{"Short_Answer__76":"201905337","Date__77":"08\/15\/2019","Multiple_Choice__78":"David Vukelich","Multiple_Choice__79":"Scott Schifsky","Short_Answer__80":"Pinewood-Duluth","Short_Answer__81":"Dana Tchida","Short_Answer__82":"dana@pinewoodcloq-duluth.com","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"St. Louis","Date__86":"07\/23\/2019","Free_Text__87":"Theresa Reilly (TR) was found outside approximately of a city block away from the Pinewood building by staff\r\nSteve Anderson (SA) who was heading out to a job site. TR was at the business 4th Street Auto attempting to open a vehicle door (she\r\nlikes to go on car rides). SA was able to gain her attention and asked her to come with him back to Pinewood. She complied and\r\naccompanied SA back to Pinewood.\r\n\r\nEarlier that morning, the \"daily schedule\" created by staff Sherri Ross (SR) had listed staff Sherrill McDonald (SM) to provide supervision\r\nfor TR. TR is not a 1:1, however she requires close supervision as she has a history of elopements. SM had spoken to SR earlier in the\r\nmorning, before any clients had arrived, and told her she was not able to provide supervision for TR because she would be busy working\r\non a project in a separate area from where TR was going to be. SR was going to make the change on the \"daily schedule\" but got busy\r\nwith other things and forgot to update it with a different staff for TR's supervision. With no eligible staff listed for TR s supervision, TR was\r\nable to leave the building unnoticed. It is unknown exactly what time TR left Pinewood, but other staff member Connie Lepak (CL) reported\r\nthat she had last interacted with TR at 9:10am. SA reported that when he found TR it was approximately 9:15am.","Multiple_Choice__96":"1","Short_Answer__91":"Staff was not aware the individual left the program.","True_or_False__94":"Yes","Date__97":"09\/24\/2019","Free_Text__98":"Pinewood debriefing.  9\/24\/2019\r\nLearning point:  The staff was not aware that the individual left the program.\r\n\r\nDebrief SP1:   The day of the incident SP1 provided direct supervision of the individual in the early morning as the individual would ride with SP1 in her vehicle to drop off a different employee for off-site work.  SP1 had been doing this most of the summer as this staff person was not able to drive the company vehicles due to age restrictions.  SP1 returned to the facility with the individual around 9:00a.m. and the individual returned to her program area in the basement of the facility.  \r\nSP1 was not providing direct supervision to the individual beyond the ride in her vehicle.  SP1 did state that she makes a schedule every week that reflects which staff will be in what program areas.  She stated there is one individual that requires 1:1 supervision and the individual that eloped does not require 1:1 supervision, but the agency does designate a staff person to supervise her as she has a history of elopement.  SP1 stated that she creates this schedule (paper\/electronic document) and on the day of the incident SP3 was scheduled to supervise the individual who eloped.  SP1 stated that there are generally a lot of changes to the schedule throughout the week, so staff utilizes a whiteboard to reflect the changes.  SP1 stated that there are approximately 11-14 clients and approximately 4 staff providing supervision.  \r\nIn regards to the individual\u2019s behaviors, SP1 describes her as \u201cninja like.\u201d  SP1 stated that the individual will attempt to leave the program daily and some days she is really determined to leave and will make numerous attempts throughout the day.  \r\nSP1 was unaware that the individual left the program\/building.\r\nDebrief SP2:  SP2 confirms SP1\u2019s history of events.  SP2 stated that she has been working with the individual for 19 years and is very familiar with her behaviors.  \r\nSP2 was supervising multiple individuals in the program area the day of the incident and was unaware that the individual left the program\/building.\r\n\r\nDebrief SP3:  SP3 was identified on the paper schedule as the staff person who would be working with the individual the day of the alleged incident.  SP3 stated that she was also scheduled to learn a different job duty the day of the incident, so she informed others that she was going to be working in an office that day. \r\nShe also noted that the physical location of the staff desk upstairs doesn\u2019t provide the optimal vantage point to the entrances\/exits.  \r\nSP3 was unaware that the individual left the program\/building.","Free_Text__100":"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. \r\n\r\nThe individual\u2019s 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\u2019s 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\u2019s 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. \r\n\r\nAlthough 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\u2019s requirement to support the health, safety, and well-being of residents through the adherence to the fire codes.","Multiple_Choice__101":"0","Multiple_Choice__103":"1","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"3","Free_Text__110":"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.  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.  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. \r\nThe individual\u2019s 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.","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"0","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"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.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}