving, receiving, trading, or borrowing gifts, money, personal belongings, or food with clients. Staff were prohibited from using, selling, possessing, soliciting, passing, or working under the influence of a controlled substance or alcohol. The G, CM1, and CM2 provided the following information: · The G said that when Minnesota legalized cannabis-use, “all hell broke loose” regarding the VA’s use of THC products. Immediately prior to moving into the facility, “[The VA] had more drug use.” · The G and CM1 each said that when the VA moved into the facility, they requested that staff not bring the VA to stores that sold THC products or alcohol, or to places near such stores. However, the VA was over 21 years old and did not have any restrictions on his/her rights. Staff were to encourage the VA to not use THC products and alcohol; however, they could not stop him/her if s/he wanted to. The G said that if the VA was determined to do something, s/he would find a way. The VA had a history of running away from staff in the community to buy THC products or alcohol and staff were not always able to stop him/her. The VA’s substance use continued throughout his/her stay at the facility and on April 27, 2026, the VA moved out of the facility. · The G, CM1, and CM2 each said that in mid-May 2026, the VA moved into a residence which was not owned or operated by the same license holder as the facility. On July 1, 2026, the VA, the G, CM1, and CM2 met to review the VA’s first 45 days at his/her new home; and during that meeting, the VA provided information about what happened when s/he lived at the facility. The VA said that SP1 gave the VA “residue” from SP1’s “bag of weed,” which got the VA “really high,” and that SP2 bought at least one THC vape for the VA.
· The G, CM1, and CM2 each said that the VA did not have a history of making similar statements about staff conduct. The G said that the VA typically declined to talk about things that might get someone else in trouble. CM1 said that the VA was a “guarded person” and typically “kept things private.” Note: At the time of the site visit, the VA told this investigator, “I don’t want to talk to you. I don’t want to get anyone in trouble.” A review of the facility’s daily notes for the month leading to the VA moving out of the facility provided the following information: · Seven different times, staff documented that the VA smoked THC at or outside the facility. · One time, staff brought the VA to a park where s/he obtained a “cart” (cartridge of cannabis oil for a vape pen) from an unidentified community person. · One time, the VA bought a THC pipe when s/he was out in the community with staff. P1, P2, and P3 each said that they had no information or awareness of any staff buying or giving THC products to the VA. The G had previously asked staff to avoid bringing the VA to stores that sold THC products or alcohol or to places near such stores. However, the VA had unsupervised time in the community and would buy or consume THC products and alcohol during that time. Staff encouraged the VA not to use controlled substances, but s/he was old enough to legally purchase these items and did not have any restrictions on his/her rights. If the VA brought a controlled substance back to the facility with him/her, there was not much staff could do to stop it. The VA did not have a history of making similar statements about staff; however, some staff said that s/he could be “manipulative” and/or had a history of being influenced by the H, who the VA mostly hung out with. SP1 and SP2 each said that they did not provide the VA with THC products and did not know why the allegations were made against them. The H said that s/he had no information or awareness of any staff buying or giving THC products to the VA. Facility documentation stated that SP1, SP2, P1, P2, and P3 received training on the VA’s support plans, including Support Plan Addendum-Intensive Services, and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The G, CM1, and CM2 each said that the VA told them that SP1 gave the VA “residue” from SP1’s “bag of weed,” which got the VA “really high,” and that SP2 bought at least one THC vape for the VA. The G, CM1, and CM2 each said that the VA did not have a history of making similar statements about staff conduct. At the time of the site visit, the VA told this investigator, “I don’t want to talk to you. I don’t want to get anyone in trouble.” SP1 and SP2 each denied the allegations; P1-P3 and the H had no similar concerns; and without additional information, it was not determined whose account was more credible. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary for the VA’s physical or mental health or safety and/or whether a staff person was responsible for supplying the VA with THC products. 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 and determined that policies and procedures were adequate and followed, and that there was not a need for additional staff training or corrective action. The VA had a history of purchasing his/her own THC products with his/her own money and the VA had no restrictions on what purchases s/he made. SP1 and SP2 each did not have prior related concerns with their conduct. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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