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22:17:13'),(26509,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38109,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Chrysa Reichel\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38109}','68.53.115.247','2021-05-26 22:17:13'),(26510,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38110,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38110}','68.53.115.247','2021-05-26 22:17:13'),(26511,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38111,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38111}','68.53.115.247','2021-05-26 22:17:13'),(26512,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38112,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38112}','68.53.115.247','2021-05-26 22:17:13'),(26513,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38113,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Hennepin County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38113}','68.53.115.247','2021-05-26 22:17:13'),(26514,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38114,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"02\\/02\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38114}','68.53.115.247','2021-05-26 22:17:13'),(26515,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38115,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Individual is a 25 year old woman who lives in a 1 bedroom 245D group home in a residential area in Maple Grove.  It was reported in the CEP Intake Form that the individual was agitated around 12:00 am due to being told she could not call friends as it was too late.  An on call staff was called to help support the individual to understand it was too late to call friends.  The individual went to bed around 1:30 and locked her bedroom door.\\r\\n\\r\\nMorning staff arrived at 8:00 and knocked on individual\\u2019s door as medications needed to be administered.  Staff heard no response.  Being the door was locked, the staff obtained the key and it was then discovered the individual was not in her room.  Staff followed elopement protocol and notified on-call staff and non-emergency police.  Staff and police searched local area and found individual walking near the home and she was taken back home.\\r\\n\\r\\nIndividual stated she waited until overnight staff were in bathroom and then left the home.  She reported she walked to local Walmart, called a friend and then walked to his apartment as he was going call her an Uber.  Her friend came down to meet her, called her an Uber, she instructed the driver to drop her off at park near her group home vs her group home as she wanted to swing.  Originally the individual stated she left at 12:30 am but then stated she wasn\\u2019t sure when she left the home.\\r\\n\\r\\nIndividual complained of back and foot pain but refused to go to Urgent Care but opted to sleep.  The next morning she was willing to go and was diagnosed with First Degree Frostbite.  Doctor prescribed over the counter medication for blistering and pain.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38115}','68.53.115.247','2021-05-26 22:17:13'),(26516,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38116,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38116}','68.53.115.247','2021-05-26 22:17:13'),(26517,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38117,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"The individual\\u2019s plan was to have one awake and one asleep staff on overnight shift. There was no asleep staff.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38117}','68.53.115.247','2021-05-26 22:17:13'),(26518,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38118,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38118}','68.53.115.247','2021-05-26 22:17:13'),(26519,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38119,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"06\\/10\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38119}','68.53.115.247','2021-05-26 22:17:13'),(26520,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38120,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"orning staff arrived at 8:00 and knocked on individual\\u2019s door as medications needed to be administered.  Staff heard no response.  Being the door was locked, the staff obtained the key and it was then discovered the individual was not in her room.  Staff followed elopement protocol and notified on-call staff and non-emergency police.  Staff and police searched local area and found individual walking near the home and she was taken back home.\\r\\n\\r\\nIndividual stated she waited until overnight staff were in bathroom and then left the home.  She reported she walked to local Walmart, called friend and then walked to his apartment as he was going call her an Uber.  Her friend came down to meet her, called her an Uber, she instructed the driver to drop her off at park near her group home vs her group home as she wanted to swing.  Originally the individual stated she left at 12:30 am but then stated she wasn\\u2019t sure when she left the home.\\r\\n\\r\\nIndividual complained of back and foot pain but refused to go to Urgent Care but opted to sleep.  The next morning she was willing to go and was diagnosed with First Degree Frostbite.  Doctor prescribed over the counter medication for blistering and pain.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38120}','68.53.115.247','2021-05-26 22:17:13'),(26521,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38121,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38121}','68.53.115.247','2021-05-26 22:17:13'),(26522,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38122,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"No asleep staff for the overnight shift was influenced by the staff who was scheduled being ill and no one else available to cover the shift. Other staff were unwilling to cover this shift because the home is further away than most of the provider\\u2019s other homes. Also, the asleep shift was likely to be awake because the person was known for having challenging behaviors.  Further supporting staff\\u2019s unwillingness to cover this shift was that they would only receive $10\\/hour.\\r\\n\\r\\nAn additional factor that influenced the shift to go unfilled was that the provider didn\\u2019t feel pressure to fill the shift. The individual\\u2019s team, including the case manager at Hennepin County, had previously agreed that due to known staffing shortages with the provider, when an overnight asleep was not available the individual\\u2019s plan would allow for only the one awake overnight staff.\\r\\n\\r\\nMinnesota\\u2019s Rate Management System (RMS) determines a reimbursement rate for an individuals required supports (staffing pattern), which is agreed upon by the provider and case manager at the county per the DHS 6790 form.  This RMS rate then affects the provider determining they could pay overnight staff $10\\/hour for asleep shifts.  \\r\\n\\r\\nAnother influence was the Minnesota State Legislature, who creates laws governing provider rates, enforcing a 7% decrease in reimbursement rates to providers in July of 2018.  This impacted the provider\\u2019s ability to give an annual raises to staff and in turn influenced the provider having a staff shortage.  This was influenced by Federal (CMS) action determining Minnesota\\u2019s reimbursement rates were increased too much in recent years, and the Minnesota Department of Human Services\\u2019 decision to determine which rates needed to be cut and by how much to come into compliance with the CMS decision.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38122}','68.53.115.247','2021-05-26 22:17:13'),(26523,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38123,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38123}','68.53.115.247','2021-05-26 22:17:13'),(26524,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38124,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38124}','68.53.115.247','2021-05-26 22:17:13'),(26525,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38125,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38125}','68.53.115.247','2021-05-26 22:17:13'),(26526,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38126,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38126}','68.53.115.247','2021-05-26 22:17:13'),(26527,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38127,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38127}','68.53.115.247','2021-05-26 22:17:13'),(26528,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38128,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:13 pm\",\"created_at\":\"5\\/26\\/2021 5:17:13 pm\",\"id\":38128}','68.53.115.247','2021-05-26 22:17:14'),(26529,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38129,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38129}','68.53.115.247','2021-05-26 22:17:14'),(26530,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38130,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38130}','68.53.115.247','2021-05-26 22:17:14'),(26531,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38131,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"Other staff were unwilling to cover this shift because the home is further away than most of the provider\\u2019s other homes. Also, the asleep shift was likely to be awake because the person was known for having challenging behaviors.  Further supporting staff\\u2019s unwillingness to cover this shift was that they would only receive $10\\/hour.\\r\\n\\r\\nThis RMS rate then affects the provider determining they could pay overnight staff $10\\/hour for asleep shifts.  \\r\\n\\r\\nAnother influence was the Minnesota State Legislature, who creates laws governing provider rates, enforcing a 7% decrease in reimbursement rates to providers in July of 2018.  This impacted the provider\\u2019s ability to give an annual raises to staff and in turn influenced the provider having a staff shortage.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38131}','68.53.115.247','2021-05-26 22:17:14'),(26532,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38132,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38132}','68.53.115.247','2021-05-26 22:17:14'),(26533,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38133,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38133}','68.53.115.247','2021-05-26 22:17:14'),(26534,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38134,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38134}','68.53.115.247','2021-05-26 22:17:14'),(26535,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38135,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38135}','68.53.115.247','2021-05-26 22:17:14'),(26536,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38136,'{\"report_id\":221,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:17:14 pm\",\"created_at\":\"5\\/26\\/2021 5:17:14 pm\",\"id\":38136}','68.53.115.247','2021-05-26 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22:18:34'),(26616,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38216,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"07\\/21\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38216}','68.53.115.247','2021-05-26 22:18:34'),(26617,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38217,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Person had confirmed plans with staff to go to the metro area and see a friend. Due to staffing constraints, there was a change resulting in the cancellation or postponement of the trip. \\r\\n\\r\\nOn 7\\/21\\/19 the person went out for a cigarette at 2am and then allegedly went back to his room. That was the last time he was seen. It was during this time he eloped to Burnsville and MSP. Staff called 911 on or around 5:00 pm the next day once they noticed he was not in his bedroom.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38217}','68.53.115.247','2021-05-26 22:18:34'),(26618,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38218,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38218}','68.53.115.247','2021-05-26 22:18:34'),(26619,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38219,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Provider cancelled a person\'s planned trip\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38219}','68.53.115.247','2021-05-26 22:18:34'),(26620,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38220,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38220}','68.53.115.247','2021-05-26 22:18:34'),(26621,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38221,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38221}','68.53.115.247','2021-05-26 22:18:34'),(26622,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38222,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Person had been living at this house only months but had been with the same provider in a different home previously. He wanted to visit a friend near the metro area. Staff conveyed because of the distance and time for the trip it made sense that someone who was working a double shift would make the drive with him. Person followed usual and proper channels to schedule the out of town social activity.\\r\\nStaff felt that scheduling had become complicated at the time due to employees utilizing vacation time and also during that time the agency was very short staffed. The staff who was scheduled to take him on the trip during a double shift ended up not working the double shift because of how vacation was utilized. When the team saw this schedule conflict, the person was informed they couldn\\u2019t go on that weekend. He was initially disappointed, but he seemed to handle the news well after the initial disappointment. \\r\\nThe house manager usually has an assistant who arranges trips for residents. They work hard to prioritize social outings for people, trips and activities are accommodated. That assistant position was vacant and the house manager was feeling the \\u201cburn\\u201d of long hours and covering duties outside of her position. The staffing shortage made it hard to be sure residents were able to participate in desired activities.\\r\\nThe day they noticed person had eloped, staff had assumed he was sleeping in. He usually wakes by 9:00 but since he wasn\\u2019t utilizing a job coach during that time, there was no regular asleep\\/awake schedule. Also, there were no required checks in his plan. During counts, they noticed the bedroom door locked, but saw the window was open and that\\u2019s when they discovered he wasn\\u2019t there. Some of the staff were aware of his schedule change and that he was originally upset but had seemed to be fine with the change. \\r\\nPerson has history of elopement. He has a hard time making and keeping friends.  All of his housemates have girlfriends. When he elopes, they believe it is to see a female. Some of his housemates take trips together which he can\\u2019t attend due to his inability to afford the trips they take. \\r\\nHis adoptive mother\\/guardian is seen as unsupportive. There\\u2019s an impression among staff his adoptive mom and him bring out the worst in each other. They believe she expects the worst in him, affecting how he sees himself. They believe their relationship impacts his decisions in a negative way.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38222}','68.53.115.247','2021-05-26 22:18:34'),(26623,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38223,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38223}','68.53.115.247','2021-05-26 22:18:34'),(26624,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38224,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"The provider cancelling a planned trip for a person they served had a number of influences. On the morning the person was going to go on the trip, the provider was short staffed. Originally, the overnight staff was going to work a double shift by staying on for the morning shift. This staff ended up unable to work the morning shift, leaving the home with 2 staff instead of the typical 3. The provider agency was short staffed in general and did not fill the 3rd staff position for this day. The home served 4 people, 2 of which frequently exhibited challenging behavior. This level of need impacted the assignation of 3 staff to the day shifts. Also, the person\\u2019s CSSP addendum approved by the county required that the person be staffed at least 1:1 for trips, so due to short staffing it was not possible to send another staff on the trip. A factor into why 1:1 was necessary for trips was that the person had a history of abuse and because of this the guardian usually did not allow the person to meet people they met online without the 1:1 supervision required by the CSSP. Playing into the staffing requirements of the home too was the negotiation process between the county and the provider facilitated by DHS Form 6790 which determines staffing levels. This negotiation is impacted by each person in the home\\u2019s MnCHOICES assessment of need completed by the lead agency, as well as the Disability Waiver Rate Setting System which calculates service rates based on staffing needs. The Minnesota Legislature created both MnCHOICES and DWRS requirements. \\r\\nThis specific staff who couldn\\u2019t work the morning shift was the staff the person wanted to take him on the trip and he did not want to go with the other available staff. The person did not want the friend he was going to see to know he lived at the group home, and reportedly felt more comfortable going with the staff who was unable to work the morning shift. \\r\\nAnother influence to cancelling the trip was that the house manager felt burned out. The influences to the manager feeling burned out included the fact that the provider was \\u2013 as noted above - short staffed as an agency, the scheduler position who typically takes care of trips was also vacant, a number of staff were taking vacations at this time and the manager was filling a number of shifts themselves. Low unemployment rates in Minnesota and the region contributed to the provider\\u2019s short staff issue. Also, this specific trip required a staff to work more than 8 hours due to the distance of trip: driving from Duluth to the Twin Cities required 5-6 hours of drive time alone. This is why the overnight staff who was going to work the double was going to take the person. There was not any staff who could work an extra shift to take this person on the trip, let alone a staff the person wanted to go with. Typical policy was that the provider required 2 weeks notice before long trips to accommodate obtaining a guardian\\u2019s permission, case manager agreement and putting together the staffing needs, which made accommodating unexpected staff shortages difficult.  \\r\\nThe last of the influences identified was that this trip wasn\\u2019t a top priority for the staff. The person wanted to see a friend they met online in the metro area, but this person had a history of misusing social media. Specifically, when using social media, the person had a history of pretending to be someone else (known as catfishing) and, as mentioned above, had a history of being abused by people they met online. Partly due to this history, the staff wasn\\u2019t sure that the person their client wanted to visit was fully aware of who he was. Due to the vulnerability of the person and their history, the spontaneous trip didn\\u2019t meet the needs of the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38224}','68.53.115.247','2021-05-26 22:18:34'),(26625,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38225,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not perform visual checks between 2am and 5pm\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38225}','68.53.115.247','2021-05-26 22:18:34'),(26626,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38226,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"128\",\"question_type\":\"Yes_or_No\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38226}','68.53.115.247','2021-05-26 22:18:34'),(26627,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38227,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38227}','68.53.115.247','2021-05-26 22:18:34'),(26628,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38228,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":\"Person had been living at this house only months but had been with the same provider in a different home previously. He wanted to visit a friend near the metro area. Staff conveyed because of the distance and time for the trip it made sense that someone who was working a double shift would make the drive with him. Person followed usual and proper channels to schedule the out of town social activity.\\r\\nStaff felt that scheduling had become complicated at the time due to employees utilizing vacation time and also during that time the agency was very short staffed. The staff who was scheduled to take him on the trip during a double shift ended up not working the double shift because of how vacation was utilized. When the team saw this schedule conflict, the person was informed they couldn\\u2019t go on that weekend. He was initially disappointed, but he seemed to handle the news well after the initial disappointment. \\r\\nThe house manager usually has an assistant who arranges trips for residents. They work hard to prioritize social outings for people, trips and activities are accommodated. That assistant position was vacant and the house manager was feeling the \\u201cburn\\u201d of long hours and covering duties outside of her position. The staffing shortage made it hard to be sure residents were able to participate in desired activities.\\r\\nThe day they noticed person had eloped, staff had assumed he was sleeping in. He usually wakes by 9:00 but since he wasn\\u2019t utilizing a job coach during that time, there was no regular asleep\\/awake schedule. Also, there were no required checks in his plan. During counts, they noticed the bedroom door locked, but saw the window was open and that\\u2019s when they discovered he wasn\\u2019t there. Some of the staff were aware of his schedule change and that he was originally upset but had seemed to be fine with the change. \\r\\nPerson has history of elopement. He has a hard time making and keeping friends.  All of his housemates have girlfriends. When he elopes, they believe it is to see a female. Some of his housemates take trips together which he can\\u2019t attend due to his inability to afford the trips they take. \\r\\nHis adoptive mother\\/guardian is seen as unsupportive. There\\u2019s an impression among staff his adoptive mom and him bring out the worst in each other. They believe she expects the worst in him, affecting how he sees himself. They believe their relationship impacts his decisions in a negative way.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38228}','68.53.115.247','2021-05-26 22:18:34'),(26629,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38229,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38229}','68.53.115.247','2021-05-26 22:18:34'),(26630,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38230,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not performing visual checks on a person between 2am and 5pm had a number of influences. On the day the checks were not performed, the staff did not have any reason to believe that the person had eloped. While the person did have a history of elopement, he usually exhibited telltale signs of leaving the house such as telling staff they were leaving and\\/or taking a bag with him. These typical signs were not present this day. Instead the person left without telling anyone or taking a bag with him. Adding to the lack of reason to believe the person eloped was that the person often slept in, had an inconsistent sleep schedule, and refused to eat breakfast on the weekends, so sleeping in on Saturdays was a norm . This person also did not like to be bothered and often wanted his privacy while in his room. Due to cultural norms to allow privacy to people in their bedrooms along with the provider\\u2019s licensing statute \\u2013 MS 245D \\u2013 guaranteeing a person the right to privacy, this was wish was respected. \\r\\nAn additional influence to why checks weren\\u2019t performed was that the morning shift was short staffed. The house typically required 3 staff to be on in the morning. The overnight staff was going to work a double shift by staying on for the morning shift, but was unable to work. This left the provider with only 2 staff working in the morning shift. It was a norm at the house that they were comfortable only having 2 staff on if both staff were veteran staff, which was the case this day. Although the veteran staff were comfortable working short staffed, this did mean that the two staff had more responsibilities and were thus somewhat overworked and busy that day . \\r\\n The last influence identified by the mapping team into why staff did not perform checks was that the person\\u2019s plan did not require visual checks when he was at home. The provider typically does not perform visual checks on any person while they are in their own home. This practice is impacted by cultural norms to allow people privacy in their bedroom, an emphasis on person-centered planning and thinking and 245D rights to privacy. The provider noted that the only scenario in which they provide visual checks on a person when they were at home was if the person\\u2019s Coordinated Service and Support Plan (CSSP), created by the person\\u2019s case manager at the lead agency, indicated a need for them and assigned the provider responsibility for it. But considering the person\\u2019s history and his desire for privacy, the CSSP did not identify this as a need for this person at the time . The CSSP is created after a MnCHOICES assessment of the person\\u2019s needs is completed and neither the assessment nor the plan identified this level of need. Levels of need identified in the CSSP are reflected in the negotiation between the lead agency and the provider facilitated by the DHS-6790 Form. This form is influenced by the provider\\u2019s needs, the lead agency\\u2019s identification of the person\\u2019s needs and the Disability Waiver Rates System which provides a calculation for the person\\u2019s service rates. It was the final 6790 which ultimately allowed for the home to sometimes have 3 staff working the morning shift.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38230}','68.53.115.247','2021-05-26 22:18:34'),(26631,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38231,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38231}','68.53.115.247','2021-05-26 22:18:34'),(26632,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38232,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"On the day the checks were not performed, the staff did not have any reason to believe that the person had eloped. While the person did have a history of elopement, he usually exhibited telltale signs of leaving the house such as telling staff they were leaving and\\/or taking a bag with him. These typical signs were not present this day.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38232}','68.53.115.247','2021-05-26 22:18:34'),(26633,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38233,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38233}','68.53.115.247','2021-05-26 22:18:34'),(26634,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38234,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"On the morning the person was going to go on the trip, the provider was short staffed. The provider agency was short staffed in general and did not fill the 3rd staff position for this day.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38234}','68.53.115.247','2021-05-26 22:18:34'),(26635,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38235,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38235}','68.53.115.247','2021-05-26 22:18:34'),(26636,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38236,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38236}','68.53.115.247','2021-05-26 22:18:34'),(26637,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38237,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38237}','68.53.115.247','2021-05-26 22:18:34'),(26638,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38238,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38238}','68.53.115.247','2021-05-26 22:18:34'),(26639,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38239,'{\"report_id\":223,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:18:34 pm\",\"created_at\":\"5\\/26\\/2021 5:18:34 pm\",\"id\":38239}','68.53.115.247','2021-05-26 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22:21:09'),(26722,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38322,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38322}','68.53.115.247','2021-05-26 22:21:09'),(26723,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38323,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff administered more than one dose of PRN on several days in October 2018.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38323}','68.53.115.247','2021-05-26 22:21:09'),(26724,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38324,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38324}','68.53.115.247','2021-05-26 22:21:09'),(26725,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38325,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"06\\/25\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38325}','68.53.115.247','2021-05-26 22:21:09'),(26726,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38326,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Several workers administered the medication in the same way resulting in the error. Their decision to administer the medication in the way they did was driven by the instructions on the MAR which they all interpreted the same way, and which was also the incorrect interpretation. The staff interpreted the instruction of \\u201cdaily\\u201d to mean he could have it daily instead it meant a maximum daily (meant once a day and must be 4-6 hours after the last medication and only once a day, not every 4-6 hours daily), thus the over administration. The instructions were on the MAR and not on the med label, which was common practice. The staff followed the policy to check the label and MAR 3x any time there\\u2019s a med pass. All staff had received the required training and followed the signature and other MAR review requirements.\\r\\nThere were four people who signed off as over-administering the PRN. Two were DSPs, one area manager and one program director. The area manager and program director were covering for DSP hours due to a staffing shortage. The DSPs there were new to the agency, as was the program supervisor and the person. It was also noted the person subjected to the overmedication was a new client to the provider. It was conveyed that in a perfect world the provider wouldn\\u2019t take new service recipients until all staff were trained specific to a person. He came into a house that was already short-staffed. \\r\\n\\r\\nThe person had a high level of care, high needs, compared to others served at the home and was a newer resident of the home, moved there in September and incidents occurred in October. He began receiving services from this home after being in a hospital long after he required a hospital level of care. The transition from the hospital was described as hard: hospital social worker and care team communications were strained and confusing, and the med orders were also described as confusing. When a person with controlled meds transfers from a hospital to a provider, that time was described as being filled with angst. The sense of urgency leads to added stress. He was at the hospital for almost a year and there was extreme pressure to move him out of the hospital. The transition and care planning for this person were complicated by the fact that his guardian and contracted case manager were from Ramsey County. \\r\\n\\r\\nHe had multiple controlled meds and overlapping PRNs. For example, one PRN can only be taken X# of hours after another PRN, and there were several of these time lines and instructions to monitor. There was also one other man at the home who had a high contingent of medications. \\r\\n\\r\\nThe decision to administer the PRNs was also driven by the prescriber\\u2019s instruction to \\u201cgive him the PRN if he asks for it.\\u201d Person had been asking for many PRNs frequently. It was common for him to have more than one agitation a day. He had a diagnosis that included schizophrenia, delusional behavior. He had a long history of chemical abuse. Some of his PRNs included an inhaler, med to reduce nausea, ointment for gums. Staff describe his as having high seeking behavior and describe him as liking to be in control of his medications. He was seen by the staff as being very anxious and demanding. He occasionally raised his voice, swore, used power moves, his thoughts could get \\u201cout of control\\u201d and turn delusional. It was difficult for staff who had no experience with that. \\r\\nStaff attribute staffing of the house as a challenge. The house was very short staffed. The provider was not receiving exception rates for the people at this home. They attempted to increase the wage. The location of the home may have been a barrier to keeping it staffed. \\r\\nThe incident on 11\\/20\\/2018, the omission of a medication on the MAR, was influenced by a staffing shortage. The medication was not added to the MAR and it would have been a supervisor\\u2019s role to ensure the MAR was correct. The supervisor in charge of the MAR at that time is no longer with the company and was not debriefed. The person who attended the appointment, which was likely the same supervisor, also had a duty to ensure the correct instructions were passed along but that did not happen.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38326}','68.53.115.247','2021-05-26 22:21:09'),(26727,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38327,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38327}','68.53.115.247','2021-05-26 22:21:09'),(26728,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38328,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Several staff were involved in administering more than one dose of PRN to a person on several dates. This was influenced by a misinterpretation of instructions on the Medication Administration Report (MAR) which is created by the pharmacy. The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\\r\\n\\r\\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.\\r\\n\\r\\nWhile the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff.There are circumstances that can make a typical intake feel rushed and urgent, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \\r\\nEven under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \\u201crushed\\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process. \\r\\n\\r\\nAnother factor that contributed to the administration of more than one dose of PRN was staff felt pressure to administer PRNs. The person\\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\\u2019s instruction to give the person the PRN when he asked for it. Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.\\r\\n\\r\\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38328}','68.53.115.247','2021-05-26 22:21:09'),(26729,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38329,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38329}','68.53.115.247','2021-05-26 22:21:09'),(26730,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38330,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38330}','68.53.115.247','2021-05-26 22:21:09'),(26731,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38331,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38331}','68.53.115.247','2021-05-26 22:21:09'),(26732,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38332,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38332}','68.53.115.247','2021-05-26 22:21:09'),(26733,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38333,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38333}','68.53.115.247','2021-05-26 22:21:09'),(26734,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38334,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38334}','68.53.115.247','2021-05-26 22:21:09'),(26735,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38335,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"The person\\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\\u2019s instruction to give the person the PRN when he asked for it.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38335}','68.53.115.247','2021-05-26 22:21:09'),(26736,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38336,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38336}','68.53.115.247','2021-05-26 22:21:09'),(26737,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38337,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38337}','68.53.115.247','2021-05-26 22:21:09'),(26738,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38338,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38338}','68.53.115.247','2021-05-26 22:21:09'),(26739,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38339,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38339}','68.53.115.247','2021-05-26 22:21:09'),(26740,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38340,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:09 pm\",\"created_at\":\"5\\/26\\/2021 5:21:09 pm\",\"id\":38340}','68.53.115.247','2021-05-26 22:21:10'),(26741,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38341,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38341}','68.53.115.247','2021-05-26 22:21:10'),(26742,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38342,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38342}','68.53.115.247','2021-05-26 22:21:10'),(26743,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38343,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"110\",\"question_type\":\"Free_Text\",\"text_answer\":\"Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. Even under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \\u201crushed\\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38343}','68.53.115.247','2021-05-26 22:21:10'),(26744,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38344,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38344}','68.53.115.247','2021-05-26 22:21:10'),(26745,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38345,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38345}','68.53.115.247','2021-05-26 22:21:10'),(26746,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38346,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"113\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38346}','68.53.115.247','2021-05-26 22:21:10'),(26747,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38347,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":\"The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\\r\\n\\r\\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38347}','68.53.115.247','2021-05-26 22:21:10'),(26748,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38348,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38348}','68.53.115.247','2021-05-26 22:21:10'),(26749,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38349,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38349}','68.53.115.247','2021-05-26 22:21:10'),(26750,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38350,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38350}','68.53.115.247','2021-05-26 22:21:10'),(26751,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38351,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"118\",\"question_type\":\"Free_Text\",\"text_answer\":\"While the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff. There are circumstances that can make a typical intake feel more urgent or even rushed, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \\r\\n\\r\\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38351}','68.53.115.247','2021-05-26 22:21:10'),(26752,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38352,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38352}','68.53.115.247','2021-05-26 22:21:10'),(26753,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38353,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"120\",\"question_type\":\"Free_Text\",\"text_answer\":\"The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38353}','68.53.115.247','2021-05-26 22:21:10'),(26754,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38354,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"121\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38354}','68.53.115.247','2021-05-26 22:21:10'),(26755,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38355,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"122\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38355}','68.53.115.247','2021-05-26 22:21:10'),(26756,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38356,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"123\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38356}','68.53.115.247','2021-05-26 22:21:10'),(26757,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38357,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"124\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38357}','68.53.115.247','2021-05-26 22:21:10'),(26758,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38358,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"125\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38358}','68.53.115.247','2021-05-26 22:21:10'),(26759,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38359,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"126\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38359}','68.53.115.247','2021-05-26 22:21:10'),(26760,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38360,'{\"report_id\":225,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"432\",\"question_type\":\"Yes_or_No\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:21:10 pm\",\"created_at\":\"5\\/26\\/2021 5:21:10 pm\",\"id\":38360}','68.53.115.247','2021-05-26 22:21:10'),(26761,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38361,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"09\\/19\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:12 pm\",\"created_at\":\"5\\/26\\/2021 5:24:12 pm\",\"id\":38361}','68.53.115.247','2021-05-26 22:24:12'),(26762,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38362,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"76\",\"question_type\":\"Short_Answer\",\"text_answer\":\"201906864\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38362}','68.53.115.247','2021-05-26 22:24:21'),(26763,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38363,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"77\",\"question_type\":\"Date\",\"text_answer\":\"10\\/15\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38363}','68.53.115.247','2021-05-26 22:24:21'),(26764,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38364,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"78\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Sara Beauchene\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38364}','68.53.115.247','2021-05-26 22:24:21'),(26765,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38365,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"79\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Tony Gantenbein\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38365}','68.53.115.247','2021-05-26 22:24:21'),(26766,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38366,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Stepping Stones for Living\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38366}','68.53.115.247','2021-05-26 22:24:21'),(26767,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38367,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Laura Flynn\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38367}','68.53.115.247','2021-05-26 22:24:21'),(26768,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38368,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"laura.flynn@sslduluth.com\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38368}','68.53.115.247','2021-05-26 22:24:21'),(26769,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38369,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":\"218-336-6413\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38369}','68.53.115.247','2021-05-26 22:24:21'),(26770,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38370,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Staff Sleeping on Duty\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38370}','68.53.115.247','2021-05-26 22:24:21'),(26771,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38371,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"St. Louis County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38371}','68.53.115.247','2021-05-26 22:24:21'),(26772,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38372,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"09\\/19\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38372}','68.53.115.247','2021-05-26 22:24:21'),(26773,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38373,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"On 09\\/19\\/2019, it was reported that AP was found sleeping during their shift when they were to be supervising VA. At this time it is undetermined how long AP was asleep for. No harm came to VA during this time.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38373}','68.53.115.247','2021-05-26 22:24:21'),(26774,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38374,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38374}','68.53.115.247','2021-05-26 22:24:21'),(26775,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38375,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"One staff fell asleep during the day shift.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38375}','68.53.115.247','2021-05-26 22:24:21'),(26776,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38376,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"No\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38376}','68.53.115.247','2021-05-26 22:24:21'),(26777,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38377,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38377}','68.53.115.247','2021-05-26 22:24:21'),(26778,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38378,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38378}','68.53.115.247','2021-05-26 22:24:21'),(26779,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38379,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Staff No Longer Employed\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38379}','68.53.115.247','2021-05-26 22:24:21'),(26780,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38380,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"St. Louis County (Provider-Stepping Stones for Living)\\r\\nNarrative-Staff Sleeping\\r\\n\\r\\nLearning point: One staff fell asleep during the day shift. \\r\\n\\r\\nA DSP was found sleeping during the day shift while supervising two VAs. No harm came to VAs as a result. The staff sleeping was influenced by environmental factors in the home as well as outside factors. \\r\\n\\r\\nOne environmental factor in the home the day of the incident was that there were less people for the DSP to supervise than normal. There is usually an additional person to supervise, as the staffing ratio was 1:3. The third person was at an activity at the time. Due to this, the house was more quiet than usual which allowed for a more relaxed environment that lent itself to rest. For residents of the home, their needs are defined by assessment results and outlined in a Community Services and Support Plan. The level of staffing needed to address these needs is agreed to by provider and lead agency via a rate management worksheet called a 6790. The rates for the services which take into account shared and individual staffing are then entered into and set by the Disability Waiver Rates System (DWRS). \\r\\nAnother environmental factor in the home was the daily program consisted of unstructured home time and TV watching. That day, the house was quiet and there was unstructured TV watching time. Programs or daily schedules for residents are outlined in their CSSP and supported by policies that emphasize and protect personal preference. Personal preference and control over one\\u2019s schedule is a tenant of the federal Home and Community Based Services Rule which governs HCBS providers. Additionally, residential providers are required to carry a 245D license which secures a person\\u2019s right to choose activities they prefer and have a say in their daily schedule. This unstructured time was an additional factor that led to a quiet house in which the staff experienced down time, leading to sleep. \\r\\nOutside factors that contributed to staff sleeping were also present. One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. The fact the provider had unfilled shifts is due to the well-known and highly publicized state and national workforce shortage.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38380}','68.53.115.247','2021-05-26 22:24:21'),(26781,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38381,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38381}','68.53.115.247','2021-05-26 22:24:21'),(26782,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38382,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38382}','68.53.115.247','2021-05-26 22:24:21'),(26783,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38383,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38383}','68.53.115.247','2021-05-26 22:24:21'),(26784,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38384,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38384}','68.53.115.247','2021-05-26 22:24:21'),(26785,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38385,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38385}','68.53.115.247','2021-05-26 22:24:21'),(26786,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38386,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:24:21 pm\",\"created_at\":\"5\\/26\\/2021 5:24:21 pm\",\"id\":38386}','68.53.115.247','2021-05-26 22:24:21'),(26787,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38387,'{\"report_id\":226,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"One environmental factor in the home the day of the incident was that there were less people for the DSP to supervise than normal. There is usually an additional person to supervise, as the staffing ratio was 1:3. The third person was at an activity at the time. Due to this, the house was more quiet than usual which allowed for a more relaxed environment that lent itself to rest. For residents of the home, their needs are defined by assessment results and outlined in a Community Services and Support Plan. The level of staffing needed to address these needs is agreed to by provider and lead agency via a rate management worksheet called a 6790. The rates for the services which take into account shared and individual staffing are then entered into and set by the Disability Waiver Rates System (DWRS). \\r\\nAnother environmental factor in the home was the daily program consisted of unstructured home time and TV watching. That day, the house was quiet and there was unstructured TV watching time. 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One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. 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One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. 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22:25:48'),(26819,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38419,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Bridges MN\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38419}','68.53.115.247','2021-05-26 22:25:48'),(26820,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38420,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Kelsey Traynor (completed the BIRF)\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38420}','68.53.115.247','2021-05-26 22:25:48'),(26821,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38421,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"kelseyt@bridgesmn.com\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38421}','68.53.115.247','2021-05-26 22:25:48'),(26822,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38422,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":\"651-334-9629\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38422}','68.53.115.247','2021-05-26 22:25:48'),(26823,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38423,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38423}','68.53.115.247','2021-05-26 22:25:48'),(26824,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38424,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Hennepin County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38424}','68.53.115.247','2021-05-26 22:25:48'),(26825,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38425,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"06\\/29\\/2020\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38425}','68.53.115.247','2021-05-26 22:25:48'),(26826,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38426,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"On 06\\/29\\/2020 VA packed up his belongings at approximately 6:00 pm and left the home, stating he was going to\\r\\nChicago to visit his sister. VA then proceeded to walk towards the bus stop and waited. Staff followed the bus once VA got on the bus. Staff\\r\\ncontacted Metro Transit Police for assistance, who then intervened. The officer called the Supervisor, who then called in the Community\\r\\nLiving Director (CLD) as well, via phone, to discuss the situation. The CLD explained VA\'s situation and that he is on a commitment and\\r\\nprovisional discharge, and requested assistance in getting the VA back to the residence. The officer informed the CLD and supervisor that\\r\\ndue to VA being their own guardian and not being a danger to himself or others, they could not do anything except encourage VA to go with\\r\\nstaff. The CLD then met VA and staff at the Greyhound Bus Station in Minneapolis a little before 8:00 pm, just as VA was purchasing a bus\\r\\nticket to Chicago. Staff and CLD attempted every approach they could think of to get VA to reconsider leaving the state, but VA still planned\\r\\nto get on the bus. VA reported having connections in Chicago and has a plan, but would not share any further details. VA recently\\r\\npurchased a cell phone, but refused to give staff the phone number to the new phone. The CLD called Fairview Hospital to discuss the\\r\\nsituation, but they also stated \\\"our hands are tied\\\" since VA is his own guardian. Staff remained with VA at the bus station until 1:00 am on\\r\\n06\\/30\\/2020, when VA left on the greyhound bus to Chicago. The CLD filed a missing persons report with the Minneapolis Police\\r\\nDepartment, who stated they would pass this report along to the Chicago Police Department as well. The CLD attempted to contact VA\'s\\r\\nmother, but the mother\'s phone was disconnected. The CLD also attempted to call VA\'s grandmother, who did not answer or respond to\\r\\nthe CLD\'s voicemails.\\r\\nStaff followed all care plans and attempted to redirect VA into not going on the bus, but VA made the choice to leave. VA did not have any\\r\\nmedications packed and is due for an injection on 07\\/08\\/2020. VA is prescribed multiple psychotropic medications, including an injection.\\r\\nVA has a history of attempting to\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38426}','68.53.115.247','2021-05-26 22:25:48'),(26827,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38427,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38427}','68.53.115.247','2021-05-26 22:25:48'),(26828,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38428,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38428}','68.53.115.247','2021-05-26 22:25:48'),(26829,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38429,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38429}','68.53.115.247','2021-05-26 22:25:48'),(26830,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38430,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"10\\/06\\/2020\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38430}','68.53.115.247','2021-05-26 22:25:48'),(26831,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38431,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Two night staff from Bridges were de-briefed.  They relieved two second shift staff who followed the person to the bus station and worked to help attempt to help the person return home.  \\r\\n\\r\\nThe staff worked by relieving each other in the bus station as there was not adequate parking at the bus station so they had to park on the street and one person needed to remain in the car to assure it did not get towed.   They both stated the person would not talk to them and the bus station was very busy.  The person smoked frequently outside the bus station while waiting for departure.   Staff also had one mask to share while switching spots from the car to inside the bus station next to the person.  Staff would use their shirt as a mask while switching.   The person spent most of their time listening to music and ignoring staff.   Staff attempted several times to have a conversation in an effort to persuade the person to return back to the home.   At about 1:00 AM the person departed on the bus and staff returned back to the home.   Staff were in frequent contact with the home manager for guidance. Staff were instructed to remain with the person at the bus station, however, they were instructed that he was his own guardian and could leave.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38431}','68.53.115.247','2021-05-26 22:25:48'),(26832,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38432,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38432}','68.53.115.247','2021-05-26 22:25:48'),(26833,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38433,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Learning Point:  Staff were unable to redirect a person from departing on a bus to Chicago.  \\r\\n\\r\\nStaff was unable to redirect a person from departing on a bus to Chicago and this was influenced by wanting to go to Chicago to visit their sister. This matter was complicated given the person wouldn\\u2019t communicate with staff present.  All efforts to redirect the person were unsuccessful while exhausting all other safe alternatives. The person was earlier hospitalized regarding mental health and aggression and the staff was hesitant at the moment and didn\\u2019t want to anger the person further. Another contributing factor was that the person received a COVID stimulus check that created the means for the visit to Chicago.    \\r\\n\\r\\nStaff being unable to redirect the person was influenced by the provider ultimately determining the risk was low to take the trip without staff. After many unsuccessful attempts to redirect, the provider reviewed the person\\u2019s risk management plan and it was affirmed. Contributing factors that further influenced the staffs\\u2019 decision to remain at the bus station was the expectation of the lead agency and CSSP was not to follow a person to another state while eloping and assure full communication with all team members and agency staff.\\r\\n\\r\\nAnother influence to the inability to redirect was that staff were hesitant to anger the person. This was further supported by the person having a history of aggressive behavior. The person wouldn\\u2019t communicate with the staff present and they were hesitant to coerce the person too much in their efforts to support him in being safe. Staff also did offer to support this trip at a future date with proper planning to assure health and safety. This moment was further complicated by contacting the hospital who stated there was nothing they or staff could do given the person was his own guardian which further limited staff in their efforts to help him return home.\\r\\n\\r\\nAn additional feature that impacted the support lent to the person was the agency\\u2019s practice of person-centered efforts in trying to find balance of what was important to and for the person while making decisions at that moment. Their operating philosophy supported personal freedoms and choices based on experiences over time.  There is also an overall systemic expectation that providers support experiences, choices, and the person\\u2019s rights.   \\r\\n\\r\\nStaff being unable to redirect was influenced by the provider exhausting all safe alternatives. The person is their own guardian and did have a provisional discharge from the program.  Furthermore, COVID and the Governor\\u2019s stay at home order also influenced the person\\u2019s decision to leave as his routine was limited to low activity. This elopement influenced the agency, team, and staff present to honor the person\\u2019s civil rights which connected directly to their philosophy of protecting his rights which put him in charge of making the decision to leave on the bus.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38433}','68.53.115.247','2021-05-26 22:25:48'),(26834,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38434,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38434}','68.53.115.247','2021-05-26 22:25:48'),(26835,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38435,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38435}','68.53.115.247','2021-05-26 22:25:48'),(26836,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38436,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38436}','68.53.115.247','2021-05-26 22:25:48'),(26837,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38437,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38437}','68.53.115.247','2021-05-26 22:25:48'),(26838,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38438,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38438}','68.53.115.247','2021-05-26 22:25:48'),(26839,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38439,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38439}','68.53.115.247','2021-05-26 22:25:48'),(26840,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38440,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38440}','68.53.115.247','2021-05-26 22:25:48'),(26841,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38441,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38441}','68.53.115.247','2021-05-26 22:25:48'),(26842,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38442,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38442}','68.53.115.247','2021-05-26 22:25:48'),(26843,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38443,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38443}','68.53.115.247','2021-05-26 22:25:48'),(26844,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38444,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38444}','68.53.115.247','2021-05-26 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22:25:48'),(26853,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38453,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38453}','68.53.115.247','2021-05-26 22:25:48'),(26854,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38454,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff was unable to redirect a person from departing on a bus to Chicago and this was influenced by wanting to go to Chicago to visit their sister. This matter was complicated given the person wouldn\\u2019t communicate with staff present.  All efforts to redirect the person were unsuccessful while exhausting all other safe alternatives. The person was earlier hospitalized regarding mental health and aggression and the staff was hesitant at the moment and didn\\u2019t want to anger the person further. Another contributing factor was that the person received a COVID stimulus check that created the means for the visit to Chicago.    \\r\\n\\r\\nStaff being unable to redirect the person was influenced by the provider ultimately determining the risk was low to take the trip without staff. After many unsuccessful attempts to redirect, the provider reviewed the person\\u2019s risk management plan and it was affirmed. Contributing factors that further influenced the staffs\\u2019 decision to remain at the bus station was the expectation of the lead agency and CSSP was not to follow a person to another state while eloping and assure full communication with all team members and agency staff.\\r\\n\\r\\nAnother influence to the inability to redirect was that staff were hesitant to anger the person. This was further supported by the person having a history of aggressive behavior. The person wouldn\\u2019t communicate with the staff present and they were hesitant to coerce the person too much in their efforts to support him in being safe. Staff also did offer to support this trip at a future date with proper planning to assure health and safety. This moment was further complicated by contacting the hospital who stated there was nothing they or staff could do given the person was his own guardian which further limited staff in their efforts to help him return home.\\r\\n\\r\\nAn additional feature that impacted the support lent to the person was the agency\\u2019s practice of person-centered efforts in trying to find balance of what was important to and for the person while making decisions at that moment. Their operating philosophy supported personal freedoms and choices based on experiences over time.  There is also an overall systemic expectation that providers support experiences, choices, and the person\\u2019s rights.   \\r\\n\\r\\nStaff being unable to redirect was influenced by the provider exhausting all safe alternatives. The person is their own guardian and did have a provisional discharge from the program.  Furthermore, COVID and the Governor\\u2019s stay at home order also influenced the person\\u2019s decision to leave as his routine was limited to low activity. This elopement influenced the agency, team, and staff present to honor the person\\u2019s civil rights which connected directly to their philosophy of protecting his rights which put him in charge of making the decision to leave on the bus.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38454}','68.53.115.247','2021-05-26 22:25:48'),(26855,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38455,'{\"report_id\":227,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:25:48 pm\",\"created_at\":\"5\\/26\\/2021 5:25:48 pm\",\"id\":38455}','68.53.115.247','2021-05-26 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22:26:26'),(26868,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38468,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"76\",\"question_type\":\"Short_Answer\",\"text_answer\":\"201908690\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38468}','68.53.115.247','2021-05-26 22:26:30'),(26869,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38469,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"77\",\"question_type\":\"Date\",\"text_answer\":\"12\\/16\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38469}','68.53.115.247','2021-05-26 22:26:30'),(26870,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38470,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"78\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Scott Schifsky\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38470}','68.53.115.247','2021-05-26 22:26:30'),(26871,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38471,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"79\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Sara Beauchene\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38471}','68.53.115.247','2021-05-26 22:26:30'),(26872,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38472,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"JEC Miller\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38472}','68.53.115.247','2021-05-26 22:26:30'),(26873,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38473,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Adam Gregg\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38473}','68.53.115.247','2021-05-26 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22:26:30'),(26876,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38476,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38476}','68.53.115.247','2021-05-26 22:26:30'),(26877,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38477,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Hennepin County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38477}','68.53.115.247','2021-05-26 22:26:30'),(26878,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38478,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"11\\/23\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38478}','68.53.115.247','2021-05-26 22:26:30'),(26879,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38479,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Peter walked to the store down the road from his home. He was gone for roughly 30 minutes. Peter does not have alone time.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38479}','68.53.115.247','2021-05-26 22:26:30'),(26880,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38480,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38480}','68.53.115.247','2021-05-26 22:26:30'),(26881,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38481,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38481}','68.53.115.247','2021-05-26 22:26:30'),(26882,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38482,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38482}','68.53.115.247','2021-05-26 22:26:30'),(26883,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38483,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"02\\/12\\/2020\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38483}','68.53.115.247','2021-05-26 22:26:30'),(26884,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38484,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38484}','68.53.115.247','2021-05-26 22:26:30'),(26885,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38485,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38485}','68.53.115.247','2021-05-26 22:26:30'),(26886,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38486,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. Low unemployment rates in the region and the state contributed to low unemployment rates, which in turn contributed the provider being short staffed. Adding to the unfamiliarity the staff had with the home, the person who eloped was difficult to understand and was noted to often test boundaries with staff which made it difficult for staff to understand that the person was not supposed to be alone.\\r\\n\\r\\nThe staff\\u2019s understanding of the difference between alone and community time further influenced the staff not following the person\\u2019s plan.  There was also another person in the home that did not have alone time which was contrary to the house norm which implied that each person had some alone time.  Furthermore, the two staff\\u2019s roles were not clearly communicated to them and the second staff didn\\u2019t counter the support staff\\u2019s understanding and may not have been aware.   The person\\u2019s plan stated they did have 10 minutes of home time alone but no unsupervised time in the community.  This created confusion for the staff who was new working in the home and had to train fast. \\r\\n\\r\\nThe basis for alone time according to the provider can be difficult to manage as staff have to read multiple plans for a person.  There was also pressure due to the staff shortage that is directly tied to regional and statewide staff shortages and overall low unemployment rates.  The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.  The DWRS further influences the 6790 which connects to provider resources and their need to share a van with multiple locations that support people with disabilities.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38486}','68.53.115.247','2021-05-26 22:26:30'),(26887,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38487,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38487}','68.53.115.247','2021-05-26 22:26:30'),(26888,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38488,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38488}','68.53.115.247','2021-05-26 22:26:30'),(26889,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38489,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38489}','68.53.115.247','2021-05-26 22:26:30'),(26890,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38490,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38490}','68.53.115.247','2021-05-26 22:26:30'),(26891,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38491,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38491}','68.53.115.247','2021-05-26 22:26:30'),(26892,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38492,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38492}','68.53.115.247','2021-05-26 22:26:30'),(26893,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38493,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38493}','68.53.115.247','2021-05-26 22:26:30'),(26894,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38494,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:26:30 pm\",\"created_at\":\"5\\/26\\/2021 5:26:30 pm\",\"id\":38494}','68.53.115.247','2021-05-26 22:26:30'),(26895,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38495,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. 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He was gone for roughly 30 minutes. Peter does not have alone time.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38530}','68.53.115.247','2021-05-26 22:27:12'),(26931,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38531,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38531}','68.53.115.247','2021-05-26 22:27:12'),(26932,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38532,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38532}','68.53.115.247','2021-05-26 22:27:12'),(26933,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38533,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38533}','68.53.115.247','2021-05-26 22:27:12'),(26934,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38534,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"02\\/12\\/2020\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38534}','68.53.115.247','2021-05-26 22:27:12'),(26935,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38535,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38535}','68.53.115.247','2021-05-26 22:27:12'),(26936,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38536,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38536}','68.53.115.247','2021-05-26 22:27:12'),(26937,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38537,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. Low unemployment rates in the region and the state contributed to low unemployment rates, which in turn contributed the provider being short staffed. Adding to the unfamiliarity the staff had with the home, the person who eloped was difficult to understand and was noted to often test boundaries with staff which made it difficult for staff to understand that the person was not supposed to be alone.\\r\\n\\r\\nThe staff\\u2019s understanding of the difference between alone and community time further influenced the staff not following the person\\u2019s plan.  There was also another person in the home that did not have alone time which was contrary to the house norm which implied that each person had some alone time.  Furthermore, the two staff\\u2019s roles were not clearly communicated to them and the second staff didn\\u2019t counter the support staff\\u2019s understanding and may not have been aware.   The person\\u2019s plan stated they did have 10 minutes of home time alone but no unsupervised time in the community.  This created confusion for the staff who was new working in the home and had to train fast. \\r\\n\\r\\nThe basis for alone time according to the provider can be difficult to manage as staff have to read multiple plans for a person.  There was also pressure due to the staff shortage that is directly tied to regional and statewide staff shortages and overall low unemployment rates.  The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.  The DWRS further influences the 6790 which connects to provider resources and their need to share a van with multiple locations that support people with disabilities.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38537}','68.53.115.247','2021-05-26 22:27:12'),(26938,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38538,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38538}','68.53.115.247','2021-05-26 22:27:12'),(26939,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38539,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38539}','68.53.115.247','2021-05-26 22:27:12'),(26940,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38540,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38540}','68.53.115.247','2021-05-26 22:27:12'),(26941,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38541,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38541}','68.53.115.247','2021-05-26 22:27:12'),(26942,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38542,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38542}','68.53.115.247','2021-05-26 22:27:12'),(26943,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38543,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38543}','68.53.115.247','2021-05-26 22:27:12'),(26944,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38544,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38544}','68.53.115.247','2021-05-26 22:27:12'),(26945,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38545,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38545}','68.53.115.247','2021-05-26 22:27:12'),(26946,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38546,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. The basis for alone time according to the provider can be difficult to manage as staff have to read multiple plans for a person.   The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.  The DWRS further influences the 6790 which connects to provider resources and their need to share a van with multiple locations that support people with disabilities.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38546}','68.53.115.247','2021-05-26 22:27:12'),(26947,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38547,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38547}','68.53.115.247','2021-05-26 22:27:12'),(26948,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38548,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":\"The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38548}','68.53.115.247','2021-05-26 22:27:12'),(26949,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38549,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38549}','68.53.115.247','2021-05-26 22:27:12'),(26950,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38550,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38550}','68.53.115.247','2021-05-26 22:27:12'),(26951,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38551,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38551}','68.53.115.247','2021-05-26 22:27:12'),(26952,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38552,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"110\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38552}','68.53.115.247','2021-05-26 22:27:12'),(26953,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38553,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38553}','68.53.115.247','2021-05-26 22:27:12'),(26954,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38554,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. Low unemployment rates in the region and the state contributed to low unemployment rates, which in turn contributed the provider being short staffed. Adding to the unfamiliarity the staff had with the home, the person who eloped was difficult to understand and was noted to often test boundaries with staff which made it difficult for staff to understand that the person was not supposed to be alone.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38554}','68.53.115.247','2021-05-26 22:27:12'),(26955,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38555,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"113\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38555}','68.53.115.247','2021-05-26 22:27:12'),(26956,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38556,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38556}','68.53.115.247','2021-05-26 22:27:12'),(26957,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38557,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38557}','68.53.115.247','2021-05-26 22:27:12'),(26958,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38558,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38558}','68.53.115.247','2021-05-26 22:27:12'),(26959,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38559,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38559}','68.53.115.247','2021-05-26 22:27:12'),(26960,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38560,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"118\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38560}','68.53.115.247','2021-05-26 22:27:12'),(26961,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38561,'{\"report_id\":228,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:12 pm\",\"created_at\":\"5\\/26\\/2021 5:27:12 pm\",\"id\":38561}','68.53.115.247','2021-05-26 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22:27:58'),(26976,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38576,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Opportunity Partners - Keith\'s Place\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38576}','68.53.115.247','2021-05-26 22:27:58'),(26977,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38577,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Jay McKibbins\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38577}','68.53.115.247','2021-05-26 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22:27:58'),(26982,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38582,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"08\\/24\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38582}','68.53.115.247','2021-05-26 22:27:58'),(26983,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38583,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"VA, Housemate and AP were at food court in Eden Prairie mall. VA needed to go to the bathroom. Bathroom was at sight so AP let VA walk\\r\\nto the bathroom by himself. AP observed VA walk in to the bathroom but did not observe VA come out. After about 10 minutes, AP went to\\r\\ncheck the bathroom with Housemate but VA was not there. AP talked to an unknown cleaning lady about contacting the security. AP\\r\\ncontacted security and also called Nurse and Reporter. Nurse contacted Coordinator.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38583}','68.53.115.247','2021-05-26 22:27:58'),(26984,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38584,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38584}','68.53.115.247','2021-05-26 22:27:58'),(26985,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38585,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not continuously monitor a public restroom door a person with dementia was using.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38585}','68.53.115.247','2021-05-26 22:27:58'),(26986,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38586,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38586}','68.53.115.247','2021-05-26 22:27:58'),(26987,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38587,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"10\\/13\\/2020\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38587}','68.53.115.247','2021-05-26 22:27:58'),(26988,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38588,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff drove two housemates to the Eden Prairie mall. The staff and housemates frequent the mall and are very familiar with the area. They parked in the back of the mall parking lot as they prefer the walk into the mall for some exercise. After shopping in the mall they stopped at the food court for lunch. The person who went missing brought his own lunch and after eating needed to use the restroom. This person had never used the restroom at this mall before. Staff stayed with the other person while he walked to the restroom. The restroom sign was in line of sight for the staff and staff saw the person enter the hallway that led to the restroom. There was only one entrance to the restroom area.  \\r\\n\\r\\nWhile the person was using the restroom, the staff reported the other person was experiencing anxiety. Staff is trained in positive behavior approaches and did help the person by talking to them while they used a paper bag to take some deep breaths. After about 10 minutes, staff and the person she was supporting went to the restroom area to check on the person as they did not see him exit. While she was assisting the person, she did have line of sight on the exit to her best knowledge. Staff checked the family and womens restroom, while the other person checked the mens restroom. The person was not present. Staff then spoke with a cleaning attendant and she helped contact the mall security.   \\r\\n\\r\\nMall security searched for the person while the staff and other person searched around the food court. Mall security then asked the staff to remain at the food court and that they would contact the police to assist.  Staff then called the Opportunity Partners nurse as the typical program manager was on vacation.  \\r\\n\\r\\nAt about 12:45 the mall security found the person standing by the staff\\u2019s vehicle. Mall security then reunited the staff with the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38588}','68.53.115.247','2021-05-26 22:27:58'),(26989,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38589,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38589}','68.53.115.247','2021-05-26 22:27:58'),(26990,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38590,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff did not continuously monitor a public restroom door a person with dementia was using. This was influenced by staff\\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety. The staff and the two people routinely went to this mall and the one person did not return from the restroom as anticipated.  Staff was within line of sight of the the entrance to the bathroom that only had one exit. The staff did not think using the restroom was a risk and assumed he\\u2019d return safely given they frequent the mall and are familiar. Staff knew there was not a back door behind the restrooms. \\r\\n\\r\\nThe person had only recently been diagnosed with dementia. While the company nurse trained the staff on supporting people with dementia, the staff was not certain what that meant for the person, but did have familiarity with supporting the person. The person also had been grieving the loss  of a long-time friend\\/room mate. Person-Centered practices influenced the decision to adhere to the person\\u2019s routine and community inclusion activities to have lunch at the mall. This situation was further complicated as the definition of the need of support was not synonimous with the agency\\u2019s definition. While the person\\u2019s CSSP required 24\\/7 supervision, it did not require \\u201cdirect line of sight\\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \\u201cdirect line of sight\\u201d supervision would require 1:1 staffing, which was not supported in the person\\u2019s CSSP or 6790 rate form. \\r\\n\\r\\n\\r\\nThe providers policies allowed for a 1:2 staffing ratio which is influenced by the county via the 6790 rates form and DHS\\u2019s DWRS system. The person\\u2019s MNCHOICES assessment was not up for renewal for several months which creates more complexity while the person\\u2019s dementia as the condition possibly changes or is not understood over time and new symptoms develop. The provider noted that while many times a person with dementia has a higher staffing level in the community, this person did not yet have a higher staffing level as the person\\u2019s dementia had just recently developed. The provider had not sought out additional staff or funding for the person yet because they weren\\u2019t sure they could add more staff due to the workforce shortage and that the person had not yet had an episode of elopement. The provider noted that staffing levels were typically reactive after incidents rather than proactive to prevent them.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38590}','68.53.115.247','2021-05-26 22:27:58'),(26991,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38591,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38591}','68.53.115.247','2021-05-26 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22:27:58'),(26994,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38594,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38594}','68.53.115.247','2021-05-26 22:27:58'),(26995,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38595,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38595}','68.53.115.247','2021-05-26 22:27:58'),(26996,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38596,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38596}','68.53.115.247','2021-05-26 22:27:58'),(26997,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38597,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"This was influenced by staff\\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38597}','68.53.115.247','2021-05-26 22:27:58'),(26998,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38598,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38598}','68.53.115.247','2021-05-26 22:27:58'),(26999,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38599,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38599}','68.53.115.247','2021-05-26 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22:27:58'),(27006,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38606,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38606}','68.53.115.247','2021-05-26 22:27:58'),(27007,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38607,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38607}','68.53.115.247','2021-05-26 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22:27:58'),(27010,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38610,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38610}','68.53.115.247','2021-05-26 22:27:58'),(27011,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38611,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":\"This situation was further complicated as the definition of the need of support was not synonymous with the agency\\u2019s definition. While the person\\u2019s CSSP required 24\\/7 supervision, it did not require \\u201cdirect line of sight\\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \\u201cdirect line of sight\\u201d supervision would require 1:1 staffing, which was not supported in the person\\u2019s CSSP or 6790 rate form.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38611}','68.53.115.247','2021-05-26 22:27:58'),(27012,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38612,'{\"report_id\":230,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:27:58 pm\",\"created_at\":\"5\\/26\\/2021 5:27:58 pm\",\"id\":38612}','68.53.115.247','2021-05-26 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22:29:33'),(27033,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38633,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Medication Error\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38633}','68.53.115.247','2021-05-26 22:29:33'),(27034,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38634,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38634}','68.53.115.247','2021-05-26 22:29:33'),(27035,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38635,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"03\\/22\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38635}','68.53.115.247','2021-05-26 22:29:33'),(27036,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38636,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 administered the person another roommates\\u2019 medication at 8:15pm on 3\\/22\\/19. Immediately following, Staff 1 notified the facility\'s RN Consultant, the person\'s primary physician, poison control, and the home\'s Associate Director. Poison Control suggested that the person be transported to a local emergency room for treatment. The Staff 1 immediately dialed 9-1-1and activated EMS. EMS arrived and brought the person to St. Mary\'s Medical Center ER in Duluth via Gold Cross Ambulance. VA was brought into an ER room and assessment began. The Associate Director met the person at the hospital. The person was given IV fluids as a precaution. Blood was drawn and x-rays were taken. ER MD planned on transferring person from the ER to a regular room for overnight observation. In the interim, the person had a seizure in the ER and the ER MD\'s plan was changed to have him transferred to an ICU bed for monitoring. The person was moved from the ICU to a regular hospital room on 4 East the next day. The person was discharged from the hospital on 3\\/24 at 1:30pm as he returned to baseline without any adverse effects per Hospitalist.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38636}','68.53.115.247','2021-05-26 22:29:33'),(27037,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38637,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38637}','68.53.115.247','2021-05-26 22:29:33'),(27038,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38638,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Agency staff administered incorrect medication to a person living in the home.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38638}','68.53.115.247','2021-05-26 22:29:33'),(27039,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38639,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38639}','68.53.115.247','2021-05-26 22:29:33'),(27040,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38640,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"08\\/01\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38640}','68.53.115.247','2021-05-26 22:29:33'),(27041,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38641,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 arrived at work at 2:00pm and described it as a normal day.  The person 1 who received the incorrect medication was picked up by his Mother around 3:00pm and staff was told they would be back at 6:00pm.   Staff 1 stated that the person receives seizure medications and it is important to administer at specific times per doctors\\u2019 orders.   Missing medications or being untimely can trigger seizures.   Evening medication pass is at 7:00pm and as of 7:30pm the person 1 did not arrive home.  Staff 1 stated they felt anxious about not being able to pass medications, however, there is a one hour window on each side of medication passes.   Therefore, medications could be passed between 6:00pm and 8:00pm.   As of 8:30pm, the person 1 did not arrive and staff 2\\u2019s shift ended. Staff 2 asked staff 1 if he could administer all medications to the people who lived there.  Staff 1 agreed and continued to feel anxious given the person was not home and was not able to administer medications.     \\r\\n\\r\\nStaff 1 began the process of a blood check that is routine for person 2 who lives in the home.   Person 2 receives sleep medication (Trazadone 300mg).   Staff 1 described that person 2 needed a lot of time to prepare for his blood check and taking his medications which required significant attention.  Person 2 was watching TV and required a lot of reminders to eventually transition to the kitchen area to take medications.  Staff 1 was eventually at the kitchen table with person 2 and began the blood check. At about 9pm, person 1 arrived home and staff 1 went to lock the medication cabinet that he had left open.  Staff 1 had already prepared person 1 and 2\\u2019s medications.  Staff 1 put both sets of medications on the table in apple sauce and then quickly passed medications to person 1.   Person 1 proceeded to eat a snack while staff 1 was finishing the blood check with person 2.   \\r\\n\\r\\nShortly after the medication was passed, staff 1 realized he gave person 1 the incorrect medication and proceeded to contact the house LPN and director.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38641}','68.53.115.247','2021-05-26 22:29:33'),(27042,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38642,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38642}','68.53.115.247','2021-05-26 22:29:33'),(27043,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38643,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differientiate between the medications in apple sauce.   An additional factor influencing giving the incorrect medication to the person was that the provider had one less staff working than they typically did during medication administration. The provider typically had a 2 staff to 4 person ratio until 8pm, so that two staff would be on during the 6p-8p med administration window. On this day, the person\\u2019s mother kept him out past the medication window, so that when he returned the second staff had left, leaving one staff on to administer the person\\u2019s meds when he arrived. The provider\'s staff ratio and schedule is influenced by the county\\u2019s service agreement with the provider to deliver services. MNCHOICES also influences how the county determines how many staffing hours to include in their service agreement and what medication administration responsibility they assign to the provider.    \\r\\n\\r\\nStaff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.  \\r\\n\\r\\nThe DWRS, MNCHOICES assessment, and county service agreement also impacted the staff schedule and further complicated the medication protocol.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38643}','68.53.115.247','2021-05-26 22:29:33'),(27044,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38644,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38644}','68.53.115.247','2021-05-26 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This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38666}','68.53.115.247','2021-05-26 22:29:33'),(27067,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38667,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38667}','68.53.115.247','2021-05-26 22:29:33'),(27068,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38668,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"120\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38668}','68.53.115.247','2021-05-26 22:29:33'),(27069,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38669,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"121\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38669}','68.53.115.247','2021-05-26 22:29:33'),(27070,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38670,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"122\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38670}','68.53.115.247','2021-05-26 22:29:33'),(27071,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38671,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"123\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38671}','68.53.115.247','2021-05-26 22:29:33'),(27072,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38672,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"124\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differentiate between the medications in apple sauce.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38672}','68.53.115.247','2021-05-26 22:29:33'),(27073,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38673,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"125\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:29:33 pm\",\"created_at\":\"5\\/26\\/2021 5:29:33 pm\",\"id\":38673}','68.53.115.247','2021-05-26 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22:30:29'),(27088,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38688,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"06\\/27\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38688}','68.53.115.247','2021-05-26 22:30:29'),(27089,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38689,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"On 6\\/27\\/2019 between 8:00am and 9:30am, Staff 1 was driving person in their electronic wheelchair.  Staff 1 ran into door way, and the person\\u2019s leg got caught. The person\\u2019s leg looked swollen, so Reporter told Program Manager to bring VA to an Urgent Care (unknown information.) Reporter notified Guardian, Case Manager (unknown information,) and County Licensor. Urgent Care Physician (unknown information) told Program Manager to bring VA to an ER. Program Manager brought VA to an ER (unknown information,) and VA has a hairline fracture in VAs\' foot (unknown information.) VA was admitted to Hospital (unknown information.) Reporter is waiting to hear back to see what plan of action Hospital plans to take. Reporter will train AP on how to drive VAs\' wheelchair.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38689}','68.53.115.247','2021-05-26 22:30:29'),(27090,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38690,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38690}','68.53.115.247','2021-05-26 22:30:29'),(27091,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38691,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff did not have foot pedals on person\\u2019s wheelchair while driving the person to the restroom.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38691}','68.53.115.247','2021-05-26 22:30:29'),(27092,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38692,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38692}','68.53.115.247','2021-05-26 22:30:29'),(27093,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38693,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"09\\/05\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38693}','68.53.115.247','2021-05-26 22:30:29'),(27094,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38694,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff arrived at 6:00am and described the morning as a typical shift.  Staff took a Benadryl for allergy relief at 5:00am and described that the medication did not make her sleepy.  Staff then assisted the person with their morning routine by helping them use the restroom, bathing, and then going to the kitchen for breakfast.  The person has difficulty swallowing food and requires assistance eating and reminders to swallow twice.  Staff was doing a variety of household tasks and was helping people get ready between 6:00am and 8:00am.  There were three staff on duty that morning. \\r\\n\\r\\nAfter breakfast staff then assisted the person by driving her electric chair from the kitchen to the restroom without foot pedals.  The person does not like their foot pedals on the chair.  The person has a lot of rigidity in her muscles and her legs were sticking out the sides of the chair.  Staff stopped shortly before the doorway to do a task and then proceeded driving the person in their chair.  The person\\u2019s leg broke when their foot got caught on a cupboard door jam.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38694}','68.53.115.247','2021-05-26 22:30:29'),(27095,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38695,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38695}','68.53.115.247','2021-05-26 22:30:29'),(27096,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38696,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff not having foot pedals on while driving the person\\u2019s wheelchair was influenced by the staffs\\u2019 divided attention.  Staff could not recall the specific task that divided her attention while being midway through the kitchen. The person had a preference against using foot pedals and communicates their preference by their rigidity and loud vocalizations.  This was further complicated by typical morning routine that resembles the practice of most busy group homes.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \\r\\n\\r\\nThe CSSP and risk management plan followed standard wheelchair safety and practice related to the wheelchair manufacturer guidelines.  The general practice for wheel chair use conflicted with the agency\\u2019s practice. Team conversations about how this person wanted to live did not have consistency with the person\\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38696}','68.53.115.247','2021-05-26 22:30:29'),(27097,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38697,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38697}','68.53.115.247','2021-05-26 22:30:29'),(27098,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38698,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38698}','68.53.115.247','2021-05-26 22:30:29'),(27099,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38699,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38699}','68.53.115.247','2021-05-26 22:30:29'),(27100,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38700,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38700}','68.53.115.247','2021-05-26 22:30:29'),(27101,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38701,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38701}','68.53.115.247','2021-05-26 22:30:29'),(27102,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38702,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38702}','68.53.115.247','2021-05-26 22:30:29'),(27103,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38703,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38703}','68.53.115.247','2021-05-26 22:30:29'),(27104,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38704,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38704}','68.53.115.247','2021-05-26 22:30:29'),(27105,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38705,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38705}','68.53.115.247','2021-05-26 22:30:29'),(27106,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38706,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38706}','68.53.115.247','2021-05-26 22:30:29'),(27107,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38707,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38707}','68.53.115.247','2021-05-26 22:30:29'),(27108,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38708,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38708}','68.53.115.247','2021-05-26 22:30:29'),(27109,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38709,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38709}','68.53.115.247','2021-05-26 22:30:29'),(27110,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38710,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38710}','68.53.115.247','2021-05-26 22:30:29'),(27111,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38711,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"110\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38711}','68.53.115.247','2021-05-26 22:30:29'),(27112,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38712,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38712}','68.53.115.247','2021-05-26 22:30:29'),(27113,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38713,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38713}','68.53.115.247','2021-05-26 22:30:29'),(27114,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38714,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"113\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38714}','68.53.115.247','2021-05-26 22:30:29'),(27115,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38715,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38715}','68.53.115.247','2021-05-26 22:30:29'),(27116,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38716,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38716}','68.53.115.247','2021-05-26 22:30:29'),(27117,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38717,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff not having foot pedals on while driving the person\\u2019s wheelchair was influenced by the staffs\\u2019 divided attention.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \\r\\n\\r\\nThe general practice for wheel chair use conflicted with the agency\\u2019s practice.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38717}','68.53.115.247','2021-05-26 22:30:29'),(27118,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38718,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38718}','68.53.115.247','2021-05-26 22:30:29'),(27119,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38719,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"118\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38719}','68.53.115.247','2021-05-26 22:30:29'),(27120,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38720,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38720}','68.53.115.247','2021-05-26 22:30:29'),(27121,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38721,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"120\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38721}','68.53.115.247','2021-05-26 22:30:29'),(27122,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38722,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"121\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38722}','68.53.115.247','2021-05-26 22:30:29'),(27123,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38723,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"122\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38723}','68.53.115.247','2021-05-26 22:30:29'),(27124,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38724,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"123\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38724}','68.53.115.247','2021-05-26 22:30:29'),(27125,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38725,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"124\",\"question_type\":\"Free_Text\",\"text_answer\":\"Team conversations about how this person wanted to live did not have consistency with the person\\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38725}','68.53.115.247','2021-05-26 22:30:29'),(27126,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38726,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"125\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38726}','68.53.115.247','2021-05-26 22:30:29'),(27127,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38727,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"126\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38727}','68.53.115.247','2021-05-26 22:30:29'),(27128,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38728,'{\"report_id\":233,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"432\",\"question_type\":\"Yes_or_No\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:29 pm\",\"created_at\":\"5\\/26\\/2021 5:30:29 pm\",\"id\":38728}','68.53.115.247','2021-05-26 22:30:29'),(27129,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38729,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"76\",\"question_type\":\"Short_Answer\",\"text_answer\":\"201902151\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38729}','68.53.115.247','2021-05-26 22:30:52'),(27130,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38730,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"77\",\"question_type\":\"Date\",\"text_answer\":\"06\\/18\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38730}','68.53.115.247','2021-05-26 22:30:52'),(27131,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38731,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"78\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Scott Schifsky\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38731}','68.53.115.247','2021-05-26 22:30:52'),(27132,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38732,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"79\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Sara Beauchene\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38732}','68.53.115.247','2021-05-26 22:30:52'),(27133,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38733,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Taylor SLS\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38733}','68.53.115.247','2021-05-26 22:30:52'),(27134,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38734,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Michael Taylor\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38734}','68.53.115.247','2021-05-26 22:30:52'),(27135,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38735,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"miket.sls@charter.net\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38735}','68.53.115.247','2021-05-26 22:30:52'),(27136,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38736,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38736}','68.53.115.247','2021-05-26 22:30:52'),(27137,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38737,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Medication Error\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38737}','68.53.115.247','2021-05-26 22:30:52'),(27138,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38738,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"St. Louis County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38738}','68.53.115.247','2021-05-26 22:30:52'),(27139,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38739,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"03\\/22\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38739}','68.53.115.247','2021-05-26 22:30:52'),(27140,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38740,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 administered the person another roommates\\u2019 medication at 8:15pm on 3\\/22\\/19. Immediately following, Staff 1 notified the facility\'s RN Consultant, the person\'s primary physician, poison control, and the home\'s Associate Director. Poison Control suggested that the person be transported to a local emergency room for treatment. The Staff 1 immediately dialed 9-1-1and activated EMS. EMS arrived and brought the person to St. Mary\'s Medical Center ER in Duluth via Gold Cross Ambulance. VA was brought into an ER room and assessment began. The Associate Director met the person at the hospital. The person was given IV fluids as a precaution. Blood was drawn and x-rays were taken. ER MD planned on transferring person from the ER to a regular room for overnight observation. In the interim, the person had a seizure in the ER and the ER MD\'s plan was changed to have him transferred to an ICU bed for monitoring. The person was moved from the ICU to a regular hospital room on 4 East the next day. The person was discharged from the hospital on 3\\/24 at 1:30pm as he returned to baseline without any adverse effects per Hospitalist.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38740}','68.53.115.247','2021-05-26 22:30:52'),(27141,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38741,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38741}','68.53.115.247','2021-05-26 22:30:52'),(27142,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38742,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Agency staff administered incorrect medication to a person living in the home.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38742}','68.53.115.247','2021-05-26 22:30:52'),(27143,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38743,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38743}','68.53.115.247','2021-05-26 22:30:52'),(27144,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38744,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"08\\/01\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38744}','68.53.115.247','2021-05-26 22:30:52'),(27145,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38745,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 arrived at work at 2:00pm and described it as a normal day.  The person 1 who received the incorrect medication was picked up by his Mother around 3:00pm and staff was told they would be back at 6:00pm.   Staff 1 stated that the person receives seizure medications and it is important to administer at specific times per doctors\\u2019 orders.   Missing medications or being untimely can trigger seizures.   Evening medication pass is at 7:00pm and as of 7:30pm the person 1 did not arrive home.  Staff 1 stated they felt anxious about not being able to pass medications, however, there is a one hour window on each side of medication passes.   Therefore, medications could be passed between 6:00pm and 8:00pm.   As of 8:30pm, the person 1 did not arrive and staff 2\\u2019s shift ended. Staff 2 asked staff 1 if he could administer all medications to the people who lived there.  Staff 1 agreed and continued to feel anxious given the person was not home and was not able to administer medications.     \\r\\n\\r\\nStaff 1 began the process of a blood check that is routine for person 2 who lives in the home.   Person 2 receives sleep medication (Trazadone 300mg).   Staff 1 described that person 2 needed a lot of time to prepare for his blood check and taking his medications which required significant attention.  Person 2 was watching TV and required a lot of reminders to eventually transition to the kitchen area to take medications.  Staff 1 was eventually at the kitchen table with person 2 and began the blood check. At about 9pm, person 1 arrived home and staff 1 went to lock the medication cabinet that he had left open.  Staff 1 had already prepared person 1 and 2\\u2019s medications.  Staff 1 put both sets of medications on the table in apple sauce and then quickly passed medications to person 1.   Person 1 proceeded to eat a snack while staff 1 was finishing the blood check with person 2.   \\r\\n\\r\\nShortly after the medication was passed, staff 1 realized he gave person 1 the incorrect medication and proceeded to contact the house LPN and director.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38745}','68.53.115.247','2021-05-26 22:30:52'),(27146,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38746,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:52 pm\",\"created_at\":\"5\\/26\\/2021 5:30:52 pm\",\"id\":38746}','68.53.115.247','2021-05-26 22:30:53'),(27147,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38747,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differientiate between the medications in apple sauce.   An additional factor influencing giving the incorrect medication to the person was that the provider had one less staff working than they typically did during medication administration. The provider typically had a 2 staff to 4 person ratio until 8pm, so that two staff would be on during the 6p-8p med administration window. On this day, the person\\u2019s mother kept him out past the medication window, so that when he returned the second staff had left, leaving one staff on to administer the person\\u2019s meds when he arrived. The provider\'s staff ratio and schedule is influenced by the county\\u2019s service agreement with the provider to deliver services. MNCHOICES also influences how the county determines how many staffing hours to include in their service agreement and what medication administration responsibility they assign to the provider.    \\r\\n\\r\\nStaff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.  \\r\\n\\r\\nThe DWRS, MNCHOICES assessment, and county service agreement also impacted the staff schedule and further complicated the medication protocol.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38747}','68.53.115.247','2021-05-26 22:30:53'),(27148,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38748,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38748}','68.53.115.247','2021-05-26 22:30:53'),(27149,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38749,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38749}','68.53.115.247','2021-05-26 22:30:53'),(27150,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38750,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38750}','68.53.115.247','2021-05-26 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This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38770}','68.53.115.247','2021-05-26 22:30:53'),(27171,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38771,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38771}','68.53.115.247','2021-05-26 22:30:53'),(27172,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38772,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"120\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38772}','68.53.115.247','2021-05-26 22:30:53'),(27173,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38773,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"121\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38773}','68.53.115.247','2021-05-26 22:30:53'),(27174,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38774,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"122\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38774}','68.53.115.247','2021-05-26 22:30:53'),(27175,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38775,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"123\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38775}','68.53.115.247','2021-05-26 22:30:53'),(27176,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38776,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"124\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differentiate between the medications in apple sauce.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38776}','68.53.115.247','2021-05-26 22:30:53'),(27177,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38777,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"125\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:53 pm\",\"created_at\":\"5\\/26\\/2021 5:30:53 pm\",\"id\":38777}','68.53.115.247','2021-05-26 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22:30:56'),(27190,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38790,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"03\\/22\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38790}','68.53.115.247','2021-05-26 22:30:56'),(27191,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38791,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 administered the person another roommates\\u2019 medication at 8:15pm on 3\\/22\\/19. Immediately following, Staff 1 notified the facility\'s RN Consultant, the person\'s primary physician, poison control, and the home\'s Associate Director. Poison Control suggested that the person be transported to a local emergency room for treatment. The Staff 1 immediately dialed 9-1-1and activated EMS. EMS arrived and brought the person to St. Mary\'s Medical Center ER in Duluth via Gold Cross Ambulance. VA was brought into an ER room and assessment began. The Associate Director met the person at the hospital. The person was given IV fluids as a precaution. Blood was drawn and x-rays were taken. ER MD planned on transferring person from the ER to a regular room for overnight observation. In the interim, the person had a seizure in the ER and the ER MD\'s plan was changed to have him transferred to an ICU bed for monitoring. The person was moved from the ICU to a regular hospital room on 4 East the next day. The person was discharged from the hospital on 3\\/24 at 1:30pm as he returned to baseline without any adverse effects per Hospitalist.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38791}','68.53.115.247','2021-05-26 22:30:56'),(27192,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38792,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38792}','68.53.115.247','2021-05-26 22:30:56'),(27193,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38793,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Agency staff administered incorrect medication to a person living in the home.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38793}','68.53.115.247','2021-05-26 22:30:56'),(27194,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38794,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38794}','68.53.115.247','2021-05-26 22:30:56'),(27195,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38795,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"08\\/01\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38795}','68.53.115.247','2021-05-26 22:30:56'),(27196,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38796,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff 1 arrived at work at 2:00pm and described it as a normal day.  The person 1 who received the incorrect medication was picked up by his Mother around 3:00pm and staff was told they would be back at 6:00pm.   Staff 1 stated that the person receives seizure medications and it is important to administer at specific times per doctors\\u2019 orders.   Missing medications or being untimely can trigger seizures.   Evening medication pass is at 7:00pm and as of 7:30pm the person 1 did not arrive home.  Staff 1 stated they felt anxious about not being able to pass medications, however, there is a one hour window on each side of medication passes.   Therefore, medications could be passed between 6:00pm and 8:00pm.   As of 8:30pm, the person 1 did not arrive and staff 2\\u2019s shift ended. Staff 2 asked staff 1 if he could administer all medications to the people who lived there.  Staff 1 agreed and continued to feel anxious given the person was not home and was not able to administer medications.     \\r\\n\\r\\nStaff 1 began the process of a blood check that is routine for person 2 who lives in the home.   Person 2 receives sleep medication (Trazadone 300mg).   Staff 1 described that person 2 needed a lot of time to prepare for his blood check and taking his medications which required significant attention.  Person 2 was watching TV and required a lot of reminders to eventually transition to the kitchen area to take medications.  Staff 1 was eventually at the kitchen table with person 2 and began the blood check. At about 9pm, person 1 arrived home and staff 1 went to lock the medication cabinet that he had left open.  Staff 1 had already prepared person 1 and 2\\u2019s medications.  Staff 1 put both sets of medications on the table in apple sauce and then quickly passed medications to person 1.   Person 1 proceeded to eat a snack while staff 1 was finishing the blood check with person 2.   \\r\\n\\r\\nShortly after the medication was passed, staff 1 realized he gave person 1 the incorrect medication and proceeded to contact the house LPN and director.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38796}','68.53.115.247','2021-05-26 22:30:56'),(27197,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38797,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38797}','68.53.115.247','2021-05-26 22:30:56'),(27198,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38798,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differientiate between the medications in apple sauce.   An additional factor influencing giving the incorrect medication to the person was that the provider had one less staff working than they typically did during medication administration. The provider typically had a 2 staff to 4 person ratio until 8pm, so that two staff would be on during the 6p-8p med administration window. On this day, the person\\u2019s mother kept him out past the medication window, so that when he returned the second staff had left, leaving one staff on to administer the person\\u2019s meds when he arrived. The provider\'s staff ratio and schedule is influenced by the county\\u2019s service agreement with the provider to deliver services. MNCHOICES also influences how the county determines how many staffing hours to include in their service agreement and what medication administration responsibility they assign to the provider.    \\r\\n\\r\\nStaff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.  \\r\\n\\r\\nThe DWRS, MNCHOICES assessment, and county service agreement also impacted the staff schedule and further complicated the medication protocol.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38798}','68.53.115.247','2021-05-26 22:30:56'),(27199,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38799,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38799}','68.53.115.247','2021-05-26 22:30:56'),(27200,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38800,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38800}','68.53.115.247','2021-05-26 22:30:56'),(27201,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38801,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38801}','68.53.115.247','2021-05-26 22:30:56'),(27202,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38802,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38802}','68.53.115.247','2021-05-26 22:30:56'),(27203,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38803,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38803}','68.53.115.247','2021-05-26 22:30:56'),(27204,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38804,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38804}','68.53.115.247','2021-05-26 22:30:56'),(27205,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38805,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38805}','68.53.115.247','2021-05-26 22:30:56'),(27206,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38806,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38806}','68.53.115.247','2021-05-26 22:30:56'),(27207,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38807,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38807}','68.53.115.247','2021-05-26 22:30:56'),(27208,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38808,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38808}','68.53.115.247','2021-05-26 22:30:56'),(27209,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38809,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38809}','68.53.115.247','2021-05-26 22:30:56'),(27210,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38810,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38810}','68.53.115.247','2021-05-26 22:30:56'),(27211,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38811,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38811}','68.53.115.247','2021-05-26 22:30:56'),(27212,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38812,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38812}','68.53.115.247','2021-05-26 22:30:56'),(27213,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38813,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"110\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38813}','68.53.115.247','2021-05-26 22:30:56'),(27214,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38814,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38814}','68.53.115.247','2021-05-26 22:30:56'),(27215,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38815,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38815}','68.53.115.247','2021-05-26 22:30:56'),(27216,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38816,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"113\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38816}','68.53.115.247','2021-05-26 22:30:56'),(27217,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38817,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38817}','68.53.115.247','2021-05-26 22:30:56'),(27218,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38818,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38818}','68.53.115.247','2021-05-26 22:30:56'),(27219,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38819,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38819}','68.53.115.247','2021-05-26 22:30:56'),(27220,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38820,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38820}','68.53.115.247','2021-05-26 22:30:56'),(27221,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38821,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"118\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38821}','68.53.115.247','2021-05-26 22:30:56'),(27222,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38822,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"119\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38822}','68.53.115.247','2021-05-26 22:30:56'),(27223,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38823,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"120\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38823}','68.53.115.247','2021-05-26 22:30:56'),(27224,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38824,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"121\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38824}','68.53.115.247','2021-05-26 22:30:56'),(27225,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38825,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"122\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38825}','68.53.115.247','2021-05-26 22:30:56'),(27226,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38826,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"123\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38826}','68.53.115.247','2021-05-26 22:30:56'),(27227,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38827,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"124\",\"question_type\":\"Free_Text\",\"text_answer\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differentiate between the medications in apple sauce.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38827}','68.53.115.247','2021-05-26 22:30:56'),(27228,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38828,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"125\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38828}','68.53.115.247','2021-05-26 22:30:56'),(27229,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38829,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"126\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38829}','68.53.115.247','2021-05-26 22:30:56'),(27230,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38830,'{\"report_id\":232,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"432\",\"question_type\":\"Yes_or_No\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:30:56 pm\",\"created_at\":\"5\\/26\\/2021 5:30:56 pm\",\"id\":38830}','68.53.115.247','2021-05-26 22:30:56'),(27231,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38831,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"08\\/24\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:36 pm\",\"created_at\":\"5\\/26\\/2021 5:31:36 pm\",\"id\":38831}','68.53.115.247','2021-05-26 22:31:36'),(27232,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38832,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"10\\/25\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:43 pm\",\"created_at\":\"5\\/26\\/2021 5:31:43 pm\",\"id\":38832}','68.53.115.247','2021-05-26 22:31:43'),(27233,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38833,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"76\",\"question_type\":\"Short_Answer\",\"text_answer\":\"201906219\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38833}','68.53.115.247','2021-05-26 22:31:46'),(27234,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38834,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"77\",\"question_type\":\"Date\",\"text_answer\":\"09\\/16\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38834}','68.53.115.247','2021-05-26 22:31:46'),(27235,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38835,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"78\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Tony Gantenbein\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38835}','68.53.115.247','2021-05-26 22:31:46'),(27236,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38836,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"79\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Jill Tilbury\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38836}','68.53.115.247','2021-05-26 22:31:46'),(27237,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38837,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Dungarvin - Brooklyn Park\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38837}','68.53.115.247','2021-05-26 22:31:46'),(27238,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38838,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Heather Golden\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38838}','68.53.115.247','2021-05-26 22:31:46'),(27239,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38839,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"hgolden@dungarvin.com\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38839}','68.53.115.247','2021-05-26 22:31:46'),(27240,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38840,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38840}','68.53.115.247','2021-05-26 22:31:46'),(27241,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38841,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38841}','68.53.115.247','2021-05-26 22:31:46'),(27242,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38842,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Hennepin County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38842}','68.53.115.247','2021-05-26 22:31:46'),(27243,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38843,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"08\\/24\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38843}','68.53.115.247','2021-05-26 22:31:46'),(27244,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38844,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"On 8\\/24\\/2019, VA and AP went to the Minnesota State Fair. An unknown event occurred between 12:30 PM and 5:30 PM wile VA was\\r\\nunsupervised. VA was unsupervised for approximately thirty minutes.\\r\\n\\r\\nReporter found out 8\\/26\\/2019. VA had appointment with Psychologist at 3:30 PM. Behavior Specialist accompanied VA to appointment. VA\\r\\ntold Psychologist \\\"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\\\" VA said AP walked away from VA. VA\\r\\ncould not find AP. AP found VA.\\r\\n\\r\\nReporter asked AP to explain. AP said VA had a rental scooter while at the Minnesota State Fair. VA told AP she was going to the bathroom\\r\\non scooter, and took off. AP could not keep up with scooter and soon lost VA. AP continued to search for VA. Approximately thirty minutes\\r\\nlater AP found VA near a bathroom.\\r\\n\\r\\nReporter noted that VA has a previous history of false reporting.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38844}','68.53.115.247','2021-05-26 22:31:46'),(27245,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38845,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38845}','68.53.115.247','2021-05-26 22:31:46'),(27246,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38846,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff lost sight of a person at the State Fair\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38846}','68.53.115.247','2021-05-26 22:31:46'),(27247,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38847,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38847}','68.53.115.247','2021-05-26 22:31:46'),(27248,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38848,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"10\\/25\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38848}','68.53.115.247','2021-05-26 22:31:46'),(27249,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38849,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Collaborative Safety \\u2013 Systems Mapping \\r\\nCase Summary\\r\\nOctober 14, 2019\\r\\nHennepin County\\r\\n\\r\\n\\r\\nLearning Point #1: Staff lost sight of a person at the State Fair.\\r\\n\\r\\nLearning Point #2: Staff brought his son along on this community outing. \\r\\n\\r\\nIncident report description\\r\\n\\u2022\\tIncident date: 8\\/24\\/2019, between 12:30 PM and 5:30 PM\\r\\n\\u2022\\tReport date: 8\\/27\\/2019 4:11PM\\r\\n\\r\\nStaff and person went to the Minnesota State Fair on a Saturday afternoon. During this outing, the person was unsupervised for approximately thirty minutes. The person had a rental scooter and took off on it to go to use the bathroom. The staff could not keep up with the scooter and lost sight of the person. Approximately 30 minutes later, staff found the person near the bathroom. \\r\\n\\r\\nTwo days later, the reporter found out about the incident during an appointment between the person and a Psychologist when the person told the Psychologist \\\"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\\\" \\r\\n\\r\\nDebriefing information for learning Point #1, October 25, 2019\\r\\n\\r\\nStaff participated in a human factors debriefing, led by a Safety Analyst, on October 25, 2019.\\r\\n\\r\\nUpon arrival at the State Fair, the person rented an electric mobility scooter for people with disabilities. The staff brought his 10 year old son along to the event. The staff\\u2019s attention was influenced by the person\\u2019s behavior as they began walking into the Fair, when the person said she wanted to go to the beer garden and drink beer. This action triggered the staff to wonder if this was a good idea. \\r\\n\\r\\nShortly after arriving, the staff and his son sat down to eat some food while the person used the scooter to go and browse at a souvenir stand within eyesight. The crowd at the Fair impacted the staff\\u2019s focus when he lost sight of the person on the scooter during the outing. Staff reported he was not distracted by his son\\u2019s presence. \\r\\n\\r\\nDebriefing information for learning Point #2, October 25, 2019\\r\\n\\r\\nDuring the debriefing session for Learning Point #1, Staff shared he brought his son along to the outing after the VA told him she thought it was fine. He explained it was a last minute decision because of issues around child care coverage.\\r\\n\\r\\nResult of Incident\\r\\nStaff reported going to the beer garden to search for the person. She was not there, so he called her on her cell phone. She answered his call, but could not tell staff exactly where she was. This phone call went on for about 30 minutes until staff located the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38849}','68.53.115.247','2021-05-26 22:31:46'),(27250,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38850,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38850}','68.53.115.247','2021-05-26 22:31:46'),(27251,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38851,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. Staff brought their son along on the outing because the person offered for him to come along. The person likely offered because if staff was unable to work the person would be unable to go to the fair as the person overheard a conversation the staff had about his son not having childcare on the day of the Fair. The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person. \\r\\n\\r\\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.  The provider has a policy that allows staff to use judgment\\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose. \\r\\n\\r\\nThe Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\\u2019s history of challenging behaviors influenced the Guardian\\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager\'s decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing. An industry wide staffing shortage impacted the providers\\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38851}','68.53.115.247','2021-05-26 22:31:46'),(27252,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38852,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38852}','68.53.115.247','2021-05-26 22:31:46'),(27253,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38853,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38853}','68.53.115.247','2021-05-26 22:31:46'),(27254,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38854,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38854}','68.53.115.247','2021-05-26 22:31:46'),(27255,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38855,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38855}','68.53.115.247','2021-05-26 22:31:46'),(27256,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38856,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38856}','68.53.115.247','2021-05-26 22:31:46'),(27257,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38857,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38857}','68.53.115.247','2021-05-26 22:31:46'),(27258,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38858,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. \\r\\n\\r\\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38858}','68.53.115.247','2021-05-26 22:31:46'),(27259,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38859,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:46 pm\",\"created_at\":\"5\\/26\\/2021 5:31:46 pm\",\"id\":38859}','68.53.115.247','2021-05-26 22:31:46'),(27260,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38860,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person.  \\r\\n\\r\\nAn industry wide staffing shortage impacted the providers\\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38860}','68.53.115.247','2021-05-26 22:31:47'),(27261,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38861,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38861}','68.53.115.247','2021-05-26 22:31:47'),(27262,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38862,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"106\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38862}','68.53.115.247','2021-05-26 22:31:47'),(27263,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38863,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"107\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38863}','68.53.115.247','2021-05-26 22:31:47'),(27264,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38864,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"108\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38864}','68.53.115.247','2021-05-26 22:31:47'),(27265,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38865,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"109\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38865}','68.53.115.247','2021-05-26 22:31:47'),(27266,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38866,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"110\",\"question_type\":\"Free_Text\",\"text_answer\":\"The Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\\u2019s history of challenging behaviors influenced the Guardian\\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager\'s decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing .\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38866}','68.53.115.247','2021-05-26 22:31:47'),(27267,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38867,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"111\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38867}','68.53.115.247','2021-05-26 22:31:47'),(27268,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38868,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"112\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38868}','68.53.115.247','2021-05-26 22:31:47'),(27269,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38869,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"113\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38869}','68.53.115.247','2021-05-26 22:31:47'),(27270,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38870,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38870}','68.53.115.247','2021-05-26 22:31:47'),(27271,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38871,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38871}','68.53.115.247','2021-05-26 22:31:47'),(27272,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38872,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":\"The provider has a policy that allows staff to use judgment\\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38872}','68.53.115.247','2021-05-26 22:31:47'),(27273,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38873,'{\"report_id\":234,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:31:47 pm\",\"created_at\":\"5\\/26\\/2021 5:31:47 pm\",\"id\":38873}','68.53.115.247','2021-05-26 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The DSPs who were working at the time of this incident are no longer employed.\\r\\nOne of the residents ran out of medication several days early and staff noticed pills were missing. The house was searched until the empty packaging was discovered in a resident\\u2019s room. Quality assurance staff conducted an internal investigation where the person served (VA) admitted taking the medications. The residential facility was not able to determine when the medications went missing and therefore did not know what staff was working when the theft occurred. All staff working at the residential facility during the general time frame of the theft are no longer employed by the provider.\\r\\nMedication is stored in bins in a pantry located in the kitchen under lock and key. There is a key ring kept in a drawer for staff. The investigation revealed the key is not always used and there were times staff not sure where the key was or if the pantry is always locked. 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Inc.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38991}','68.53.115.247','2021-05-26 22:33:54'),(27392,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38992,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Gordon Clark\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38992}','68.53.115.247','2021-05-26 22:33:54'),(27393,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38993,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"gordonc@marytinc.com\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38993}','68.53.115.247','2021-05-26 22:33:54'),(27394,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38994,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38994}','68.53.115.247','2021-05-26 22:33:54'),(27395,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38995,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38995}','68.53.115.247','2021-05-26 22:33:54'),(27396,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38996,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Hennepin County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38996}','68.53.115.247','2021-05-26 22:33:54'),(27397,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38997,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"06\\/01\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38997}','68.53.115.247','2021-05-26 22:33:54'),(27398,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38998,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff brought four housemates to the Como Park Zoo on a summer Saturday afternoon. After spending some time walking around the crowed zoo looking at animals, one person wandered away from the group. Staff was not sure what to do so he brought the other guys back to the van, leaving the windows down, to keep them together. He went back to look for the missing person with the help of zoo staff.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38998}','68.53.115.247','2021-05-26 22:33:54'),(27399,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',38999,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":38999}','68.53.115.247','2021-05-26 22:33:54'),(27400,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39000,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Staff lost sight of person at Como Zoo\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39000}','68.53.115.247','2021-05-26 22:33:54'),(27401,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39001,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39001}','68.53.115.247','2021-05-26 22:33:54'),(27402,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39002,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"97\",\"question_type\":\"Date\",\"text_answer\":\"08\\/27\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39002}','68.53.115.247','2021-05-26 22:33:54'),(27403,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39003,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"98\",\"question_type\":\"Free_Text\",\"text_answer\":\"Staff participated in a human factors debriefing, led by a Safety Analyst, on August 27, 2019 at the group home in Richfield where the VA resides.\\r\\n\\r\\nThe slow pace of one of the people on the outing impacted the staff persons focus during the outing and he lost sight of one the housemates. The staff placed importance on the safety of the other people in the group when he made the decision to place them in the van while he sought help in locating the missing person. He did not want to lose other people. This decision was further influenced by fact, he was the only staff person on the outing and he had never been to Como Park before so he was not familiar with the park or available resources.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39003}','68.53.115.247','2021-05-26 22:33:54'),(27404,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39004,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"99\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39004}','68.53.115.247','2021-05-26 22:33:54'),(27405,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39005,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"100\",\"question_type\":\"Free_Text\",\"text_answer\":\"Losing sight of a person was influenced by staff being distracted while holding the hand of a slow walker in the group and watching their footing. This was further influenced by the crowded zoo and the varying needs of each of the four people in the group. Also this was the staffs first time at Como Park Zoo and he was unfamiliar with the park and available resources. He wanted to do an activity the group enjoyed and was not afraid to take risks by going to a new place for an outing. It was known that the people living in the home enjoyed seeing animals, and considering that Como Zoo was a free activity, this outing was selected. The staff\\u2019s willingness to take risk was likely impacted by the disability advocacy community\\u2019s emphasis on allowing people with disabilities the dignity of risk. \\r\\nAdditional factors that influenced the Como Park outing and staff decision making were the community inclusion goals developed by the provider. These goals are outlined in the CSP\\/CSSP for each person in the group based on the MN Choices Assessment and the Person Centered\\/Informed Choice protocols. \\r\\n\\r\\nThe staffing pattern on the day of the outing to Como Zoo was impacted by the provider\\u2019s budget and the hours allocated to the home during the negotiation process facilitated by DHS Form 6790. This process is impacted by the individual needs of each person in the home, assessed by MnCHOICES and developed into each person\\u2019s Coordinated Services and Support Plan. The hours and rate are further impacted by the Disability Waiver Rate System created by the Minnesota Legislature. \\r\\n\\r\\nThe staff training established in 245D statute and the Positive Supports Rule influenced the provider required training to prepare staff for community based outings and discretion for decision making. Staff demonstrated competency in this area when he was able to describe the clothing worn by the missing person and share \\u201cthe book\\u201d with details about the person.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39005}','68.53.115.247','2021-05-26 22:33:54'),(27406,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39006,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"127\",\"question_type\":\"Short_Answer\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39006}','68.53.115.247','2021-05-26 22:33:54'),(27407,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39007,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"129\",\"question_type\":\"Date\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39007}','68.53.115.247','2021-05-26 22:33:54'),(27408,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39008,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"130\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39008}','68.53.115.247','2021-05-26 22:33:54'),(27409,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39009,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"131\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39009}','68.53.115.247','2021-05-26 22:33:54'),(27410,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39010,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"132\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39010}','68.53.115.247','2021-05-26 22:33:54'),(27411,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39011,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"101\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"2\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39011}','68.53.115.247','2021-05-26 22:33:54'),(27412,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39012,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"102\",\"question_type\":\"Free_Text\",\"text_answer\":\"Losing sight of a person was influenced by staff being distracted while holding the hand of a slow walker in the group and watching their footing. This was further influenced by the crowded zoo and the varying needs of each of the four people in the group.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39012}','68.53.115.247','2021-05-26 22:33:54'),(27413,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39013,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"103\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39013}','68.53.115.247','2021-05-26 22:33:54'),(27414,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39014,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"104\",\"question_type\":\"Free_Text\",\"text_answer\":\"The staffing pattern on the day of the outing to Como Zoo was impacted by the provider\\u2019s budget and the hours allocated to the home during the negotiation process facilitated by DHS Form 6790. This process is impacted by the individual needs of each person in the home, assessed by MnCHOICES and developed into each person\\u2019s Coordinated Services and Support Plan. The hours and rate are further impacted by the Disability Waiver Rate System created by the Minnesota Legislature.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39014}','68.53.115.247','2021-05-26 22:33:54'),(27415,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39015,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"105\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39015}','68.53.115.247','2021-05-26 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22:33:54'),(27424,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39024,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"114\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39024}','68.53.115.247','2021-05-26 22:33:54'),(27425,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39025,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"115\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"3\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39025}','68.53.115.247','2021-05-26 22:33:54'),(27426,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39026,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"116\",\"question_type\":\"Free_Text\",\"text_answer\":\"We may need to edit the narrative and this example to emphasize the conflict between the \\\"health, safety, and well-being\\\" and community inclusion\\r\\n\\r\\nIt was known that the people living in the home enjoyed seeing animals, and considering that Como Zoo was a free activity, this outing was selected. The staff\\u2019s willingness to take risk was likely impacted by the disability advocacy community\\u2019s emphasis on allowing people with disabilities the dignity of risk. \\r\\nAdditional factors that influenced the Como Park outing and staff decision making were the community inclusion goals developed by the provider.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39026}','68.53.115.247','2021-05-26 22:33:54'),(27427,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39027,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"117\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"0\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39027}','68.53.115.247','2021-05-26 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pm\",\"id\":39035}','68.53.115.247','2021-05-26 22:33:54'),(27436,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39036,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"126\",\"question_type\":\"Free_Text\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39036}','68.53.115.247','2021-05-26 22:33:54'),(27437,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39037,'{\"report_id\":237,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"432\",\"question_type\":\"Yes_or_No\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:33:54 pm\",\"created_at\":\"5\\/26\\/2021 5:33:54 pm\",\"id\":39037}','68.53.115.247','2021-05-26 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22:34:47'),(27442,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39042,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"78\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Tony Gantenbein\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39042}','68.53.115.247','2021-05-26 22:34:47'),(27443,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39043,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"79\",\"question_type\":\"Multiple_Choice\",\"text_answer\":null,\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39043}','68.53.115.247','2021-05-26 22:34:47'),(27444,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39044,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"80\",\"question_type\":\"Short_Answer\",\"text_answer\":\"TBI Residential & Community Services\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39044}','68.53.115.247','2021-05-26 22:34:47'),(27445,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39045,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"81\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Keith Comstock\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39045}','68.53.115.247','2021-05-26 22:34:47'),(27446,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39046,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"82\",\"question_type\":\"Short_Answer\",\"text_answer\":\"k.comstock@tbiduluthmn.com\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39046}','68.53.115.247','2021-05-26 22:34:47'),(27447,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39047,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"83\",\"question_type\":\"Short_Answer\",\"text_answer\":\"218-733-1331\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39047}','68.53.115.247','2021-05-26 22:34:47'),(27448,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39048,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"84\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"Elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39048}','68.53.115.247','2021-05-26 22:34:47'),(27449,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39049,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"85\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"St. Louis County\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39049}','68.53.115.247','2021-05-26 22:34:47'),(27450,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39050,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"86\",\"question_type\":\"Date\",\"text_answer\":\"03\\/20\\/2019\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39050}','68.53.115.247','2021-05-26 22:34:47'),(27451,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39051,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"87\",\"question_type\":\"Free_Text\",\"text_answer\":\"TBI Crisis Float was at the Alder home at 5:45pm on Friday, March 20th talking with Dwayne. Crisis Float and\\r\\nDwayne were outside during the conversation. Dwayne asked if he was able to get his hair done soon and Crisis Float explained that due\\r\\nto the pandemic the salon was closed until further notice. Dwayne was disappointed that he could not get his hair done. After the\\r\\nconversation Dwayne walked inside and Crisis Float left the Alder home. At 6:00pm Khun (staff) went to check on Dwayne and he was not\\r\\nin his bedroom. Khun checked the inside of the house then walked around the outside of the house and could not locate Dwayne. Khun\\r\\nthen called the Crisis Float to notify them of the situation. Crisis Float began driving around the area looking for Dwayne. At 7:00pm Crisis\\r\\nFloat notified the Sheriff and completed an Attempt to Locate for Dwayne. Crisis Float continued to search for Dwayne. At 8:30pm the Crisis\\r\\nFloat asked that the Attempt to Locate be changed to a Missing Persons report. At 4:00am on Saturday, March 21st the TBI Crisis Float\\r\\nreceived a call from the Duluth Police Department saying that Dwayne had approached them looking for a ride home. Dwayne reported to\\r\\nthe police and TBI Crisis Float that he eloped from the Alder house and walked to the Kwik Trip where he was able to catch a bus to\\r\\ndowntown Duluth. Dwayne reported he walked around downtown for several hours before finding a police officer at CVS Pharmacy in\\r\\ndowntown Duluth. Dwayne returned home at 5:00am and went to bed.\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39051}','68.53.115.247','2021-05-26 22:34:47'),(27452,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39052,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"96\",\"question_type\":\"Multiple_Choice\",\"text_answer\":\"1\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39052}','68.53.115.247','2021-05-26 22:34:47'),(27453,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39053,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"91\",\"question_type\":\"Short_Answer\",\"text_answer\":\"Float staff waited four hours to contact their supervisor about an elopement\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39053}','68.53.115.247','2021-05-26 22:34:47'),(27454,'e6VDpcj7xuKlFWAHFjzCyIpYOvCCmp44Bbf6JqMy',81,'reports_answer','create',39054,'{\"report_id\":238,\"form_id\":\"23\",\"user_id\":81,\"organization_id\":10,\"question_id\":\"94\",\"question_type\":\"True_or_False\",\"text_answer\":\"Yes\",\"created_by\":81,\"updated_by\":81,\"updated_at\":\"5\\/26\\/2021 5:34:47 pm\",\"created_at\":\"5\\/26\\/2021 5:34:47 pm\",\"id\":39054}','68.53.115.247','2021-05-26 22:34:47'),