Influencing why the ICF/DD provider terminated this person’s services due to challenging behavior was that the person was posing a safety risk to others in the home. The other 3 individuals in the home were considered to be more vulnerable to abuse due to their lower functioning levels, and so the person posed a greater risk to them. The provider had to balance their responsibility to protect the health and safety of three people in the home with their responsibility to meet the needs of the person whose services they terminated. The guardians of the other 3 individuals had an expectation that the provider would keep them safe, and due to their higher vulnerability the guardians expressed their concern often in this instance. Another impact to the provider’s responsibility for people’s health and safety include county case managers assigning this function to providers via the CSSP. Unique to ICF/DDs is that they are licensed by both the Department of Human Services and the Minnesota Department of Health. Both Departments require providers to protect the health and safety of the people they serve. Minnesota Statutes 245D outlines the requirements for providers enforced by DHS while MDH relies on other statutory requirements in Minnesota statutes 144 and Rule. A unique requirement enforced by MDH is that ICF/DDs are expected to protect the people they serve from “immediate jeopardy”. The provider in this instance noted that many times in the past they had been asked after a critical incident how they were going to protect the people they served from “immediate jeopardy” in the future, so this mandate shaped the perception of the provider’s managers and supervisors whenever a health and safety concern arose and placed pressure on them to prioritize their response in a way that would satisfy MDH reviewers. The provider in this instance noted that terminating the person’s services was part of their response as to how they would respond to MDH’s questioning of how they were protecting the health and safety of the other people in the home. Between the requirements of DHS and MDH as well as the expectations of the guardians and case managers, the provider felt a strong need to act in this situation and felt that termination was the only way they could keep the majority of the people in the home safe. 
The provider noted that the team had explored the possibility of implementing rights restrictions with the individual, but the team determined they wouldn’t be possible due to the requirements of 245D surrounding rights restrictions, or wouldn’t be sufficient to meet the safety needs of the person and others in the home. Due to the ineffectiveness of a rights restriction, the provider felt they had few options to address the person’s challenging behavior. 
Another influence as to why the provider terminated a person’s services due to challenging behavior was that the person’s challenging behavior did not dissipate as expected after the person moved to the home. While it was known prior to intake that the person sometimes exhibited challenging behavior, there was an assumption by the team that this environment would likely help decrease the triggers that impacted the challenging behavior in the past. 
A number of factors were identified that  person’s challenging behavior not dissipating. For one, the provider noted that the staff at the site were trained more on meeting the medical needs of the other people in the home than de-escalating challenging behavior. While Minnesota Statutes 245D and the Positive Supports Rule (9544) required the provider to ensure their staff had training and were competent on positive support strategies, de-escalation techniques and the use of restrictive interventions, because the other people in the home didn’t exhibit challenging behavior, the focus of their training was centered more on medical needs than ‘behavioral needs’. The provider also noted that the staff felt a fear to administer pro re nata (PRN) medication to the person during mental health episodes due to the stigma of providing medication at these times and the training and reporting requirements of the Positive Supports Rule. The Positive Supports Rule (MN Rule 9544) requires providers to report the use of PRN medications when administered in a behavioral situation, and there was a belief among staff that the use of PRNs in this manner were not ok because they required reporting. 
The provider – and the person’s team - expected the person’s challenging behavior to dissipate after intake not only because they thought the environment would suit the person, but they assumed that a behavior support plan would positively effect change and decrease the person’s interfering behavior and that other external services would be able to assist with challenging episodes. Unfortunately, upon arrival the provider found there was a lack of external behavior services in their area and that they had a lack of information about what mental health services were available. Additionally, the person’s case manager – who would typically be expected to also help find needed services – was very busy and unable to devote much time to the person’s case. A number of influences as to why case managers would be busy were identified – between high case load and recent federal and state initiatives changing services. MnCHOICES, HCBS rule and person-centered planning initiatives were all noted as positive changes, but changes that took a lot of time away from case managers to learn and meet the new requirements. This program was located in southern Minnesota, and the team noted that this region in particular has a scarcity of mental health resources. The provider and the team did find a neuropsych practitioner that was willing to work with the person, but unfortunately they were too far away and the drive was too long. This made it hard to make regular meetings and implement the neuropsych’s recommendations. Additionally, the provider was able to bring the person to a nearby hospital during challenging episodes, but noted that any interventions offered by the hospital unfortunately were ineffective.
Along with the lack of mental health resources, the provider also noted there was a lack of behavioral resources available to the person. Some practitioners had recommended that the person be admitted to an inpatient facility where they could try a “med holiday” – taking the person off all their meds and slowly re-introducing medication to determine their effectiveness. The provider could only find 1 program in the state that offered “med holidays”, and that program had only 9 beds and waiting list of 25 people. The mapping team noted that the Jensen Settlement, which limited community base intensive services and the interventions they could use, influenced the lack of behavioral services like this one. 
Without interventions that met the needs of the person, coupled with the lack of training of the staff, the provider noted their staff were stressed at the site. They often times engaged in power struggles with the individual and spent time trying to keep the other 3 residents safe. The provider did note that one option they wanted to explore before terminating the person’s services was to find out if they could obtain 1 on 1 staffing for the individual, but didn’t know who to ask or where to start. ICF/DD rates have many regulations and oftentimes hard to navigate they noted. The provider noted that the ability to obtain reimbursement beyond the facility’s establish rate was a mystifying process.