The staff's awareness that the individual left the program was influenced by Staff 3's assignments to two tasks, supervising the individual and completing a training. Staff 1 created staff assignments on paper. The paper schedule was not updated to reflect the staffing change after Staff 3 told Staff 1 they needed to complete the training instead of supervising. An additional influence was Staff 1 being new to the role of making staff assignments. This new role was further complicated as the staff assignments change frequently to support the varied needs of individuals. The facility also utilizes a whiteboard for staff assignments. As changes are made to the assignment schedule, the whiteboard is updated to reflect the changes. The whiteboard and paper schedules do not match once there are changes to the whiteboard. 

The individual’s behaviors influenced staff's awareness of the individual leaving the facility.  The individual moves around a lot during her time in the program area and was described as elusive.  Staff indicated that the individual deliberately observes staff and when staff appears to be distracted or less attentive she will attempt to leave the program area. There are up to 17 participants and 5 staff in the program area at any given time. This ratio influences each staff person to provide support and supervision to multiple participants in the program area. Ideally, the provider said they'd have more staff, but this staff to person ratio is typical. This ratio is influenced by a workforce shortage across the region and state that has impacted the provider's ability to increase their staff ratio. Per the individual’s 6790, they did not require one-on-one supervision impacting the decision to assign one staff to this individual. The 6790 is influenced by the DWRS which provides a calculation for the person’s service rates and the staff ratios required of day service facilities (DSFs) in Minn. Stat. 245D. The recent push by the legislature over the last few years shifting from daily and partial day payment in DSFs to community- and unit-based funding made the process of negotiating a 6790 more complex. This push to community- and unit-based employment was influenced by a number of national and regional initiatives such as the HCBS Final Rule, the Workforce Investment and Opportunities Act, the Minnesota Olmstead Plan and recent lawsuits regarding congregate work by the Department of Justice. The provider noted that adapting to this change influenced the business of the program and frequent staff changes as they moved to work with some clients in the community and some at their congregate site, which required staff to move around and pivot roles frequently. 

Although the individual's plan does not require 1:1 staffing, the day program assigned a specific staff person to supervise the individual on this day. The assigned staff person was unable provide 1:1 supervision to the individual as they were also required to supervise/support other people. The program area was described as busy and distracting.  Some participants are more vocal adding to the distractions and some participants require higher supervision than others including one-to-one supervision. Such distractions further supported staff not realizing that the individuals had left the home. The building has three levels and multiple exits which impacts staff's ability to see all exits while supporting people. The doors do have chimes; however, the staff have become desensitized to the chimes as the staff, people served, and community members use the entrances and exits frequently.  The doors are equipped with alarms because providers are responsible for the health, safety and well-bring of individuals served. Local fire codes influenced requirements for exits being unlocked and able to be used in case of emergency. The facility fire codes are influenced by 245D and city fire codes. The fire code says that exit doors shall have the ability to be opened from inside in case of a fire. This contributed to the individual's ability to exit the program.  As a result of the multiple exits with chimes continually occurring, staff have been desensitized to them. This desensitization further impacted staff not realizing that the individual left the program. The chimes were implemented as a result of the building needing multiple exits which is governed by the agency’s requirement to support the health, safety, and well-being of residents through the adherence to the fire codes.