{"Short_Answer__76":"2019-08-SLC-SR","Date__77":"08\/15\/2019","Multiple_Choice__78":"Sara Beauchene","Multiple_Choice__79":"Kelly Sather","Short_Answer__80":"Northland AFC","Short_Answer__81":"Lindsay Nash","Short_Answer__82":"Lindsay Nash","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"St. Louis County","Date__86":"07\/21\/2019","Free_Text__87":"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.","Multiple_Choice__96":"2","Short_Answer__91":"Provider cancelled a person's planned trip","True_or_False__94":"Yes","Free_Text__98":"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.","Free_Text__100":"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.","Short_Answer__127":"Staff did not perform visual checks between 2am and 5pm","Yes_or_No__128":"Yes","Free_Text__130":"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.","Free_Text__132":"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.","Multiple_Choice__101":"2","Free_Text__102":"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.","Multiple_Choice__103":"3","Free_Text__104":"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.","Multiple_Choice__115":"3","Free_Text__116":"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\n\r\nThe 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.","Multiple_Choice__117":"1","Multiple_Choice__123":"2","Free_Text__124":"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.","Multiple_Choice__125":"1","Yes_or_No__432":"Yes"}