{"Short_Answer__76":"KS_Rural Living Environment-SLC-2019-12","Date__77":"12\/16\/2019","Multiple_Choice__78":"Kelly Sather","Short_Answer__80":"Rural Living Environment","Short_Answer__81":"Don Negley","Short_Answer__82":"dnegley@rurallivingmn.com","Short_Answer__83":"218-827-2322","Multiple_Choice__84":"Termination of Services","Multiple_Choice__85":"St. Louis County","Date__86":"11\/01\/2019","Free_Text__87":"The reason for the service termination is: \r\n- the termination is necessary for Dominic's welfare and his needs cannot be met in our programs\r\n- Dominic's safety and that of his housemate and staff is endangered and positive support strategies that have been attempted have not achieved and effectively maintained safety for Dominic and others. \r\n- Dominic requires a minimum of 2:1 staffing which is not possible with banded rates nor does RLE have the ability to provider additional staffing for this purpose","Multiple_Choice__96":"1","Short_Answer__91":"Services terminated due to concerns for staff safety.","True_or_False__94":"Yes","Date__97":"02\/04\/2020","Free_Text__98":"Debriefing 1 \r\nThe home was created in 2007 and licensed for 3 beds. Referrals were in from other counties; however, at the same time 2 MSOCS homes were being closed in the county and St. Louis County needed those beds. Host county concurrence from St. Louis County was denied on the 3 out of county individuals. Administration felt that they were forced into taking the three people who eventually moved in. All three had 1:1 staffing ratios when they came in. Even at that time, staff felt that the one individual should have been a 2:1; however, this was not approved by the county. He would bite himself, bite others, hit things which often resulted in daily restraints. He was on a Rule 40 program that created a plan for these restraints. Through the years adjustments were made to the home, attempting to reinforce walls, replacing toilets, industrial sheetrock, etc. \r\n\r\nIn 2017, one of the individuals in the home passed away. The home then went from 3 licensed beds to 2 licensed beds, subsequently only now having 2 staff members in the home where prior to 2017 there were 3. Through the next few years, the individual\u2019s behaviors continued to be present but with the loss of the one staff member, it made it more difficult to intervene. This even resulted in a 60 day termination notice being issued in April 2018; however, no alternative housing option was ever found so the individual never did move from the home .The county was approached about developing a specialized home for the one individual; however, due to banding, which is when rates are locked only allowing incremental increases, they were told this couldn\u2019t happen. In 2019, the banding was frozen so there was no slight increase they saw on their rate. They realize they could have put in 2:1 staffing, but they would have \u201cate the cost\u201d for this as they would not be reimbursed for the extra staffing. \r\nThrough the years, the individual worked with one staff member who he tended to do better with. This was helpful in having to bring the individual places because they would try to schedule it with the one staff member. However, the staff member resigned in the fall of 2019. With the staff member\u2019s departure, it appeared that the individual\u2019s behaviors started to increase. They attempted various things, some even being quite non-conventional such as getting \u201cgay man pheromones\u201d. At the time of the notice, 911 was called 2 days in a row. They eventually brought him to the Duluth ER where once there, he was restrained by 8 hospital staff.\r\n\r\nWhen asked about other impacts of the situation they found themselves in, the quality of employees was quickly brought up. There continues to be a staffing shortage and it is difficult to find staff, let alone finding staff with any experience or other qualifications. There is also a concern that our state is missing a part of the continuum of care, specifically that there is little to no institutional care option that would allow individuals a longer period of stabilization. \r\n\r\nDebriefing 2 \r\nStaff members were at a point where they were no longer being effective in managing the individual\u2019s behaviors. He went to the annual assessment meeting and saw the extremely high number of PRN\u2019s being given. He realized they were using that as a means to control and \u201cif we\u2019re doing that something is wrong.\u201d In further looking at this, he discovered that the documentation wasn\u2019t always consistent depending on what staff member was documenting. Many behaviors were not being reported in the documentation or if they were, it wasn\u2019t consistent amongst staff on how they were recorded. He felt that they weren\u2019t training staff right. It was difficult to get staff to recognize what they were seeing. The house manager did not experience the same behaviors as the other staff; therefore, what he was reporting was not consistent with what staff experienced. The individual tended to treat certain staff differently, being particularly worse for women.\r\n\r\nAbout three years ago, the number of injuries that staff were sustaining started to rise consistently. Many workman\u2019s comp claims, particularly with concerns about staff being bit. It came down to the realization that they did not have the right house for him and the concerns for staff\u2019s safety. He felt strongly that staff did not fail the individual but rather the individual needed different suppor","Free_Text__100":"The services being terminated for a person due to concerns for staff safety were impacted by increased staff injuries. The physical aggression displayed by the person was increasing, which led to the increased staff injuries and the person damaging the house. Staff were not always able to be consistent when redirecting behavior with just one staff which impacted the increased staff injuries. The pressure from the worker\u2019s compensation agency influenced the services terminated due to the concerns for staff safety. The number of workman\u2019s comp claims influenced the pressure from this agency, which was impacted by the increased injuries to staff.\r\n\r\nStaff injuries was also influenced by the staff being unable to consistently redirect behaviors with one staff. One of the impacts to the inconsistency in redirecting behaviors, which included physical aggression, property distruction and self injurious, was the physical layout of the house due to narrow hallways and bathroom made it difficult to give space or intervene so the way staff chose to intervene was dependent on where the staff and individual were physically at in the home at the time of the behavior.The physical layout of the house not only impacted the consistency of redirecting these behaviors, but this also directly impacted the increased staff injuries and the requests to develop a new site around the person\u2019s sensory needs. This request was subsequently denied by the county due to the county being unaware of available funds for modification for new development and that the county had limited foster care development. The limited foster care development was influenced by the county having a high number of foster care homes serving individuals from other counties along with a statewide moratorium on the creation of foster care beds, which in essence was a hold in developing further beds. This moratorium not only limited the foster care development in the county, but it also impacted the elimination of institutions in the state and left few alternative housing options. Other influences of the elimination of institutions was the Jensen Settlement and the Minnesota Olmstead Plan which found that individuals with disabilities were unconstitutionally secluded and the plan detailed a way to ensure that individuals with disabilities live in the most integrated setting appropriate for their needs. Another impact of staff being unable to consistently redirect behaviors with one staff was the staffing level dropped in the home in 2017 after a roommate passed away. When the person passed away, the home reduced their staff level to coincide with the reduced reimbursement that came from that person\u2019s residence in the home. The staff attached to the roommate who passed away would often intervene in de-escalating and responding to the person\u2019s physically aggressive behavior. When the roommate passed away, the provider inquired about adding a staff but were told that 2:1 staff couldn\u2019t be reimbursed. This was impacted by the county not moving forward with the rate exception due to the needs of the person not changing, which in turn was influenced by the banding for the state rate allowing limited rate increase for service intensity. The Disability Waiver Rate System (DWRS) has impacted the banding requirements. The last impact to the staff being unable to consistently redirect behavior with one staff was the difficulty in matching staff to the needs of the people in the home. The difficulty in matching staff was influenced by the person tending to work best with male staff (2 particular staff) but also the low applicant pool fitting the person\u2019s preference.  The low applicant pool was influenced by the current workforce shortage in the community and state. \r\n\r\nThe attempts and barriers to create the right service environment were also an influence to the terminating the person\u2019s services due to concerns for staff safety. This was due to the 2:1 staff not being able to be reimbursed as previously mentioned because the staffing in the home changed but not the person\u2019s needs. It also was influenced by county\u2019s denial of the request to develop a new site around the person\u2019s sensory needs. Subsequently, previous attempts to terminate service were not followed through on due to lack of providers which was impacted by the view that a part of the continuum of care for people with challenging behaviors statewide is missing. This missing part of the continuum is influenced by the lack of crisis respite providers, a lack of service availability between crisis residential services and hospitals, and few services for adults with autism. The effort to eliminate institutions and the DWRS has impacted the missing part of the continuum. The goal of the elimination of institutions to promote community living is generally seen as good; however, the lack of alternatives is what is most problematic to serve this population.","Multiple_Choice__101":"0","Multiple_Choice__103":"3","Free_Text__104":"Staff injuries was also influenced by the staff being unable to consistently redirect behaviors with one staff. One of the impacts to the inconsistency in redirecting behaviors, which included physical aggression, property destruction and self injurious, was the physical layout of the house due to narrow hallways and bathroom made it difficult to give space or intervene so the way staff chose to intervene was dependent on where the staff and individual were physically at in the home at the time of the behavior.The physical layout of the house not only impacted the consistency of redirecting these behaviors, but this also directly impacted the increased staff injuries and the requests to develop a new site around the person\u2019s sensory needs. \r\n\r\nThe last impact to the staff being unable to consistently redirect behavior with one staff was the difficulty in matching staff to the needs of the people in the home. The difficulty in matching staff was influenced by the person tending to work best with male staff (2 particular staff) but also the low applicant pool fitting the person\u2019s preference.  The low applicant pool was influenced by the current workforce shortage in the community and state.","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"2","Free_Text__110":"The examples of Demand Resource Mismatch & Prescribed Practice (policies, resource constraints, etc.) influenced the ability to have \"success\" working as a team. \r\n\r\nThis request was subsequently denied by the county due to the county being unaware of available funds for modification for new development and that the county had limited foster care development. The limited foster care development was influenced by the county having a high number of foster care homes serving individuals from other counties along with a statewide moratorium on the creation of foster care beds, which in essence was a hold in developing further beds. This moratorium not only limited the foster care development in the county, but it also impacted the elimination of institutions in the state and left few alternative housing options. Other influences of the elimination of institutions was the Jensen Settlement and the Minnesota Olmstead Plan which found that individuals with disabilities were unconstitutionally secluded and the plan detailed a way to ensure that individuals with disabilities live in the most integrated setting appropriate for their needs.\r\n\r\nWhen the roommate passed away, the provider inquired about adding a staff but were told that 2:1 staff couldn\u2019t be reimbursed. This was impacted by the county not moving forward with the rate exception due to the needs of the person not changing, which in turn was influenced by the banding for the state rate allowing limited rate increase for service intensity.","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"3","Free_Text__116":"The services being terminated for a person due to concerns for staff safety were impacted by increased staff injuries. The physical aggression displayed by the person was increasing, which led to the increased staff injuries and the person damaging the house. Staff were not always able to be consistent when redirecting behavior with just one staff which impacted the increased staff injuries. The pressure from the worker\u2019s compensation agency influenced the services terminated due to the concerns for staff safety. The number of workman\u2019s comp claims influenced the pressure from this agency, which was impacted by the increased injuries to staff.\r\n\r\nThe attempts and barriers to create the right service environment were also an influence to the terminating the person\u2019s services due to concerns for staff safety. This was due to the 2:1 staff not being able to be reimbursed as previously mentioned because the staffing in the home changed but not the person\u2019s needs. It also was influenced by county\u2019s denial of the request to develop a new site around the person\u2019s sensory needs. Subsequently, previous attempts to terminate service were not followed through on due to lack of providers which was impacted by the view that a part of the continuum of care for people with challenging behaviors statewide is missing. This missing part of the continuum is influenced by the lack of crisis respite providers, a lack of service availability between crisis residential services and hospitals, and few services for adults with autism. The effort to eliminate institutions and the DWRS has impacted the missing part of the continuum. The goal of the elimination of institutions to promote community living is generally seen as good; however, the lack of alternatives is what is most problematic to serve this population.","Multiple_Choice__117":"0","Multiple_Choice__119":"2","Free_Text__120":"This missing part of the continuum is influenced by the lack of crisis respite providers, a lack of service availability between crisis residential services and hospitals, and few services for adults with autism. The effort to eliminate institutions and the DWRS has impacted the missing part of the continuum. The goal of the elimination of institutions to promote community living is generally seen as good; however, the lack of alternatives is what is most problematic to serve this population.","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"\"Note: a key part of the example of drift stems out of this...The staff attached to the roommate who passed away would often intervene in de-escalating and responding to the person\u2019s physically aggressive behavior...then additional system constraints with DWRS impacted not being able to change the staff ratio to 2:1.\"\r\n\r\nAnother impact of staff being unable to consistently redirect behaviors with one staff was the staffing level dropped in the home in 2017 after a roommate passed away. When the person passed away, the home reduced their staff level to coincide with the reduced reimbursement that came from that person\u2019s residence in the home. The staff attached to the roommate who passed away would often intervene in de-escalating and responding to the person\u2019s physically aggressive behavior. When the roommate passed away, the provider inquired about adding a staff but were told that 2:1 staff couldn\u2019t be reimbursed. This was impacted by the county not moving forward with the rate exception due to the needs of the person not changing, which in turn was influenced by the banding for the state rate allowing limited rate increase for service intensity.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}