(225,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201900095\",\"Date__77\":\"05\\/15\\/2019\",\"Multiple_Choice__78\":\"Sara Beauchene\",\"Multiple_Choice__79\":\"Charles Young\",\"Short_Answer__80\":\"REM Arrowhead\",\"Short_Answer__81\":\"Corey Labissoniere\",\"Short_Answer__82\":\"Corey.LaBissoniere@thementornetwork.com\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"St. Louis County\",\"Date__86\":\"10\\/02\\/2019\",\"Free_Text__87\":\"Several staff administered more than one dose of PRN on several occasions to a person who had been prescribed several PRNs.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff administered more than one dose of PRN on several days in October 2018.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"06\\/25\\/2019\",\"Free_Text__98\":\"Several workers administered the medication in the same way resulting in the error. Their decision to administer the medication in the way they did was driven by the instructions on the MAR which they all interpreted the same way, and which was also the incorrect interpretation. The staff interpreted the instruction of \\u201cdaily\\u201d to mean he could have it daily instead it meant a maximum daily (meant once a day and must be 4-6 hours after the last medication and only once a day, not every 4-6 hours daily), thus the over administration. The instructions were on the MAR and not on the med label, which was common practice. The staff followed the policy to check the label and MAR 3x any time there\\u2019s a med pass. All staff had received the required training and followed the signature and other MAR review requirements.\\r\\nThere were four people who signed off as over-administering the PRN. Two were DSPs, one area manager and one program director. The area manager and program director were covering for DSP hours due to a staffing shortage. The DSPs there were new to the agency, as was the program supervisor and the person. It was also noted the person subjected to the overmedication was a new client to the provider. It was conveyed that in a perfect world the provider wouldn\\u2019t take new service recipients until all staff were trained specific to a person. He came into a house that was already short-staffed. \\r\\n\\r\\nThe person had a high level of care, high needs, compared to others served at the home and was a newer resident of the home, moved there in September and incidents occurred in October. He began receiving services from this home after being in a hospital long after he required a hospital level of care. The transition from the hospital was described as hard: hospital social worker and care team communications were strained and confusing, and the med orders were also described as confusing. When a person with controlled meds transfers from a hospital to a provider, that time was described as being filled with angst. The sense of urgency leads to added stress. He was at the hospital for almost a year and there was extreme pressure to move him out of the hospital. The transition and care planning for this person were complicated by the fact that his guardian and contracted case manager were from Ramsey County. \\r\\n\\r\\nHe had multiple controlled meds and overlapping PRNs. For example, one PRN can only be taken X# of hours after another PRN, and there were several of these time lines and instructions to monitor. There was also one other man at the home who had a high contingent of medications. \\r\\n\\r\\nThe decision to administer the PRNs was also driven by the prescriber\\u2019s instruction to \\u201cgive him the PRN if he asks for it.\\u201d Person had been asking for many PRNs frequently. It was common for him to have more than one agitation a day. He had a diagnosis that included schizophrenia, delusional behavior. He had a long history of chemical abuse. Some of his PRNs included an inhaler, med to reduce nausea, ointment for gums. Staff describe his as having high seeking behavior and describe him as liking to be in control of his medications. He was seen by the staff as being very anxious and demanding. He occasionally raised his voice, swore, used power moves, his thoughts could get \\u201cout of control\\u201d and turn delusional. It was difficult for staff who had no experience with that. \\r\\nStaff attribute staffing of the house as a challenge. The house was very short staffed. The provider was not receiving exception rates for the people at this home. They attempted to increase the wage. The location of the home may have been a barrier to keeping it staffed. \\r\\nThe incident on 11\\/20\\/2018, the omission of a medication on the MAR, was influenced by a staffing shortage. The medication was not added to the MAR and it would have been a supervisor\\u2019s role to ensure the MAR was correct. The supervisor in charge of the MAR at that time is no longer with the company and was not debriefed. The person who attended the appointment, which was likely the same supervisor, also had a duty to ensure the correct instructions were passed along but that did not happen.\",\"Free_Text__100\":\"Several staff were involved in administering more than one dose of PRN to a person on several dates. This was influenced by a misinterpretation of instructions on the Medication Administration Report (MAR) which is created by the pharmacy. The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\\r\\n\\r\\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.\\r\\n\\r\\nWhile the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff.There are circumstances that can make a typical intake feel rushed and urgent, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \\r\\nEven under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \\u201crushed\\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process. \\r\\n\\r\\nAnother factor that contributed to the administration of more than one dose of PRN was staff felt pressure to administer PRNs. The person\\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\\u2019s instruction to give the person the PRN when he asked for it. Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.\\r\\n\\r\\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"The person\\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\\u2019s instruction to give the person the PRN when he asked for it.\",\"Multiple_Choice__103\":\"2\",\"Free_Text__104\":\"Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.\",\"Multiple_Choice__109\":\"3\",\"Free_Text__110\":\"Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. Even under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \\u201crushed\\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process.\",\"Multiple_Choice__113\":\"3\",\"Free_Text__114\":\"The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\\r\\n\\r\\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.\",\"Multiple_Choice__115\":\"1\",\"Multiple_Choice__117\":\"2\",\"Free_Text__118\":\"While the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff. There are circumstances that can make a typical intake feel more urgent or even rushed, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \\r\\n\\r\\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.\",\"Multiple_Choice__119\":\"3\",\"Free_Text__120\":\"The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs.\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"1\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:20:58',NULL,'SR_REM Arrowhead - SLC -2019 -05'),(226,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201906864\",\"Date__77\":\"10\\/15\\/2019\",\"Multiple_Choice__78\":\"Sara Beauchene\",\"Multiple_Choice__79\":\"Tony Gantenbein\",\"Short_Answer__80\":\"Stepping Stones for Living\",\"Short_Answer__81\":\"Laura Flynn\",\"Short_Answer__82\":\"laura.flynn@sslduluth.com\",\"Short_Answer__83\":\"218-336-6413\",\"Multiple_Choice__84\":\"Staff Sleeping on Duty\",\"Multiple_Choice__85\":\"St. Louis County\",\"Date__86\":\"09\\/19\\/2019\",\"Free_Text__87\":\"On 09\\/19\\/2019, it was reported that AP was found sleeping during their shift when they were to be supervising VA. At this time it is undetermined how long AP was asleep for. No harm came to VA during this time.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"One staff fell asleep during the day shift.\",\"True_or_False__94\":\"No\",\"Multiple_Choice__99\":\"Staff No Longer Employed\",\"Free_Text__100\":\"St. Louis County (Provider-Stepping Stones for Living)\\r\\nNarrative-Staff Sleeping\\r\\n\\r\\nLearning point: One staff fell asleep during the day shift. \\r\\n\\r\\nA DSP was found sleeping during the day shift while supervising two VAs. No harm came to VAs as a result. The staff sleeping was influenced by environmental factors in the home as well as outside factors. \\r\\n\\r\\nOne environmental factor in the home the day of the incident was that there were less people for the DSP to supervise than normal. There is usually an additional person to supervise, as the staffing ratio was 1:3. The third person was at an activity at the time. Due to this, the house was more quiet than usual which allowed for a more relaxed environment that lent itself to rest. For residents of the home, their needs are defined by assessment results and outlined in a Community Services and Support Plan. The level of staffing needed to address these needs is agreed to by provider and lead agency via a rate management worksheet called a 6790. The rates for the services which take into account shared and individual staffing are then entered into and set by the Disability Waiver Rates System (DWRS). \\r\\nAnother environmental factor in the home was the daily program consisted of unstructured home time and TV watching. That day, the house was quiet and there was unstructured TV watching time. Programs or daily schedules for residents are outlined in their CSSP and supported by policies that emphasize and protect personal preference. Personal preference and control over one\\u2019s schedule is a tenant of the federal Home and Community Based Services Rule which governs HCBS providers. Additionally, residential providers are required to carry a 245D license which secures a person\\u2019s right to choose activities they prefer and have a say in their daily schedule. This unstructured time was an additional factor that led to a quiet house in which the staff experienced down time, leading to sleep. \\r\\nOutside factors that contributed to staff sleeping were also present. One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. The fact the provider had unfilled shifts is due to the well-known and highly publicized state and national workforce shortage.\",\"Multiple_Choice__101\":\"3\",\"Free_Text__102\":\"One environmental factor in the home the day of the incident was that there were less people for the DSP to supervise than normal. There is usually an additional person to supervise, as the staffing ratio was 1:3. The third person was at an activity at the time. Due to this, the house was more quiet than usual which allowed for a more relaxed environment that lent itself to rest. For residents of the home, their needs are defined by assessment results and outlined in a Community Services and Support Plan. The level of staffing needed to address these needs is agreed to by provider and lead agency via a rate management worksheet called a 6790. The rates for the services which take into account shared and individual staffing are then entered into and set by the Disability Waiver Rates System (DWRS). \\r\\nAnother environmental factor in the home was the daily program consisted of unstructured home time and TV watching. That day, the house was quiet and there was unstructured TV watching time. Programs or daily schedules for residents are outlined in their CSSP and supported by policies that emphasize and protect personal preference. Personal preference and control over one\\u2019s schedule is a tenant of the federal Home and Community Based Services Rule which governs HCBS providers. Additionally, residential providers are required to carry a 245D license which secures a person\\u2019s right to choose activities they prefer and have a say in their daily schedule. This unstructured time was an additional factor that led to a quiet house in which the staff experienced down time, leading to sleep.\",\"Multiple_Choice__103\":\"3\",\"Free_Text__104\":\"Outside factors that contributed to staff sleeping were also present. One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. The fact the provider had unfilled shifts is due to the well-known and highly publicized state and national workforce shortage.\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"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\":\"0\",\"Multiple_Choice__125\":\"3\",\"Free_Text__126\":\"Outside factors that contributed to staff sleeping were also present. One outside factor is that the DSP was experiencing homelessness and was exhausted from that life stressor. It is not uncommon for DSPs to experience intermittent homelessness. In the Northeast MN region, there is a lack of affordable housing, housing resources and coordination. The governmental body that oversees housing and distribution of housing resources is Housing and Urban Development. \\r\\nAnother outside factor is the DSP was working extra shifts as the provider had unfilled shifts available. In doing so, the DSP\\u2019s basic needs such as having a roof over his head were met. He picked up extra shifts also because the provider was offering overtime pay. The fact the provider had unfilled shifts is due to the well-known and highly publicized state and national workforce shortage.\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:24:12',NULL,'SR_Stepping Stones - SLC -2019 -10'),(227,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"SS_BridgesMN-HC-2020-08\",\"Date__77\":\"08\\/26\\/2020\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Short_Answer__80\":\"Bridges MN\",\"Short_Answer__81\":\"Kelsey Traynor (completed the BIRF)\",\"Short_Answer__82\":\"kelseyt@bridgesmn.com\",\"Short_Answer__83\":\"651-334-9629\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"06\\/29\\/2020\",\"Free_Text__87\":\"On 06\\/29\\/2020 VA packed up his belongings at approximately 6:00 pm and left the home, stating he was going to\\r\\nChicago to visit his sister. VA then proceeded to walk towards the bus stop and waited. Staff followed the bus once VA got on the bus. Staff\\r\\ncontacted Metro Transit Police for assistance, who then intervened. The officer called the Supervisor, who then called in the Community\\r\\nLiving Director (CLD) as well, via phone, to discuss the situation. The CLD explained VA\'s situation and that he is on a commitment and\\r\\nprovisional discharge, and requested assistance in getting the VA back to the residence. The officer informed the CLD and supervisor that\\r\\ndue to VA being their own guardian and not being a danger to himself or others, they could not do anything except encourage VA to go with\\r\\nstaff. The CLD then met VA and staff at the Greyhound Bus Station in Minneapolis a little before 8:00 pm, just as VA was purchasing a bus\\r\\nticket to Chicago. Staff and CLD attempted every approach they could think of to get VA to reconsider leaving the state, but VA still planned\\r\\nto get on the bus. VA reported having connections in Chicago and has a plan, but would not share any further details. VA recently\\r\\npurchased a cell phone, but refused to give staff the phone number to the new phone. The CLD called Fairview Hospital to discuss the\\r\\nsituation, but they also stated \\\"our hands are tied\\\" since VA is his own guardian. Staff remained with VA at the bus station until 1:00 am on\\r\\n06\\/30\\/2020, when VA left on the greyhound bus to Chicago. The CLD filed a missing persons report with the Minneapolis Police\\r\\nDepartment, who stated they would pass this report along to the Chicago Police Department as well. The CLD attempted to contact VA\'s\\r\\nmother, but the mother\'s phone was disconnected. The CLD also attempted to call VA\'s grandmother, who did not answer or respond to\\r\\nthe CLD\'s voicemails.\\r\\nStaff followed all care plans and attempted to redirect VA into not going on the bus, but VA made the choice to leave. VA did not have any\\r\\nmedications packed and is due for an injection on 07\\/08\\/2020. VA is prescribed multiple psychotropic medications, including an injection.\\r\\nVA has a history of attempting to\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"10\\/06\\/2020\",\"Free_Text__98\":\"Two night staff from Bridges were de-briefed.  They relieved two second shift staff who followed the person to the bus station and worked to help attempt to help the person return home.  \\r\\n\\r\\nThe staff worked by relieving each other in the bus station as there was not adequate parking at the bus station so they had to park on the street and one person needed to remain in the car to assure it did not get towed.   They both stated the person would not talk to them and the bus station was very busy.  The person smoked frequently outside the bus station while waiting for departure.   Staff also had one mask to share while switching spots from the car to inside the bus station next to the person.  Staff would use their shirt as a mask while switching.   The person spent most of their time listening to music and ignoring staff.   Staff attempted several times to have a conversation in an effort to persuade the person to return back to the home.   At about 1:00 AM the person departed on the bus and staff returned back to the home.   Staff were in frequent contact with the home manager for guidance. Staff were instructed to remain with the person at the bus station, however, they were instructed that he was his own guardian and could leave.\",\"Free_Text__100\":\"Learning Point:  Staff were unable to redirect a person from departing on a bus to Chicago.  \\r\\n\\r\\nStaff was unable to redirect a person from departing on a bus to Chicago and this was influenced by wanting to go to Chicago to visit their sister. This matter was complicated given the person wouldn\\u2019t communicate with staff present.  All efforts to redirect the person were unsuccessful while exhausting all other safe alternatives. The person was earlier hospitalized regarding mental health and aggression and the staff was hesitant at the moment and didn\\u2019t want to anger the person further. Another contributing factor was that the person received a COVID stimulus check that created the means for the visit to Chicago.    \\r\\n\\r\\nStaff being unable to redirect the person was influenced by the provider ultimately determining the risk was low to take the trip without staff. After many unsuccessful attempts to redirect, the provider reviewed the person\\u2019s risk management plan and it was affirmed. Contributing factors that further influenced the staffs\\u2019 decision to remain at the bus station was the expectation of the lead agency and CSSP was not to follow a person to another state while eloping and assure full communication with all team members and agency staff.\\r\\n\\r\\nAnother influence to the inability to redirect was that staff were hesitant to anger the person. This was further supported by the person having a history of aggressive behavior. The person wouldn\\u2019t communicate with the staff present and they were hesitant to coerce the person too much in their efforts to support him in being safe. Staff also did offer to support this trip at a future date with proper planning to assure health and safety. This moment was further complicated by contacting the hospital who stated there was nothing they or staff could do given the person was his own guardian which further limited staff in their efforts to help him return home.\\r\\n\\r\\nAn additional feature that impacted the support lent to the person was the agency\\u2019s practice of person-centered efforts in trying to find balance of what was important to and for the person while making decisions at that moment. Their operating philosophy supported personal freedoms and choices based on experiences over time.  There is also an overall systemic expectation that providers support experiences, choices, and the person\\u2019s rights.   \\r\\n\\r\\nStaff being unable to redirect was influenced by the provider exhausting all safe alternatives. The person is their own guardian and did have a provisional discharge from the program.  Furthermore, COVID and the Governor\\u2019s stay at home order also influenced the person\\u2019s decision to leave as his routine was limited to low activity. This elopement influenced the agency, team, and staff present to honor the person\\u2019s civil rights which connected directly to their philosophy of protecting his rights which put him in charge of making the decision to leave on the bus.\",\"Multiple_Choice__101\":\"0\",\"Multiple_Choice__103\":\"0\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"0\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"3\",\"Free_Text__116\":\"Staff was unable to redirect a person from departing on a bus to Chicago and this was influenced by wanting to go to Chicago to visit their sister. This matter was complicated given the person wouldn\\u2019t communicate with staff present.  All efforts to redirect the person were unsuccessful while exhausting all other safe alternatives. The person was earlier hospitalized regarding mental health and aggression and the staff was hesitant at the moment and didn\\u2019t want to anger the person further. Another contributing factor was that the person received a COVID stimulus check that created the means for the visit to Chicago.    \\r\\n\\r\\nStaff being unable to redirect the person was influenced by the provider ultimately determining the risk was low to take the trip without staff. After many unsuccessful attempts to redirect, the provider reviewed the person\\u2019s risk management plan and it was affirmed. Contributing factors that further influenced the staffs\\u2019 decision to remain at the bus station was the expectation of the lead agency and CSSP was not to follow a person to another state while eloping and assure full communication with all team members and agency staff.\\r\\n\\r\\nAnother influence to the inability to redirect was that staff were hesitant to anger the person. This was further supported by the person having a history of aggressive behavior. The person wouldn\\u2019t communicate with the staff present and they were hesitant to coerce the person too much in their efforts to support him in being safe. Staff also did offer to support this trip at a future date with proper planning to assure health and safety. This moment was further complicated by contacting the hospital who stated there was nothing they or staff could do given the person was his own guardian which further limited staff in their efforts to help him return home.\\r\\n\\r\\nAn additional feature that impacted the support lent to the person was the agency\\u2019s practice of person-centered efforts in trying to find balance of what was important to and for the person while making decisions at that moment. Their operating philosophy supported personal freedoms and choices based on experiences over time.  There is also an overall systemic expectation that providers support experiences, choices, and the person\\u2019s rights.   \\r\\n\\r\\nStaff being unable to redirect was influenced by the provider exhausting all safe alternatives. The person is their own guardian and did have a provisional discharge from the program.  Furthermore, COVID and the Governor\\u2019s stay at home order also influenced the person\\u2019s decision to leave as his routine was limited to low activity. This elopement influenced the agency, team, and staff present to honor the person\\u2019s civil rights which connected directly to their philosophy of protecting his rights which put him in charge of making the decision to leave on the bus.\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"0\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:25:45',NULL,'SS_BridgesMN - HC -2020 -08'),(228,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201908690\",\"Date__77\":\"12\\/16\\/2019\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Multiple_Choice__79\":\"Sara Beauchene\",\"Short_Answer__80\":\"JEC Miller\",\"Short_Answer__81\":\"Adam Gregg\",\"Short_Answer__82\":\"adam@jecmiller.com\",\"Short_Answer__83\":\"952-303-1614\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"11\\/23\\/2019\",\"Free_Text__87\":\"Peter walked to the store down the road from his home. He was gone for roughly 30 minutes. Peter does not have alone time.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"02\\/12\\/2020\",\"Free_Text__98\":\"Staff did not follow person\\u2019s plan that said the person should not have alone time\",\"Free_Text__100\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. Low unemployment rates in the region and the state contributed to low unemployment rates, which in turn contributed the provider being short staffed. Adding to the unfamiliarity the staff had with the home, the person who eloped was difficult to understand and was noted to often test boundaries with staff which made it difficult for staff to understand that the person was not supposed to be alone.\\r\\n\\r\\nThe staff\\u2019s understanding of the difference between alone and community time further influenced the staff not following the person\\u2019s plan.  There was also another person in the home that did not have alone time which was contrary to the house norm which implied that each person had some alone time.  Furthermore, the two staff\\u2019s roles were not clearly communicated to them and the second staff didn\\u2019t counter the support staff\\u2019s understanding and may not have been aware.   The person\\u2019s plan stated they did have 10 minutes of home time alone but no unsupervised time in the community.  This created confusion for the staff who was new working in the home and had to train fast. \\r\\n\\r\\nThe basis for alone time according to the provider can be difficult to manage as staff have to read multiple plans for a person.  There was also pressure due to the staff shortage that is directly tied to regional and statewide staff shortages and overall low unemployment rates.  The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.  The DWRS further influences the 6790 which connects to provider resources and their need to share a van with multiple locations that support people with disabilities.\",\"Multiple_Choice__101\":\"1\",\"Multiple_Choice__103\":\"3\",\"Free_Text__104\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. The basis for alone time according to the provider can be difficult to manage as staff have to read multiple plans for a person.   The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.  The DWRS further influences the 6790 which connects to provider resources and their need to share a van with multiple locations that support people with disabilities.\",\"Multiple_Choice__105\":\"2\",\"Free_Text__106\":\"The CSSP no longer has a line to state whether a person has alone time hence creating confusion and vagueness.\",\"Multiple_Choice__107\":\"1\",\"Multiple_Choice__109\":\"1\",\"Multiple_Choice__111\":\"2\",\"Free_Text__112\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there. When a staff trains at a new home, they have to read multiple plans for each person who lives in the home. The staff present the day of the incident worked at multiple homes to help fill shifts as the provider was short staffed. Low unemployment rates in the region and the state contributed to low unemployment rates, which in turn contributed the provider being short staffed. Adding to the unfamiliarity the staff had with the home, the person who eloped was difficult to understand and was noted to often test boundaries with staff which made it difficult for staff to understand that the person was not supposed to be alone.\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"0\",\"Multiple_Choice__117\":\"2\",\"Free_Text__118\":\"Staff not following the person\\u2019s plan that said they should not have alone time was influenced by the unfamiliarity the staff had at the home as they were transferred to cover appropriate shifts as the provider was short staffed. This required the provider to train the staff quickly to become familiar with the home and the people who lived there.\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"1\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:26:27',NULL,'SS_JEC Miller - HC -2019 -12'),(229,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"SS_Merdian-HC-2021-02\",\"Date__77\":\"02\\/25\\/2021\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Short_Answer__80\":\"Meridian Services - Timber Crest\",\"Short_Answer__81\":\"Rebecca Hage-Thomley\",\"Short_Answer__82\":\"rthomley@orionassoc.net\",\"Short_Answer__83\":\"763-450-5045\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Hennepin County\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-25 16:20:39',NULL,'SS_Merdian - HC -2021 -02'),(230,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201906129\",\"Date__77\":\"09\\/16\\/2019\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Multiple_Choice__79\":\"Aric Gregg\",\"Short_Answer__80\":\"Opportunity Partners - Keith\'s Place\",\"Short_Answer__81\":\"Jay McKibbins\",\"Short_Answer__82\":\"jmckibbins@opportunities.org\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"08\\/24\\/2019\",\"Free_Text__87\":\"VA, Housemate and AP were at food court in Eden Prairie mall. VA needed to go to the bathroom. Bathroom was at sight so AP let VA walk\\r\\nto the bathroom by himself. AP observed VA walk in to the bathroom but did not observe VA come out. After about 10 minutes, AP went to\\r\\ncheck the bathroom with Housemate but VA was not there. AP talked to an unknown cleaning lady about contacting the security. AP\\r\\ncontacted security and also called Nurse and Reporter. Nurse contacted Coordinator.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not continuously monitor a public restroom door a person with dementia was using.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"10\\/13\\/2020\",\"Free_Text__98\":\"Staff drove two housemates to the Eden Prairie mall. The staff and housemates frequent the mall and are very familiar with the area. They parked in the back of the mall parking lot as they prefer the walk into the mall for some exercise. After shopping in the mall they stopped at the food court for lunch. The person who went missing brought his own lunch and after eating needed to use the restroom. This person had never used the restroom at this mall before. Staff stayed with the other person while he walked to the restroom. The restroom sign was in line of sight for the staff and staff saw the person enter the hallway that led to the restroom. There was only one entrance to the restroom area.  \\r\\n\\r\\nWhile the person was using the restroom, the staff reported the other person was experiencing anxiety. Staff is trained in positive behavior approaches and did help the person by talking to them while they used a paper bag to take some deep breaths. After about 10 minutes, staff and the person she was supporting went to the restroom area to check on the person as they did not see him exit. While she was assisting the person, she did have line of sight on the exit to her best knowledge. Staff checked the family and womens restroom, while the other person checked the mens restroom. The person was not present. Staff then spoke with a cleaning attendant and she helped contact the mall security.   \\r\\n\\r\\nMall security searched for the person while the staff and other person searched around the food court. Mall security then asked the staff to remain at the food court and that they would contact the police to assist.  Staff then called the Opportunity Partners nurse as the typical program manager was on vacation.  \\r\\n\\r\\nAt about 12:45 the mall security found the person standing by the staff\\u2019s vehicle. Mall security then reunited the staff with the person.\",\"Free_Text__100\":\"Staff did not continuously monitor a public restroom door a person with dementia was using. This was influenced by staff\\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety. The staff and the two people routinely went to this mall and the one person did not return from the restroom as anticipated.  Staff was within line of sight of the the entrance to the bathroom that only had one exit. The staff did not think using the restroom was a risk and assumed he\\u2019d return safely given they frequent the mall and are familiar. Staff knew there was not a back door behind the restrooms. \\r\\n\\r\\nThe person had only recently been diagnosed with dementia. While the company nurse trained the staff on supporting people with dementia, the staff was not certain what that meant for the person, but did have familiarity with supporting the person. The person also had been grieving the loss  of a long-time friend\\/room mate. Person-Centered practices influenced the decision to adhere to the person\\u2019s routine and community inclusion activities to have lunch at the mall. This situation was further complicated as the definition of the need of support was not synonimous with the agency\\u2019s definition. While the person\\u2019s CSSP required 24\\/7 supervision, it did not require \\u201cdirect line of sight\\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \\u201cdirect line of sight\\u201d supervision would require 1:1 staffing, which was not supported in the person\\u2019s CSSP or 6790 rate form. \\r\\n\\r\\n\\r\\nThe providers policies allowed for a 1:2 staffing ratio which is influenced by the county via the 6790 rates form and DHS\\u2019s DWRS system. The person\\u2019s MNCHOICES assessment was not up for renewal for several months which creates more complexity while the person\\u2019s dementia as the condition possibly changes or is not understood over time and new symptoms develop. The provider noted that while many times a person with dementia has a higher staffing level in the community, this person did not yet have a higher staffing level as the person\\u2019s dementia had just recently developed. The provider had not sought out additional staff or funding for the person yet because they weren\\u2019t sure they could add more staff due to the workforce shortage and that the person had not yet had an episode of elopement. The provider noted that staffing levels were typically reactive after incidents rather than proactive to prevent them.\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"This was influenced by staff\\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety.\",\"Multiple_Choice__103\":\"1\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"1\",\"Multiple_Choice__113\":\"1\",\"Multiple_Choice__115\":\"2\",\"Free_Text__116\":\"This situation was further complicated as the definition of the need of support was not synonymous with the agency\\u2019s definition. While the person\\u2019s CSSP required 24\\/7 supervision, it did not require \\u201cdirect line of sight\\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \\u201cdirect line of sight\\u201d supervision would require 1:1 staffing, which was not supported in the person\\u2019s CSSP or 6790 rate form.\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"0\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:27:54',NULL,'SS_Opportunity Partners - HC -2019 -09'),(231,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"SS_Success Homes-HC-2021-04\",\"Date__77\":\"04\\/28\\/2021\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Short_Answer__80\":\"Success Homes\",\"Short_Answer__81\":\"Amy R or P\",\"Short_Answer__83\":\"763-533-628 (main line)\",\"Multiple_Choice__84\":\"Termination of Services\",\"Multiple_Choice__85\":\"Hennepin County\",\"Free_Text__87\":\"\\\"Termination is necessary for person\'s welfare and needs can\'t be met; safety of others is endangered and positive support strategies were unsuccessful\\r\\n\\r\\nSuccess Homes, Inc. has made attempts to allow person to remain in the home by meeting with the team to find positive support approaches to minimize the behaviors that cause the outbursts that he has displayed. He has become physically aggressive with peers, staff and himself and destroyed property that has resulted in him being transferred to the hospital for assessment. Medication changes have been unsuccessful and attempts to manage these behaviors have been unsuccessful. Success Homes, Inc. feels that the behaviors require a more secure setting and structured placement. He has now displayed behaviors that pose a threat to his peers and staff that cause them to feel endangered and unsafe in their current placement. He has worked with crisis facilities that were unsuccessful in the past. Attempts have been made with medication changes and behavior supports that have been unsuccessful for staff and him. We feel he\'s a threat to his peers and the staff are immanent enough at this point to terminate services.\\\"\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-25 16:21:24',NULL,'SS_Success Homes - HC -2021 -04'),(232,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201902151\",\"Date__77\":\"06\\/18\\/2019\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Multiple_Choice__79\":\"Sara Beauchene\",\"Short_Answer__80\":\"Taylor SLS\",\"Short_Answer__81\":\"Michael Taylor\",\"Short_Answer__82\":\"miket.sls@charter.net\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"St. Louis County\",\"Date__86\":\"03\\/22\\/2019\",\"Free_Text__87\":\"Staff 1 administered the person another roommates\\u2019 medication at 8:15pm on 3\\/22\\/19. Immediately following, Staff 1 notified the facility\'s RN Consultant, the person\'s primary physician, poison control, and the home\'s Associate Director. Poison Control suggested that the person be transported to a local emergency room for treatment. The Staff 1 immediately dialed 9-1-1and activated EMS. EMS arrived and brought the person to St. Mary\'s Medical Center ER in Duluth via Gold Cross Ambulance. VA was brought into an ER room and assessment began. The Associate Director met the person at the hospital. The person was given IV fluids as a precaution. Blood was drawn and x-rays were taken. ER MD planned on transferring person from the ER to a regular room for overnight observation. In the interim, the person had a seizure in the ER and the ER MD\'s plan was changed to have him transferred to an ICU bed for monitoring. The person was moved from the ICU to a regular hospital room on 4 East the next day. The person was discharged from the hospital on 3\\/24 at 1:30pm as he returned to baseline without any adverse effects per Hospitalist.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Agency staff administered incorrect medication to a person living in the home.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"08\\/01\\/2019\",\"Free_Text__98\":\"Staff 1 arrived at work at 2:00pm and described it as a normal day.  The person 1 who received the incorrect medication was picked up by his Mother around 3:00pm and staff was told they would be back at 6:00pm.   Staff 1 stated that the person receives seizure medications and it is important to administer at specific times per doctors\\u2019 orders.   Missing medications or being untimely can trigger seizures.   Evening medication pass is at 7:00pm and as of 7:30pm the person 1 did not arrive home.  Staff 1 stated they felt anxious about not being able to pass medications, however, there is a one hour window on each side of medication passes.   Therefore, medications could be passed between 6:00pm and 8:00pm.   As of 8:30pm, the person 1 did not arrive and staff 2\\u2019s shift ended. Staff 2 asked staff 1 if he could administer all medications to the people who lived there.  Staff 1 agreed and continued to feel anxious given the person was not home and was not able to administer medications.     \\r\\n\\r\\nStaff 1 began the process of a blood check that is routine for person 2 who lives in the home.   Person 2 receives sleep medication (Trazadone 300mg).   Staff 1 described that person 2 needed a lot of time to prepare for his blood check and taking his medications which required significant attention.  Person 2 was watching TV and required a lot of reminders to eventually transition to the kitchen area to take medications.  Staff 1 was eventually at the kitchen table with person 2 and began the blood check. At about 9pm, person 1 arrived home and staff 1 went to lock the medication cabinet that he had left open.  Staff 1 had already prepared person 1 and 2\\u2019s medications.  Staff 1 put both sets of medications on the table in apple sauce and then quickly passed medications to person 1.   Person 1 proceeded to eat a snack while staff 1 was finishing the blood check with person 2.   \\r\\n\\r\\nShortly after the medication was passed, staff 1 realized he gave person 1 the incorrect medication and proceeded to contact the house LPN and director.\",\"Free_Text__100\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differientiate between the medications in apple sauce.   An additional factor influencing giving the incorrect medication to the person was that the provider had one less staff working than they typically did during medication administration. The provider typically had a 2 staff to 4 person ratio until 8pm, so that two staff would be on during the 6p-8p med administration window. On this day, the person\\u2019s mother kept him out past the medication window, so that when he returned the second staff had left, leaving one staff on to administer the person\\u2019s meds when he arrived. The provider\'s staff ratio and schedule is influenced by the county\\u2019s service agreement with the provider to deliver services. MNCHOICES also influences how the county determines how many staffing hours to include in their service agreement and what medication administration responsibility they assign to the provider.    \\r\\n\\r\\nStaff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.  \\r\\n\\r\\nThe DWRS, MNCHOICES assessment, and county service agreement also impacted the staff schedule and further complicated the medication protocol.\",\"Multiple_Choice__101\":\"0\",\"Multiple_Choice__103\":\"0\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"0\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"0\",\"Multiple_Choice__117\":\"2\",\"Free_Text__118\":\"Staff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"2\",\"Free_Text__124\":\"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differentiate between the medications in apple sauce.\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:30:45',NULL,'SS_Taylor SLS - SLC -2019 -06'),(233,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201904741\",\"Date__77\":\"07\\/24\\/2019\",\"Multiple_Choice__78\":\"Scott Schifsky\",\"Multiple_Choice__79\":\"Marilee Bengtson\",\"Short_Answer__80\":\"Thomas Allen\",\"Short_Answer__81\":\"Chet Whitmore\",\"Short_Answer__82\":\"chet.whitmore@thomasalleninc.com\",\"Multiple_Choice__84\":\"Wheelchair Safety\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"06\\/27\\/2019\",\"Free_Text__87\":\"On 6\\/27\\/2019 between 8:00am and 9:30am, Staff 1 was driving person in their electronic wheelchair.  Staff 1 ran into door way, and the person\\u2019s leg got caught. The person\\u2019s leg looked swollen, so Reporter told Program Manager to bring VA to an Urgent Care (unknown information.) Reporter notified Guardian, Case Manager (unknown information,) and County Licensor. Urgent Care Physician (unknown information) told Program Manager to bring VA to an ER. Program Manager brought VA to an ER (unknown information,) and VA has a hairline fracture in VAs\' foot (unknown information.) VA was admitted to Hospital (unknown information.) Reporter is waiting to hear back to see what plan of action Hospital plans to take. Reporter will train AP on how to drive VAs\' wheelchair.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not have foot pedals on person\\u2019s wheelchair while driving the person to the restroom.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"09\\/05\\/2019\",\"Free_Text__98\":\"Staff arrived at 6:00am and described the morning as a typical shift.  Staff took a Benadryl for allergy relief at 5:00am and described that the medication did not make her sleepy.  Staff then assisted the person with their morning routine by helping them use the restroom, bathing, and then going to the kitchen for breakfast.  The person has difficulty swallowing food and requires assistance eating and reminders to swallow twice.  Staff was doing a variety of household tasks and was helping people get ready between 6:00am and 8:00am.  There were three staff on duty that morning. \\r\\n\\r\\nAfter breakfast staff then assisted the person by driving her electric chair from the kitchen to the restroom without foot pedals.  The person does not like their foot pedals on the chair.  The person has a lot of rigidity in her muscles and her legs were sticking out the sides of the chair.  Staff stopped shortly before the doorway to do a task and then proceeded driving the person in their chair.  The person\\u2019s leg broke when their foot got caught on a cupboard door jam.\",\"Free_Text__100\":\"Agency staff not having foot pedals on while driving the person\\u2019s wheelchair was influenced by the staffs\\u2019 divided attention.  Staff could not recall the specific task that divided her attention while being midway through the kitchen. The person had a preference against using foot pedals and communicates their preference by their rigidity and loud vocalizations.  This was further complicated by typical morning routine that resembles the practice of most busy group homes.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \\r\\n\\r\\nThe CSSP and risk management plan followed standard wheelchair safety and practice related to the wheelchair manufacturer guidelines.  The general practice for wheel chair use conflicted with the agency\\u2019s practice. Team conversations about how this person wanted to live did not have consistency with the person\\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.\",\"Multiple_Choice__101\":\"0\",\"Multiple_Choice__103\":\"0\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"0\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"2\",\"Free_Text__116\":\"Agency staff not having foot pedals on while driving the person\\u2019s wheelchair was influenced by the staffs\\u2019 divided attention.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \\r\\n\\r\\nThe general practice for wheel chair use conflicted with the agency\\u2019s practice.\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"2\",\"Free_Text__124\":\"Team conversations about how this person wanted to live did not have consistency with the person\\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:30:25',NULL,'SS_Thomas Allen - HC -2019 -07'),(234,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201906219\",\"Date__77\":\"09\\/16\\/2019\",\"Multiple_Choice__78\":\"Tony Gantenbein\",\"Multiple_Choice__79\":\"Jill Tilbury\",\"Short_Answer__80\":\"Dungarvin - Brooklyn Park\",\"Short_Answer__81\":\"Heather Golden\",\"Short_Answer__82\":\"hgolden@dungarvin.com\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"08\\/24\\/2019\",\"Free_Text__87\":\"On 8\\/24\\/2019, VA and AP went to the Minnesota State Fair. An unknown event occurred between 12:30 PM and 5:30 PM wile VA was\\r\\nunsupervised. VA was unsupervised for approximately thirty minutes.\\r\\n\\r\\nReporter found out 8\\/26\\/2019. VA had appointment with Psychologist at 3:30 PM. Behavior Specialist accompanied VA to appointment. VA\\r\\ntold Psychologist \\\"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\\\" VA said AP walked away from VA. VA\\r\\ncould not find AP. AP found VA.\\r\\n\\r\\nReporter asked AP to explain. AP said VA had a rental scooter while at the Minnesota State Fair. VA told AP she was going to the bathroom\\r\\non scooter, and took off. AP could not keep up with scooter and soon lost VA. AP continued to search for VA. Approximately thirty minutes\\r\\nlater AP found VA near a bathroom.\\r\\n\\r\\nReporter noted that VA has a previous history of false reporting.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff lost sight of a person at the State Fair\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"10\\/25\\/2019\",\"Free_Text__98\":\"Collaborative Safety \\u2013 Systems Mapping \\r\\nCase Summary\\r\\nOctober 14, 2019\\r\\nHennepin County\\r\\n\\r\\n\\r\\nLearning Point #1: Staff lost sight of a person at the State Fair.\\r\\n\\r\\nLearning Point #2: Staff brought his son along on this community outing. \\r\\n\\r\\nIncident report description\\r\\n\\u2022\\tIncident date: 8\\/24\\/2019, between 12:30 PM and 5:30 PM\\r\\n\\u2022\\tReport date: 8\\/27\\/2019 4:11PM\\r\\n\\r\\nStaff and person went to the Minnesota State Fair on a Saturday afternoon. During this outing, the person was unsupervised for approximately thirty minutes. The person had a rental scooter and took off on it to go to use the bathroom. The staff could not keep up with the scooter and lost sight of the person. Approximately 30 minutes later, staff found the person near the bathroom. \\r\\n\\r\\nTwo days later, the reporter found out about the incident during an appointment between the person and a Psychologist when the person told the Psychologist \\\"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\\\" \\r\\n\\r\\nDebriefing information for learning Point #1, October 25, 2019\\r\\n\\r\\nStaff participated in a human factors debriefing, led by a Safety Analyst, on October 25, 2019.\\r\\n\\r\\nUpon arrival at the State Fair, the person rented an electric mobility scooter for people with disabilities. The staff brought his 10 year old son along to the event. The staff\\u2019s attention was influenced by the person\\u2019s behavior as they began walking into the Fair, when the person said she wanted to go to the beer garden and drink beer. This action triggered the staff to wonder if this was a good idea. \\r\\n\\r\\nShortly after arriving, the staff and his son sat down to eat some food while the person used the scooter to go and browse at a souvenir stand within eyesight. The crowd at the Fair impacted the staff\\u2019s focus when he lost sight of the person on the scooter during the outing. Staff reported he was not distracted by his son\\u2019s presence. \\r\\n\\r\\nDebriefing information for learning Point #2, October 25, 2019\\r\\n\\r\\nDuring the debriefing session for Learning Point #1, Staff shared he brought his son along to the outing after the VA told him she thought it was fine. He explained it was a last minute decision because of issues around child care coverage.\\r\\n\\r\\nResult of Incident\\r\\nStaff reported going to the beer garden to search for the person. She was not there, so he called her on her cell phone. She answered his call, but could not tell staff exactly where she was. This phone call went on for about 30 minutes until staff located the person.\",\"Free_Text__100\":\"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. Staff brought their son along on the outing because the person offered for him to come along. The person likely offered because if staff was unable to work the person would be unable to go to the fair as the person overheard a conversation the staff had about his son not having childcare on the day of the Fair. The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person. \\r\\n\\r\\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.  The provider has a policy that allows staff to use judgment\\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose. \\r\\n\\r\\nThe Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\\u2019s history of challenging behaviors influenced the Guardian\\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager\'s decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing. An industry wide staffing shortage impacted the providers\\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. \\r\\n\\r\\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.\",\"Multiple_Choice__103\":\"3\",\"Free_Text__104\":\"The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person.  \\r\\n\\r\\nAn industry wide staffing shortage impacted the providers\\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"2\",\"Free_Text__110\":\"The Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\\u2019s history of challenging behaviors influenced the Guardian\\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager\'s decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing .\",\"Multiple_Choice__111\":\"0\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"2\",\"Free_Text__116\":\"The provider has a policy that allows staff to use judgment\\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose.\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"1\",\"Multiple_Choice__123\":\"1\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:31:44',NULL,'TG_Dungarvin Brooklyn - HC -2019 -09'),(235,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"TG_DungarvinBryant-H-2020-09\",\"Date__77\":\"10\\/12\\/2020\",\"Multiple_Choice__78\":\"Tony Gantenbein\",\"Multiple_Choice__79\":\"Jill Tilbury\",\"Short_Answer__80\":\"Dungarvin\",\"Short_Answer__81\":\"Caimon Kollie\",\"Short_Answer__82\":\"ckollie@dungarvin.com\",\"Short_Answer__83\":\"651-699-6050 ext 5761\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"08\\/09\\/2020\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Medication was stole from a residential facility without staff knowledge.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"12\\/17\\/2020\",\"Free_Text__98\":\"The quality assurance staff and operations director were debriefed on 12\\/17\\/2020. The DSPs who were working at the time of this incident are no longer employed.\\r\\nOne of the residents ran out of medication several days early and staff noticed pills were missing. The house was searched until the empty packaging was discovered in a resident\\u2019s room. Quality assurance staff conducted an internal investigation where the person served (VA) admitted taking the medications. The residential facility was not able to determine when the medications went missing and therefore did not know what staff was working when the theft occurred. All staff working at the residential facility during the general time frame of the theft are no longer employed by the provider.\\r\\nMedication is stored in bins in a pantry located in the kitchen under lock and key. There is a key ring kept in a drawer for staff. The investigation revealed the key is not always used and there were times staff not sure where the key was or if the pantry is always locked. The facility provides medication management training for new staff at the time of hire and annually reviews medication policy and procedures with all staff on site during a team meetings.\\r\\nTypically the house is double staffed, two people on each shift. The majority of shifts had only one staff working. During the pandemic, there were times temporary staff was were used for some shifts. The operations director and quality assurance staff also filled in to cover direct care shifts.\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:32:19',NULL,'TG_DungarvinBryant - H -2020 -09'),(236,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"TG_MSOCS-HC-2021-01\",\"Date__77\":\"01\\/29\\/2021\",\"Multiple_Choice__78\":\"Tony Gantenbein\",\"Short_Answer__80\":\"MSOCS - West Metro Community Resources\",\"Short_Answer__81\":\"Donovan Chandler\",\"Short_Answer__82\":\"donovan.chandler@state.mn.us\",\"Short_Answer__83\":\"218-831-5409\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"11\\/09\\/2020\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:33:12',NULL,'TG_MSOCS - HC -2021 -01'),(237,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201904039\",\"Date__77\":\"07\\/24\\/2019\",\"Multiple_Choice__78\":\"Tony Gantenbein\",\"Multiple_Choice__79\":\"Tim Sullivan\",\"Short_Answer__80\":\"Mary T. Inc.\",\"Short_Answer__81\":\"Gordon Clark\",\"Short_Answer__82\":\"gordonc@marytinc.com\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"06\\/01\\/2019\",\"Free_Text__87\":\"Staff brought four housemates to the Como Park Zoo on a summer Saturday afternoon. After spending some time walking around the crowed zoo looking at animals, one person wandered away from the group. Staff was not sure what to do so he brought the other guys back to the van, leaving the windows down, to keep them together. He went back to look for the missing person with the help of zoo staff.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff lost sight of person at Como Zoo\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"08\\/27\\/2019\",\"Free_Text__98\":\"Staff participated in a human factors debriefing, led by a Safety Analyst, on August 27, 2019 at the group home in Richfield where the VA resides.\\r\\n\\r\\nThe slow pace of one of the people on the outing impacted the staff persons focus during the outing and he lost sight of one the housemates. The staff placed importance on the safety of the other people in the group when he made the decision to place them in the van while he sought help in locating the missing person. He did not want to lose other people. This decision was further influenced by fact, he was the only staff person on the outing and he had never been to Como Park before so he was not familiar with the park or available resources.\",\"Free_Text__100\":\"Losing sight of a person was influenced by staff being distracted while holding the hand of a slow walker in the group and watching their footing. This was further influenced by the crowded zoo and the varying needs of each of the four people in the group. Also this was the staffs first time at Como Park Zoo and he was unfamiliar with the park and available resources. He wanted to do an activity the group enjoyed and was not afraid to take risks by going to a new place for an outing. It was known that the people living in the home enjoyed seeing animals, and considering that Como Zoo was a free activity, this outing was selected. The staff\\u2019s willingness to take risk was likely impacted by the disability advocacy community\\u2019s emphasis on allowing people with disabilities the dignity of risk. \\r\\nAdditional factors that influenced the Como Park outing and staff decision making were the community inclusion goals developed by the provider. These goals are outlined in the CSP\\/CSSP for each person in the group based on the MN Choices Assessment and the Person Centered\\/Informed Choice protocols. \\r\\n\\r\\nThe staffing pattern on the day of the outing to Como Zoo was impacted by the provider\\u2019s budget and the hours allocated to the home during the negotiation process facilitated by DHS Form 6790. This process is impacted by the individual needs of each person in the home, assessed by MnCHOICES and developed into each person\\u2019s Coordinated Services and Support Plan. The hours and rate are further impacted by the Disability Waiver Rate System created by the Minnesota Legislature. \\r\\n\\r\\nThe staff training established in 245D statute and the Positive Supports Rule influenced the provider required training to prepare staff for community based outings and discretion for decision making. Staff demonstrated competency in this area when he was able to describe the clothing worn by the missing person and share \\u201cthe book\\u201d with details about the person.\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"Losing sight of a person was influenced by staff being distracted while holding the hand of a slow walker in the group and watching their footing. This was further influenced by the crowded zoo and the varying needs of each of the four people in the group.\",\"Multiple_Choice__103\":\"3\",\"Free_Text__104\":\"The staffing pattern on the day of the outing to Como Zoo was impacted by the provider\\u2019s budget and the hours allocated to the home during the negotiation process facilitated by DHS Form 6790. This process is impacted by the individual needs of each person in the home, assessed by MnCHOICES and developed into each person\\u2019s Coordinated Services and Support Plan. The hours and rate are further impacted by the Disability Waiver Rate System created by the Minnesota Legislature.\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"1\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"3\",\"Free_Text__116\":\"We may need to edit the narrative and this example to emphasize the conflict between the \\\"health, safety, and well-being\\\" and community inclusion\\r\\n\\r\\nIt was known that the people living in the home enjoyed seeing animals, and considering that Como Zoo was a free activity, this outing was selected. The staff\\u2019s willingness to take risk was likely impacted by the disability advocacy community\\u2019s emphasis on allowing people with disabilities the dignity of risk. \\r\\nAdditional factors that influenced the Como Park outing and staff decision making were the community inclusion goals developed by the provider.\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"2\",\"Free_Text__124\":\"The staff\\u2019s willingness to take risk was likely impacted by the disability advocacy community\\u2019s emphasis on allowing people with disabilities the dignity of risk.\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:33:50',NULL,'TG_Mary T - HC -2019 -07'),(238,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"TG_TBI Residential-SLC-2020-05\",\"Date__77\":\"05\\/28\\/2020\",\"Multiple_Choice__78\":\"Tony Gantenbein\",\"Short_Answer__80\":\"TBI Residential & Community Services\",\"Short_Answer__81\":\"Keith Comstock\",\"Short_Answer__82\":\"k.comstock@tbiduluthmn.com\",\"Short_Answer__83\":\"218-733-1331\",\"Multiple_Choice__84\":\"Elopement\",\"Multiple_Choice__85\":\"St. Louis County\",\"Date__86\":\"03\\/20\\/2019\",\"Free_Text__87\":\"TBI Crisis Float was at the Alder home at 5:45pm on Friday, March 20th talking with Dwayne. Crisis Float and\\r\\nDwayne were outside during the conversation. Dwayne asked if he was able to get his hair done soon and Crisis Float explained that due\\r\\nto the pandemic the salon was closed until further notice. Dwayne was disappointed that he could not get his hair done. After the\\r\\nconversation Dwayne walked inside and Crisis Float left the Alder home. At 6:00pm Khun (staff) went to check on Dwayne and he was not\\r\\nin his bedroom. Khun checked the inside of the house then walked around the outside of the house and could not locate Dwayne. Khun\\r\\nthen called the Crisis Float to notify them of the situation. Crisis Float began driving around the area looking for Dwayne. At 7:00pm Crisis\\r\\nFloat notified the Sheriff and completed an Attempt to Locate for Dwayne. Crisis Float continued to search for Dwayne. At 8:30pm the Crisis\\r\\nFloat asked that the Attempt to Locate be changed to a Missing Persons report. At 4:00am on Saturday, March 21st the TBI Crisis Float\\r\\nreceived a call from the Duluth Police Department saying that Dwayne had approached them looking for a ride home. Dwayne reported to\\r\\nthe police and TBI Crisis Float that he eloped from the Alder house and walked to the Kwik Trip where he was able to catch a bus to\\r\\ndowntown Duluth. Dwayne reported he walked around downtown for several hours before finding a police officer at CVS Pharmacy in\\r\\ndowntown Duluth. Dwayne returned home at 5:00am and went to bed.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Float staff waited four hours to contact their supervisor about an elopement\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"08\\/27\\/2020\",\"Free_Text__98\":\"Person was talking with (Alder House staff) about going downtown Duluth to get a haircut. The salons were closed due to the Governor\\u2019s Executive Order about COVID 19. DSP went to cook food for dinner. The DSP was the only staff working, normally two staff. SP was attending to the other residents who were asking questions while the SP was cooking food. The SP knocked on bedroom door and there was no answer. The room was empty. The SP began to search the house for 10-15 minutes and then called the crisis float for direction and next steps. The SP immediately began to write up report, Incident Report Internal Review (IRIR). The Alder House DSP worked alone most of March. Quote: \\u201cIf two staff were working this elopement could have been avoided because the other staff could drive person downtown Duluth\\u201d.\\r\\nCrisis float takes over the elopement incident and the decision to call 911. Arrives at home and begins the attempt to locate. Drives and searches streets and downtown Duluth for 4 hours. It is protocol to search for 1-2 hours before contacting a supervisor. The Program manager makes the decision to call 911 and report a missing person. The call 911 was to report a non-emergency and provide a description of the person. The role of the crisis float is to fill in gaps as needed in the residential setting. The Crisis float needs to be available to respond to other crisis. The night of the incident the crisis float was moving from a crisis, de-escalating attention seeking behaviors, and then came to Alder House. Priority goes to situations that require hospitalization. During the attempt to locate the Crisis float communicates with the Alder house DSP with updates as needed, about every 15-20 minutes.\",\"Free_Text__100\":\"The float staff waiting 4 hours (instead of the policy of 1 hour) to contact their supervisor about an individual eloping, was impacted by the staff not seeing it as an emergency . Staff had ideas of where the person would go and that they\\u2019d be able to find them. The float staff\\u2019s ideas were impacted by their familiarity with the person, they knew their favorite places to go, that they had no previous elopements, and the person mentioned wanting to get a haircut. The staff feeling like they could find the person was also influenced by the empty streets in Duluth due to the Governor\\u2019s Stay at Home order. The Governor\\u2019s Stay At Home Order was issued due to COVID-19 in an attempt to slow the curve of the virus spreading. The Order required people to stay in their home unless they were conducting essential business. This influenced the streets of Duluth to be empty, businesses to be closed and the staff feeling as though the person should have been easier to spot. Other contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently .  \\r\\nAdditional influences to waiting 4 hours to call the supervisor may have been the staff\\u2019s desire to avoid the 245D\\/Positive Support Rule reporting requirements because the process can be very time consuming . Additionally, staff waited to call the supervisor because it is provider practice is not to contact supervisors if the elopement is supervised or the person\\u2019s whereabouts are known and they were confident they would be able to find the person .  St. Louis County had a recent history of attempting to decrease 911 calls, and had brought together HCBS providers, Law Enforcement Officers, County staff and Healthcare staff to work on this issue and created a Person Centered Incident Matrix to help provider\\u2019s parse out when 911 should be called and how to avoid overusing the 911 relay. The staff noted they were aware of the Person-Centered Matrix and this influenced the staff to exhaust all known places the person might go before contacting the supervisor about the elopement .\",\"Multiple_Choice__101\":\"3\",\"Free_Text__102\":\"The float staff waiting 4 hours (instead of the policy of 1 hour) to contact their supervisor about an individual eloping, was impacted by the staff not seeing it as an emergency.\\r\\n\\r\\nOther contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently . \\r\\n\\r\\n  St. Louis County had a recent history of attempting to decrease 911 calls, and had brought together HCBS providers, Law Enforcement Officers, County staff and Healthcare staff to work on this issue and created a Person Centered Incident Matrix to help provider\\u2019s parse out when 911 should be called and how to avoid overusing the 911 relay. The staff noted they were aware of the Person-Centered Matrix and this influenced the staff to exhaust all known places the person might go before contacting the supervisor about the elopement .\",\"Multiple_Choice__103\":\"0\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"1\",\"Multiple_Choice__113\":\"0\",\"Multiple_Choice__115\":\"2\",\"Free_Text__116\":\"Other contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently .\",\"Multiple_Choice__117\":\"1\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"1\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:34:43',NULL,'TG_TBI Residential - SLC -2020 -05'),(239,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201900069\",\"Date__77\":\"05\\/15\\/2019\",\"Multiple_Choice__78\":\"Tim Sullivan\",\"Multiple_Choice__79\":\"Tony Gantenbein\",\"Short_Answer__80\":\"Howry Southside\",\"Multiple_Choice__84\":\"Staff Sleeping on Duty\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"01\\/02\\/2019\",\"Free_Text__87\":\"VA is describing increasing frustration and low mood as a result of these incidents. He does not feel comfortable with staff assistance and therefore isolates himself in his room.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not hear person call for assistance after falling\",\"True_or_False__94\":\"Yes\",\"Free_Text__100\":\"The overnight asleep direct service provider\\u2019s ability to hear the vulnerable adult\\u2019s calls for assistance was impacted by the VA being a soft spoken individual and the existence of routine overnight \\u201cwhite\\u201d noise in the home from roommates (TV, radio, electronics, etc.).  \\r\\nThe direct service provider\\u2019s ability to hear the vulnerable adult\\u2019s call for assistance was impacted by the fact that the provider only provides overnight asleep staff at this site.  This decision was made by the provider based on the support needs of the other three residents in the home which reflected the information provided in their assessments and service plans and the information provided by the vulnerable adult\\u2019s CM before admission\\r\\nThe pre-admission information the case manager provides to the provider varies by person and may have been impacted by a lack of resources and options due to the current moratorium on new adult foster (CRS) beds.  Based on the information provided the case manager and provider discussed these needs prior to the VA moving into the home and all agreed that the provider could meet the needs of the VA with an asleep overnight staff person.\",\"Multiple_Choice__115\":\"3\",\"Free_Text__116\":\"The direct service provider\\u2019s ability to hear the vulnerable adult\\u2019s call for assistance was impacted by the fact that the provider only provides overnight asleep staff at this site.  This decision was made by the provider based on the support needs of the other three residents in the home which reflected the information provided in their assessments and service plans and the information provided by the vulnerable adult\\u2019s CM before admission.\",\"Multiple_Choice__119\":\"2\",\"Free_Text__120\":\"The pre-admission information the case manager provides to the provider varies by person and may have been impacted by a lack of resources and options due to the current moratorium on new adult foster (CRS) beds. Based on the information provided the case manager and provider discussed these needs prior to the VA moving into the home and all agreed that the provider could meet the needs of the VA with an asleep overnight staff person.\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:35:16',NULL,'TS_Howry - HC -2019 -05'),(240,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201904508\",\"Date__77\":\"07\\/15\\/2019\",\"Multiple_Choice__78\":\"Tim Sullivan\",\"Multiple_Choice__79\":\"Tony Gantenbein\",\"Short_Answer__80\":\"Meridian Services, Inc - Logan\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"06\\/19\\/2019\",\"Free_Text__87\":\"On 6\\/19\\/19 at 7:00PM, AP was getting pills ready and accidently gave VA the other client\'s (unknown) medication.\\r\\n\\r\\nPills Given-\\r\\nRistidome 4mg\\r\\nBaclofen 20mg\\r\\nDivalporex 500mg\\r\\nMelatonin 3mg\\r\\nAtenolol 50mg\\r\\nCyproheptad 4mg\\r\\n\\r\\nReporter contacted Facility Nurse and Facility Nurse said to contact poison control. Poison control said to monitor VA and call 911 if VA had\\r\\nany labored breathing or any issues. Reporter did not feel comfortable with the information Poison Control provided so Reporter brought\\r\\nVA to Nicollet Park Brookdale Urgent Care. Urgent Care said to keep VA home from VA\'s day program and to monitor VA\'s blood pressure\\r\\nto make sure it doesn\'t get elevated and to contact Primary Doctor. No affects at this time; however, VA appears drowsier than usual.\\r\\n\\r\\nVA attends a day program called Workabilities Monday-Friday from 9am to 4PM or 5PM.\\r\\nAP gave VA another resident\'s medications (Resperidone 4 mg, Basisen 20 mg, Divalproep 500mg, Melatonin 3 mg., Attenolol 6 mg and\\r\\nCyproheptadine 4mg,\\r\\nAP had set up 2 medications at 1 time. Reporter contacted the facility Nurse and Poison Control.\\r\\nVA was taken to last night to be checked out.\\r\\nVA stayed home from day program today so staff could monitor VA.\\r\\nReporter stated she was going to ask Manager what hospital VA was taken to. Call was disconnected. Agent attempted to reach Reporter\\r\\n3 times but message came on to leave message. Agent unable to finish report.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff administered wrong medication to the person\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:35:45',NULL,'TS_Meridian - HC -2019 -07'),(241,23,81,NULL,10,NULL,NULL,'{\"Short_Answer__76\":\"201907105\",\"Date__77\":\"10\\/15\\/2019\",\"Multiple_Choice__78\":\"Tim Sullivan\",\"Multiple_Choice__79\":\"Scott Schifsky\",\"Short_Answer__80\":\"REM Hennepin - Columbus\",\"Short_Answer__81\":\"Kris Wainwright-Tadych\",\"Short_Answer__82\":\"kris.wainwright-tadych@thementornetwork.com\",\"Short_Answer__83\":\"(952) 945-4947\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Hennepin County\",\"Date__86\":\"08\\/23\\/2019\",\"Free_Text__87\":\"On 8\\/16\\/19 the house nurse, Terri Abrahamson requested a refill of Carbamazepine 200 mg ER twice a day. The\\r\\nclinic sent Geritom Pharmacy a prescription for 200mg and 300mg which was then denied by insurance. On 8\\/16\\/19 Geritom reported that\\r\\nthey contacted REM-Hennepin Inc\\/Columbus and said that the medication was no able to be refilled. The medication supply ran out on\\r\\n8\\/23\\/19 and was not administered from 8\\/23\\/19-9\\/27\\/19. Currently-contacting the doctor and asking for directives.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"The DSP initialed the med log but did not administer the med.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"01\\/30\\/2020\",\"Free_Text__98\":\"The DSP has worked in this capacity for approximately 5 years and reports this is her first med error.  She describes the day of the incident (8\\/16\\/19) as \\u201cbusy\\u201d, with 1 of the four residents on an outing with the other staff person on duty.  The DSP volunteered that she was preparing meds for one resident at a time.  After signing the medication log for the resident in question, she noticed that one of the medications was different in color and realized the dosage was different (300 mg vs. his usual dosage of 200 mg) and notified the supervisor.  The supervisor instructed the DSP to look in the \\u201coverflow\\u201d medications and see if there were meds there until the meds could be re-ordered.  The DSP was able to administer the correct medication dosage from the resident\\u2019s \\u201coverflow\\u201d meds. However, the DSP had already initialed the med log when she pulled the incorrect dosage.  The supervisor notified the nurse and the correct dosage was ordered because there were not enough meds in overflow for more than one more day.  During her next shift, two days later, the DSP again signed the med log and then noticed the new medication bubble packs were still the wrong dosage. She again notified the house supervisor who worked with the nurse and the pharmacist to make the correction and get the correct dosage.  The DSP reports that the time lapse between the time she first noticed the incorrect dosage and when it finally arrived was no more than 4-5 days.  Because there were meds in the overflow, the resident only went without the medication a 2-3 day (not the 30+ days indicated on the CEP Report) and never received more than prescribed dosage.\",\"Multiple_Choice__109\":\"1\",\"Multiple_Choice__113\":\"1\"}',NULL,0,1,81,81,'0000-00-00 00:00:00','2021-05-26 22:36:21',NULL,'TS_REM Hennepin - HC -2019 -10'),(242,22,91,NULL,13,NULL,NULL,NULL,NULL,0,1,91,91,'2021-05-26 19:33:23','2021-05-26 20:18:51',NULL,'Abdulkadir, Jamal'),(243,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"09\\/30\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"1\",\"Multiple_Choice__301\":\"Polk\",\"Short_Answer__303\":\"Adalyn\",\"Short_Answer__304\":\"Suedel\",\"Date__305\":\"06\\/15\\/2016\",\"Date__306\":\"07\\/11\\/2016\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 14:56:23',NULL,'Adalyn Suedel'),(244,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Niki Hoglund\",\"Date__293\":\"03\\/14\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Olmsted\",\"Short_Answer__303\":\"Alayna\",\"Short_Answer__304\":\"Khamsavang\",\"Date__305\":\"06\\/16\\/2018\",\"Date__307\":\"02\\/27\\/2019\",\"Multiple_Choice__308\":\"8 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"No face-to-face contact with primary caregiver within 5-day timeline\",\"Free_Text__318\":\"The agency worker shared that the family was historically difficult to get a hold of (per coworkers and school staff). She was able to connect with the mother on the second day of the assessment by phone, at which time the mother stated her first availability was a week out. Also learned in the phone conversation was that the mother was a single parent, she was in her last months of pregnancy, she had health issues including gestational diabetes and that she was also having to make other personal appointments. The worker attempted a home visit at that time and the mother did not answer the door. She connected again with the mother and was finally able to conduct a face to face with her the following week. In attempting to find ways to best connect with the mother, the worker consulted with another agency worker, who had truancy open with an older sibling. Additionally, the case came in as an educational neglect case at the end of the school year (late April) and she reported that since the child wouldn\'t be in school over the summer, this case was not as high a priority as other cases she was working.\",\"Free_Text__319\":\"Face-to-face contact with the primary caregiver not occurring within the 5-day timeline was influenced by the mother\'s lack of engagement with the local agency.  Historically, the mother was difficult to get a hold of and when the worker connected with the mother on the second day of the assessment via phone, the mother stated her first availability was a week out, which was past the 5-day timeline.  In an attempt to find additional ways to connect with the mother, the worker consulted with another agency worker who had an open truancy case with an older sibling of the subject child.  The worker did attempt a home visit; however, the mother did not answer the door.  Additionally supporting the face-to-face not occurring was the fact that the mother was a single parent, was in her last months of pregnancy, had health issues, and was having to make other personal appointments for herself and her children. As a result, there was limited time for the mother to meet with the CP worker.\\r\\nFurthermore, this case came in as an educational neglect case, at the end of the school year, which put this case at a lower priority as the child would not be in school over the summer and this case was not as high of a priority as other cases she was working.  There was also an allocation of funds from the legislature based on performance, monitored by DHS, which reinforced the worker prioritizing timely face-to-face contacts for other cases on her caseload.  Also in existence was a perception that face-to-face timelines apply to victims only, and not to caregivers.  This perception was influenced by the pressure the agency felt from the media and the public regarding an \\u00e2\\u20ac\\u0153all or nothing\\u00e2\\u20ac\\u009d mentality, as well as the 100% compliance measure for face-to-face contact, which included a public facing dashboard that was set by DHS, placing additional pressure on the local agency to meet this compliance measure.\",\"Short_Answer__320\":\"In-home safety plan made for children between family and agency after the critical incident\",\"Free_Text__321\":\"The agency staff shared that the agency\'s protocol\\/belief is to keep children with families if possible and to help the families be the best they can be. This includes using family connections and kin to develop plans that best support the needs of the family as it is believed that the family is the expert on their children and it is best to give the family the resources to be successful long-term. The staff also noted that when it\'s possible to keep children with family, it is less traumatic for the child to stay with parents than to be placed. While developing a plan for the family arrangement, a safety plan was created through a Rapid Response Case Planning Conference (RCPC), which was held at the hospital. This meeting included family, friends, agency staff and hospital staff. During this meeting, the agency assesses the family\'s willingness to implement a safety plan based on family\'s competency, willingness, and confidence in being able to follow through with the safety plan. Through this process, a safety plan was created that included an additional adult, excluding the mother or mother\'s partner, to be present with the kids at all time. After-hour staff were utilized (often) to ensure the plan was being followed using unannounced visits, in addition to agency worker\'s unannounced visits during regular business hours. When there was a break in safety plan, the caseworker immediately had a meeting with friends, family, and the subject child\'s mother and reiterated that there always had to be two adults with the children and that could not be both the mother and her partner. Subsequently, consultation with a team (supervisor and co-workers) was utilized to evaluate whether there was sufficient evidence to continue the family arrangement. \\r\\nLastly, the agency staff shared the belief that the court process is traumatizing and utilizes too many staff resources. Also, it was shared that court timelines do not always match up with the family needs (can give families more time to work on case).\",\"Free_Text__322\":\"Normative agency practice encourages keeping children with their families when possible while using family connections and kin to develop plans that best support the needs of the family, which supported an in-home family arrangement being made for the children following the critical incident.  In addition to the in-home family arrangement, a safety plan was also created through a Rapid Response Case Planning Conference (RCPC), which was held at the hospital.  The safety plan was created using family, friends, agency and hospital staff and included using an additional adult to be present with the children at all times.  After hour staff, as well as agency staff (during business hours) conducted unannounced home visits in order to ensure there was an approved adult with the children, which supported the in-home safety plan and family arrangement that was created.  Additionally influencing an in-home safety plan and family arrangement being made was the fact that there is a push from state statute (260C.181 Subd. 2) and DHS guidance to utilize least restrictive placement options prior to placement if possible.\\r\\n\\r\\nLastly, agency staff belief that the court process is traumatizing and utilizes too many staff resources. The relationship between the local agency, law enforcement, and the county attorney\'s office played a role in supporting an in-home safety plan being created.  Specifically, law enforcement did not place the children on a 72-hour hold and the county attorney\'s office did not support out-of-home placement for children.  Furthermore, the local agency has a trauma informed agency culture, which supports creating less trauma to children by keeping them with their families when at all possible and this, in turn, reduces adversarial relationships with families when trying to complete case plan goals.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"Learning Point 1:\\r\\nAlso in existence was a perception that face-to-face timelines apply to victims only, and not to caregivers.  This perception was influenced by the pressure the agency felt from the media and the public regarding an \\u00e2\\u20ac\\u0153all or nothing\\u00e2\\u20ac\\u009d mentality, as well as the 100% compliance measure for face-to-face contact, which included a public facing dashboard that was set by DHS, placing additional pressure on the local agency to meet this compliance measure\\r\\n\\r\\nLearning Point 2:\\r\\nLastly, agency staff belief that the court process is traumatizing and utilizes too many staff resources.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"Learning Point 2:\\r\\nThe relationship between the local agency, law enforcement, and the county attorney\'s office played a role in supporting an in-home safety plan being created.  Specifically, law enforcement did not place the children on a 72-hour hold and the county attorney\'s office did not support out-of-home placement for children.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Learning Point 1:\\r\\nThere was also an allocation of funds from the legislature based on performance, monitored by DHS, which reinforced the worker prioritizing timely face-to-face contacts for other cases on her caseload.  Also in existence was a perception that face-to-face timelines apply to victims only, and not to caregivers.  This perception was influenced by the pressure the agency felt from the media and the public regarding an \\u00e2\\u20ac\\u0153all or nothing\\u00e2\\u20ac\\u009d mentality, as well as the 100% compliance measure for face-to-face contact, which included a public facing dashboard that was set by DHS, placing additional pressure on the local agency to meet this compliance measure.\\r\\n\\r\\nLearning Point 2:\\r\\nAdditionally influencing an in-home safety plan and family arrangement being made was the fact that there is a push from state statute (260C.181 Subd. 2) and DHS guidance to utilize least restrictive placement options prior to placement if possible.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"Learning Point 1: Furthermore, this case came in as an educational neglect case, at the end of the school year, which put this case at a lower priority as the child would not be in school over the summer and this case was not as high of a priority as other cases she was working.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"Learning Point 1: Furthermore, this case came in as an educational neglect case, at the end of the school year, which put this case at a lower priority as the child would not be in school over the summer and this case was not as high of a priority as other cases she was working.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:00:51',NULL,'Alayna Khamsavang'),(245,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"JoLynn Sundstrom and Fintan Moore\",\"Date__293\":\"08\\/24\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Pine\",\"Short_Answer__303\":\"Allen\",\"Short_Answer__304\":\"Audette\",\"Date__305\":\"10\\/26\\/1999\",\"Date__306\":\"05\\/18\\/2016\",\"Multiple_Choice__308\":\"16 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"Residential treatment placement was not provided to the subject child subsequent the mother\'s request for placement.\",\"Free_Text__318\":\"During the debriefing, the caseworker indicated that the agency\'s expectation is that a family must try a number of interventions prior to considering out-of-home placement.  Additionally, there is a process within the agency that is typically followed when out-of-home placement is requested.  Specifically, when a family calls and requests out-of-home placement for a child, the agency wants to know the reason for the placement request (what happened) and what other interventions the family has tried.  After the agency has learned what interventions have or have not been tried, the worker will then work with the family to engage them in least restrictive interventions.  Once the family has exhausted all least restrictive interventions, the agency then utilizes a preplacement screening team to request approval for out-of-home placement.  Once approval for the out-of-home placement is granted, the caseworker can move forward with coordinating the placement.  In the event a child is hospitalized and\\/or a hospital is recommending out-of-home placement, and the agency can immediately consider placement.  \\r\\n\\r\\nThe agency expectation for a family to exhaust least restrictive interventions and the process the agency typically follows when an out-of-home placement is requested by a family supported the caseworkers decision to not place the subject child in residential treatment and talk with the mother about other options prior to moving towards placement. This decision was further influenced by the fact that the child was not currently hospitalized and a hospital was not recommending out-of-home placement for the child.\",\"Free_Text__319\":\"The decision for placement not being provided, per the mother\'s request, was influenced by the agency\'s threshold for placement not being met.  The development of this threshold was shaped by local and state policy and guidance that supports and encourages least restrictive interventions prior to placement.  The agency\'s threshold for placement was also affected by the shortage of residential beds and lack of funding for placement services.  In addition, there has been an increase in parents calling to request placement opposed to exhausting least restrictive interventions first.  Contributing factors that further supported the agency\'s threshold for placement not being met in this case included the fact that the child was not actively suicidal and a hospital was not recommending placement at the time of the request.  Furthermore, the agency believed the child\'s needs were being met through his engagement with other service providers.\",\"Short_Answer__320\":\"Safety plan was not documented when mom indicated escalating behaviors.\",\"Free_Text__321\":\"During the debriefing, it was learned that typically, the agency does not complete a safety plan when a Children\'s Mental Health case is in assessment, which was the status of this case when the incident occurred.  This standard of practice influenced the caseworker\'s decision to not complete a safety plan. Additionally, this decision was supported by the fact that the subject child was not suicidal at the time the report was received and there was no indication the subject child was suicidal at the initial meeting with the mother. The caseworker also noted that the subject child had been seeing a therapist for approximately one year prior to the incident and believed that the therapist probably completed a safety plan with the subject child.  Lastly, the therapist did not indicate any concerns of suicidal ideation for the subject child to the agency.   \\r\\nOn April 28, 2016, the mother requested Children\'s Mental Health Services for the subject child; specifically, placement in a residential treatment facility.  The mother had previously contacted a residential treatment facility and was told she needed a county referral.  The case was assigned to the children\'s mental health caseworker on May 2, 2016 and a CMH intro letter was sent to the family that same day. The caseworker had a phone call with the mother on May 6, 2016 and a face-to-face visit took place on May 10, 2016.  The subject child was not present during the initial face-to-face visit as the caseworker let the family decide if the subject child should be present or not.  The caseworker had the mother sign releases of information during the initial visit to gather records from previous providers and sent them out on May 11.  The caseworker contacted the subject child\'s therapist that day, as well, to work on getting an updated diagnostic assessment.  The caseworker continued to gather information the next two days for an updated diagnostic assessment.  \\r\\n\\r\\nThe agency did not receive records from the hospital regarding the subject child\'s previous suicide attempt and did not get an updated diagnostic assessment prior to the subject child committing suicide on May 18, 2016.  Following the subject child\'s suicide, the caseworker attempted a home visit on May 20, 2016, but the family was not home.  The caseworker connected with the mother on June 15 to offer condolences and talk about services for the 12-year old sibling; however, the mother declined services.  The caseworker stated, \\u00e2\\u20ac\\u0153The case went exactly how they envisioned it to go\\u00e2\\u20ac\\u009d. \\r\\n\\r\\nThe subject child was involved with the following services at the time of the incident: individual therapy, physical therapy, occupational therapy, school-linked mental health worker, medication management, and chiropractic services.  \\r\\n\\r\\nAgency staff also provided the following information during the on-site meeting:\\r\\n\\u00e2\\u20ac\\u00a2\\tThey see parents requesting placements too often and County partners direct families to contact the county for placement.\",\"Free_Text__322\":\"The decision to not complete a safety plan was impacted by the staff\'s workload and need to prioritize the multiple tasks required as a CMH worker as defined by CMH policies and timelines.  Additionally, CMH workloads are affected by the number of tasks required by the agency\'s responsibility to fulfill both Title IV-E requirements and Child and Family Service Review outcomes.  Due to the multiple tasks required during this case, the worker had discretion to prioritize competing caseload tasks.  As a result, the decision to complete a safety plan was a lower priority task in this case because there was no indication the child was suicidal and that a safety plan was needed. This decision was also influenced by the child being involved with several service providers and none indicating that the child was actively suicidal, including a therapist who likely completed a safety plan with the child and his family.  The staff\'s mental model was such that the child\'s needs were being met by the service providers he was engaged with; therefore, justifying the decision to not complete a safety plan.  This decision was further reinforced by safety precautions being implemented in the home following the child\'s previous suicide attempt.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"Learning Point 1:  Contributing factors that further supported the agency\'s threshold for placement not being met in this case included the fact that the child was not actively suicidal and a hospital was not recommending placement at the time of the request.  Furthermore, the agency believed the child\'s needs were being met through his engagement with other service providers.  \\r\\n\\r\\nLearning Point 1:  The child was involved with several service providers and none indicated that the child was actively suicidal, including a therapist who likely completed a safety plan with the child and his family.  The staff\'s mental model was such that the child\'s needs were being met by the service providers he was engaged with; therefore, justifying the decision to not complete a safety plan.  Safety precautions were also implemented in the home following the child\'s previous suicide attempt.\",\"Multiple_Choice__350\":\"1\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Learning Point 1:  The development of the agency\'s threshold for placement was shaped by local and state policy and guidance that supports and encourages least restrictive interventions prior to placement.  In addition, the child\'s needs did not meet the threshold for placement.\\r\\n\\u00e2\\u20ac\\u00a2\\tLeast Restrictive \\u00e2\\u20ac\\u201c Minnesota Statutes Chapter 260C and Minnesota Rules, parts 9560.0223 and 9560.0545; Children\'s Mental Health Act,  sections 245.467, 245.457 and 245.4876\\r\\n\\u00e2\\u20ac\\u00a2\\t10 Best Interest Factors \\u00e2\\u20ac\\u201c 260C.212, Subdivision 2\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"Learning Point 2:  Due to the multiple tasks required during this case, the worker had discretion to prioritize competing caseload tasks.  As a result, the decision to complete a safety plan was a lower priority task in this case because there was no indication the child was suicidal and that a safety plan was needed.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 15:02:03',NULL,'Allen Audette'),(246,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tom Sandberg\",\"Date__293\":\"08\\/22\\/2017\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Alynn\",\"Short_Answer__304\":\"Einertson\",\"Date__305\":\"09\\/19\\/2014\",\"Date__307\":\"08\\/02\\/2017\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\'s boyfriend\",\"Short_Answer__311\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:03:05',NULL,'Alynn Einertson'),(247,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"11\\/17\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Olmsted\",\"Short_Answer__303\":\"Aniyah\",\"Short_Answer__304\":\"Sagen\",\"Date__305\":\"09\\/21\\/2017\",\"Date__306\":\"9\\/24\\/2017\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:06:17',NULL,'Aniyah Sagen'),(248,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"KariLee Pietz\",\"Date__293\":\"09\\/27\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Yes_or_No__298\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Dakota\",\"Short_Answer__303\":\"Anthony\",\"Short_Answer__304\":\"Herkal\",\"Date__305\":\"07\\/31\\/2018\",\"Date__306\":\"08\\/14\\/2018\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"At close of CP Investigation, result of the risk assessment was \\u00e2\\u20ac\\u02dchigh\', and ongoing CP services were marked needed, however ongoing CP case management was not opened.\",\"Free_Text__318\":\"\\u00e2\\u20ac\\u00a2\\tIn 2016, SSIS did not have an override\\/underride feature incorporated within the safety and risk assessments. Currently this is an available option. \\r\\n\\u00e2\\u20ac\\u00a2\\tWorker had 20+ years of experience working CP investigations\\r\\n\\u00e2\\u20ac\\u00a2\\tThe mother\'s reaction was cooperative and protective. Mother is able and willing to keep her kids safe. Mother is a safe caregiver. \\r\\n\\u00e2\\u20ac\\u00a2\\tShe followed recommendations of no contact\\/Domestic Abuse No Contact Order (DANCO)\\r\\n\\u00e2\\u20ac\\u00a2\\tHalf-sister did not report witnessing violence; had heard yelling between the adults\\r\\n\\u00e2\\u20ac\\u00a2\\tMother had family support network in the area\\r\\n\\u00e2\\u20ac\\u00a2\\tPrevious maltreatment determination was made against the half-sister\'s biological father, not the subject child\'s father. \\r\\n\\u00e2\\u20ac\\u00a2\\tFather compliant with Probation Officer and was making impressive strides at completing required programming. He was doing well. \\r\\no\\tFather comply with no contact, was not living at the home\\r\\no\\tFather was engaged in DBT therapy and domestic violence programming \\r\\no\\tFather was sober\\/ clear UA\'s\\r\\no\\tCounty Attorney would likely not accept CHIPS petition due to all the services family receiving and completing successfully \\r\\n\\u00e2\\u20ac\\u00a2\\tJudge made decision to lift the DANCO\\r\\n\\u00e2\\u20ac\\u00a2\\tConsult with Supervisor and support decision to close without opening ongoing CP case management\\r\\no\\tSDM Tool is used more for discussion during supervisory consult at CP Inv. closing for worker with more experience. Safety Assessment results were either safe\\/conditionally safe \\r\\no\\tTools are prescriptive\\/ black and white, but child protection practice is very gray\",\"Free_Text__319\":\"When determining if CP services were needed, the SDM tool\'s result of \\u00e2\\u20ac\\u02dchigh\' for the risk assessment was considered, however, it was not the only factor used to determine if CP services would be provided at the time the CP investigation closed. There was a domestic abuse no contact order (DANCO) (MN Statute 629.750), issued by the court, which was being complied with by the mother and the offender. In addition, the mother\'s protective capacities and safety assessment result of \\u00e2\\u20ac\\u0153safe\\u00e2\\u20ac\\u009d was considered following DHS FA\\/FI guidance. \\r\\nThe fact that the probable cause standard was not met for a child in need of protection and\\/or services defined by juvenile court law (MN statute 260C.007 Subd. 6 and 260C.141 Subd. 1), and\\/or the prescriptive legislation provided in MN Statute 626.556 Subd. 10e. (g), \\r\\n\\u00e2\\u20ac\\u0153a determination that child protective services are needed means that the local welfare agency has documented conditions during the investigation sufficient to cause a child protection worker, to conclude that a child is at significant risk of maltreatment if protective intervention is not provided and that the individuals responsible for the child\'s care have not taken or are not likely to take actions to protect the child from maltreatment or risk of maltreatment,\\u00e2\\u20ac\\u009d\\r\\nwhich supported the agency to close the investigation and not open ongoing CP CM workgroup, in spite of the high risk assessment result. Protective iintervention was not in the best interests of the children (MN statute 518.17), as the mother was not an offending caregiver, she was a safe parent\\/caregiver. She actively displayed protective capacities to keep the children safe.  She was engaged with the staff and followed the recommendations within the safety plan, she complied with having no contact with the offender after issuance of a Domestic Abuse No Contact Order (DANCO), and the mother was also utilizing her family for support. \\r\\nIn 2016, the agency employed professionals with a wealth of practice experience and longevity, many with 20+ years in child welfare and assessing child safety and risk. The knowledge possessed by the staff, coupled by a functional working relationship with the local agency\'s county attorney office, supported the decision to not open ongoing child protection case management services. The local agency\'s mental model was a presumption that the County Attorney would not accept a petition for CHIPS (Child in Need of Protection or Services) as the local agency had collaborated with many service providers to address safety concerns and provide the family resources, which the caregivers were compliant and completed successfully throughout the CP investigation. The circumstances did not present a need to consult with the County Attorney to file a CHIPS petition, and staff consulted with their supervisor to resolve this goal conflict.\\r\\nAlthough it is suggested in the SDM manual to consult with the county attorney when the result of a risk assessment is \\u00e2\\u20ac\\u0153high\\u00e2\\u20ac\\u009d, this case did not have unresolved safety threats efforts, and the efforts made to provide for child safety were successful, indicating the legal threshold for court intervention was not met, as there were no other conditions known at the time to indicate child safety was at risk. The staff\'s supervisor supported the decision to close the investigation without opening an ongoing CP case management workgroup. \\r\\nProfessionals believe the SDM tools are prescriptive (black and white), but child protection practice is subjective (gray), where staff are required to use their professional ethics and judgement to assess child safety and risk based on wide array of variable circumstances.  Staff considered the Probation Officer reported positive feedback regarding the offending caregiver, that he had been compliant with the DANCO and was not residing in the home, was providing clean UA\'s, and was successfully engaging and completing other programming (DBT therapy and domestic violence program). Additionally, the Judge lifted the DANCO, further influencing staff\'s perception of strengthened caregiver capacities, and lessened risk to child safety. In this case the risk to child safety was actively being controlled for using safety planning, which both caregivers engaged and followed local agency recommendations. The perception is that the risk assessment result does not speak directly to when ongoing services are necessarily needed, and the risk assessment result is used as a functional starting point during supervisor and county attorney consultation, as well as during conversations with the family. Staff believe the risk assessment is used to establish a baseline, considering many other factors when deciding if ongoing CP services need to be provided. Other factors considered is if the risk to child safety continues to exist. Although, contrary to State guidance and local practice norms, (that staff seek a consult with their supervisor and the county attorney to inquire CHIPS and the need for ongoing case management services when there is a \\u00e2\\u20ac\\u02dchigh\' result on the risk assessment at the close of a CP investigation), the staff had Supervisor support to close the CP investigation and not open a workgroup for ongoing CP case management services in this case. When the result of the risk assessment is \\u00e2\\u20ac\\u02dchigh\' in combination with a safety assessment result of \\u00e2\\u20ac\\u02dcsafe\', a discrepancy surfaces. The discrepancy highlights a double bind\\/goal conflict for staff to navigate and resolve when children are \\u00e2\\u20ac\\u02dcpresumed safe\' as the presenting reality of conditions do not suspect substantial child endangerment (Minn. Stat. 626.556, subd. 2(o )) and\\/or services are not needed to ameliorate immediate risk to child safety.\\r\\nIn 2016, when SSIS did not yet have an override\\/underride feature incorporated within the safety and decision making tools for supervisors and\\/or staff, the potential influence of training available to professionals about the purpose of the risk assessment, and how the SDM tools were developed in order to understand functional use for frontline staff was a systemic feature existing across the state and local levels. Applicability and interpretation of the results of the safety and risk assessments, and using the results to inform decision making in real time practice with children and families, in order to capture all risks, were contributing variables when staff use the SDM decision making tools. Additionally the staff\'s interpretation of the training and knowledge retained from training contributes to how knowledge is accessed when staff complete the child safety and risk assessments with the family in real time.\",\"Multiple_Choice__346\":\"3\",\"Free_Text__347\":\"In 2016, the agency employed professionals with a wealth of practice experience and longevity, many with 20+ years in child welfare and assessing child safety and risk. The knowledge possessed by the staff, coupled by a functional working relationship with the local agency\'s county attorney office, supported the decision to not open ongoing child protection case management services. The local agency\'s mental model was a presumption that the County Attorney would not accept a petition for CHIPS (Child in Need of Protection or Services) as the local agency had collaborated with many service providers to address safety concerns and provide the family resources, which the caregivers were compliant and completed successfully throughout the CP investigation. The circumstances did not present a need to consult with the County Attorney to file a CHIPS petition, and staff consulted with their supervisor to resolve this goal conflict. Although it is suggested in the SDM manual to consult with the county attorney when the result of a risk assessment is \\u00e2\\u20ac\\u0153high\\u00e2\\u20ac\\u009d, this case did not have unresolved safety threats efforts, and the efforts made to provide for child safety were successful, indicating the legal threshold for court intervention was not met, as there were no other conditions known at the time to indicate child safety was at risk. The staff\'s supervisor supported the decision to close the investigation without opening an ongoing CP case management workgroup. \\r\\n2.) Professionals believe the SDM tools are prescriptive (black and white), but child protection practice is subjective (gray), where staff are required to use their professional ethics and judgement to assess child safety and risk based on wide array of variable circumstances.  Staff considered the Probation Officer reported positive feedback regarding the offending caregiver, that he had been compliant with the DANCO and was not residing in the home, was providing clean UA\'s, and was successfully engaging and completing other programming (DBT therapy and domestic violence program). Additionally, the Judge lifted the DANCO, further influencing staff\'s perception of strengthened caregiver capacities, and lessened risk to child safety. In this case the risk to child safety was actively being controlled for using safety planning, which both caregivers engaged and followed local agency recommendations. The perception is that the risk assessment result does not speak directly to when ongoing services are necessarily needed, and the risk assessment result is used as a functional starting point during supervisor and county attorney consultation, as well as during conversations with the family. Staff believe the risk assessment is used to establish a baseline, considering many other factors when deciding if ongoing CP services need to be provided. Other factors considered is if the risk to child safety continues to exist.\\r\\n3.)In 2016, when SSIS did not yet have an override\\/underride feature incorporated within the safety and decision making tools for supervisors and\\/or staff, the potential influence of training available to professionals about the purpose of the risk assessment, and how the SDM tools were developed in order to understand functional use for frontline staff was a systemic feature existing across the state and local levels. Applicability and interpretation of the results of the safety and risk assessments, and using the results to inform decision making in real time practice with children and families, in order to capture all risks, were contributing variables when staff use the SDM decision making tools. Additionally the staff\'s interpretation of the training and knowledge retained from training contributes to how knowledge is accessed when staff complete the child safety and risk assessments with the family in real time.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"In 2016, when SSIS did not yet have an override\\/underride feature incorporated within the safety and decision making tools for supervisors and\\/or staff, the potential influence of training available to professionals about the purpose of the risk assessment, and how the SDM tools were developed in order to understand functional use for frontline staff was a systemic feature existing across the state and local levels. Applicability and interpretation of the results of the safety and risk assessments, and using the results to inform decision making in real time practice with children and families, in order to capture all risks, were contributing variables when staff use the SDM decision making tools. Additionally the staff\'s interpretation of the training and knowledge retained from training contributes to how knowledge is accessed when staff complete the child safety and risk assessments with the family in real time.\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"Staff considered the Probation Officer reported positive feedback regarding the offending caregiver, that he had been compliant with the DANCO and was not residing in the home, was providing clean UA\'s, and was successfully engaging and completing other programming (DBT therapy and domestic violence program). Additionally, the Judge lifted the DANCO, further influencing staff\'s perception of strengthened caregiver capacities, and lessened risk to child safety. In this case the risk to child safety was actively being controlled for using safety planning, which both caregivers engaged and followed local agency recommendations.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"1.) When determining if CP services were needed, the SDM tool\'s result of \\u00e2\\u20ac\\u02dchigh\' for the risk assessment was considered, however, it was not the only factor used to determine if CP services would be provided at the time the CP investigation closed. There was a domestic abuse no contact order (DANCO) (MN Statute 629.750), issued by the court, which was being complied with by the mother and the offender. In addition, the mother\'s protective capacities and safety assessment result of \\u00e2\\u20ac\\u0153safe\\u00e2\\u20ac\\u009d was considered following DHS FA\\/FI guidance. \\r\\nThe fact that the probable cause standard was not met for a child in need of protection and\\/or services defined by juvenile court law (MN statute 260C.007 Subd. 6 and 260C.141 Subd. 1), and\\/or the prescriptive legislation provided in MN Statute 626.556 Subd. 10e. (g), \\r\\n\\u00e2\\u20ac\\u0153a determination that child protective services are needed means that the local welfare agency has documented conditions during the investigation sufficient to cause a child protection worker, to conclude that a child is at significant risk of maltreatment if protective intervention is not provided and that the individuals responsible for the child\'s care have not taken or are not likely to take actions to protect the child from maltreatment or risk of maltreatment,\\u00e2\\u20ac\\u009d\\r\\nwhich supported the agency to close the investigation and not open ongoing CP CM workgroup, in spite of the high risk assessment result. Protective iintervention was not in the best interests of the children (MN statute 518.17), as the mother was not an offending caregiver, she was a safe parent\\/caregiver. She actively displayed protective capacities to keep the children safe.  She was engaged with the staff and followed the recommendations within the safety plan, she complied with having no contact with the offender after issuance of a Domestic Abuse No Contact Order (DANCO), and the mother was also utilizing her family for support. \\r\\n2.) In this case the risk to child safety was actively being controlled for using safety planning, which both caregivers engaged and followed local agency recommendations. The perception is that the risk assessment result does not speak directly to when ongoing services are necessarily needed, and the risk assessment result is used as a functional starting point during supervisor and county attorney consultation, as well as during conversations with the family. Staff believe the risk assessment is used to establish a baseline, considering many other factors when deciding if ongoing CP services need to be provided. Other factors considered is if the risk to child safety continues to exist. Although, contrary to State guidance and local practice norms, (that staff seek a consult with their supervisor and the county attorney to inquire CHIPS and the need for ongoing case management services when there is a \\u00e2\\u20ac\\u02dchigh\' result on the risk assessment at the close of a CP investigation), the staff had Supervisor support to close the CP investigation and not open a workgroup for ongoing CP case management services in this case. When the result of the risk assessment is \\u00e2\\u20ac\\u02dchigh\' in combination with a safety assessment result of \\u00e2\\u20ac\\u02dcsafe\', a discrepancy surfaces. The discrepancy highlights a double bind\\/goal conflict for staff to navigate and resolve when children are \\u00e2\\u20ac\\u02dcpresumed safe\' as the presenting reality of conditions do not suspect substantial child endangerment (Minn. Stat. 626.556, subd. 2(o )) and\\/or services are not needed to ameliorate immediate risk to child safety.\",\"Multiple_Choice__360\":\"1\",\"Multiple_Choice__362\":\"2\",\"Free_Text__363\":\"The potential influence of training available to professionals about the purpose of the risk assessment, and how the SDM tools were developed along with the staff\'s interpretation of the training and knowledge retained from training contributes to how knowledge is accessed when staff complete the child safety and risk assessments with the family in real time.\",\"Multiple_Choice__364\":\"1\",\"Multiple_Choice__366\":\"3\",\"Free_Text__367\":\"In 2016, the agency employed professionals with a wealth of practice experience and longevity, many with 20+ years in child welfare and assessing child safety and risk. The knowledge possessed by the staff, coupled by a functional working relationship with the local agency\'s county attorney office, supported the decision to not open ongoing child protection case management services. The local agency\'s mental model was a presumption that the County Attorney would not accept a petition for CHIPS (Child in Need of Protection or Services) as the local agency had collaborated with many service providers to address safety concerns and provide the family resources, which the caregivers were compliant and completed successfully throughout the CP investigation.\\r\\nThe circumstances did not present a need to consult with the County Attorney to file a CHIPS petition, and staff consulted with their supervisor to resolve this goal conflict.\\r\\nAlthough it is suggested in the SDM manual to consult with the county attorney when the result of a risk assessment is \\u00e2\\u20ac\\u0153high\\u00e2\\u20ac\\u009d, this case did not have unresolved safety threats efforts, and the efforts made to provide for child safety were successful, indicating the legal threshold for court intervention was not met, as there were no other conditions known at the time to indicate child safety was at risk. The staff\'s supervisor supported the decision to close the investigation without opening an ongoing CP case management workgroup. \\r\\nProfessionals believe the SDM tools are prescriptive (black and white), but child protection practice is subjective (gray), where staff are required to use their professional ethics and judgement to assess child safety and risk based on wide array of variable circumstances.  Staff considered the Probation Officer reported positive feedback regarding the offending caregiver, that he had been compliant with the DANCO and was not residing in the home, was providing clean UA\'s, and was successfully engaging and completing other programming (DBT therapy and domestic violence program). Additionally, the Judge lifted the DANCO, further influencing staff\'s perception of strengthened caregiver capacities, and lessened risk to child safety. In this case the risk to child safety was actively being controlled for using safety planning, which both caregivers engaged and followed local agency recommendations. The perception is that the risk assessment result does not speak directly to when ongoing services are necessarily needed, and the risk assessment result is used as a functional starting point during supervisor and county attorney consultation, as well as during conversations with the family. Staff believe the risk assessment is used to establish a baseline, considering many other factors when deciding if ongoing CP services need to be provided. Other factors considered is if the risk to child safety continues to exist. Although, contrary to State guidance and local practice norms, (that staff seek a consult with their supervisor and the county attorney to inquire CHIPS and the need for ongoing case management services when there is a \\u00e2\\u20ac\\u02dchigh\' result on the risk assessment at the close of a CP investigation), the staff had Supervisor support to close the CP investigation and not open a workgroup for ongoing CP case management services in this case. \\r\\n2.) Additionally the staff\'s interpretation of the training and knowledge retained from training contributes to how knowledge is accessed when staff complete the child safety and risk assessments with the family in real time.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,92,'2021-05-26 19:33:23','2021-06-01 19:07:29',NULL,'Anthony Herkal'),(249,22,84,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kelly Knutson\",\"Short_Answer__292\":\"Paul Lennander\",\"Date__293\":\"04\\/24\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Licensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Licensed\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Arianna\",\"Short_Answer__304\":\"Hunziker\",\"Date__305\":\"07\\/09\\/2014\",\"Date__306\":\"11\\/06\\/2017\",\"Multiple_Choice__308\":\"3 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Relative caregiver\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Change of Placement and Communication between workers\",\"Free_Text__318\":\"Debrief information was not documented at the agency\'s request due to pending litigation.  Local rationality gathered in the debrief has been incorporated into the narrative.\",\"Free_Text__319\":\"The decision to change placement was influenced by the need to find permanency for the identified child and her sibling.  Her current placement had indicated that they were not a permanency option for the subject child and her sibling.  Due to this and the fact that there are both state and federal pressures with statue and guidance to achieve timely permanency, staff were placed in a position in which they needed to locate and move the subject child and her sibling to a placement option that would be permanent for her and her brother.  Further contributing to this pressure that staff felt was that the Judge granted a TPR in this case without having an identified permanency option and the county attorney did not want the case to go to trial.  Further impacting this change of placement and in order for it to occur quickly was that the current relative provider indicated to staff that they were going to be moving out of state in the near future and that they would not be able to take the children with them.  \\r\\nIn cases such as this, the staff are likely to use the emergency placements process\\/paperwork for a change of placement when it\'s not an emergency.  It was staff\'s perception that this could more quickly get a relative licensed as the formal licensing process at the local agency is impacted by the amount of time the licensing  process can take at DHS.  This is also influenced by not having enough foster care homes for children.  The non-emergency route to get a relative licensed can also feel daunting to a relative provider.  \\r\\nIn cases such as this one, there is often a kinship worker, ongoing case worker, and an adoption worker.  As a result of the need to achieve timely (within 12 months) permanency, things were happening very quickly in this case This efficiency pressure impacted communication between all of the staff and left staff feeling like important information was not communicated amongst one another about the case.  Additionally impacting staff\'s ability to communicate effectively and thoroughly about this case was having staff located so far away from one another and staff not having a space where they are readily available to communicate on cases such as this one that involved multiple workers. This, in addition to the pressure felt to make decisions quickly in this case, the case transfer process was impacted and staff where not able to sit down all together as a team and talk through placement decisions together.   \\r\\nLastly, the older sibling in this case had many identified mental and behavioral health needs.  As a result this became staff\'s focus of attention and believed that a placement that could meet his complex mental and behavioral needs was critically important.   It was important for staff to keep both children together, and place with them with a relative that could be a permanency option for both of them.  Staff noted that the 10 best interest factors influenced this, in addition to identifying placements in which can support the children\'s needs.\",\"Multiple_Choice__346\":\"3\",\"Free_Text__347\":\".  It was staff\'s perception that this could more quickly get a relative licensed as the formal licensing process at the local agency is impacted by the amount of time the licensing  process can take at DHS. \\r\\n\\r\\nLastly, the older sibling in this case had many identified mental and behavioral health needs.  As a result this became staff\'s focus of attention and believed that a placement that could meet his complex mental and behavioral needs was critically important.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"This efficiency pressure impacted communication between all of the staff and left staff feeling like important information was not communicated amongst one another about the case.  Additionally impacting staff\'s ability to communicate effectively and thoroughly about this case was having staff located so far away from one another and staff not having a space where they are readily available to communicate on cases such as this one that involved multiple workers. This, in addition to the pressure felt to make decisions quickly in this case, the case transfer process was impacted and staff where not able to sit down all together as a team and talk through placement decisions together.   \\r\\nLastly, the older sibling in this case had many identified mental and behavioral health needs.  As a result this became staff\'s focus of attention and believed that a placement that could meet his complex mental and behavioral needs was critically important.   It was important for staff to keep both children together, and place with them with a relative that could be a permanency option for both of them.  Staff noted that the 10 best interest factors influenced this, in addition to identifying placements in which can support the children\'s needs.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"The decision to change placement was influenced by the need to find permanency for the identified child and her sibling.  Her current placement had indicated that they were not a permanency option for the subject child and her sibling.  Due to this and the fact that there are both state and federal pressures with statue and guidance to achieve timely permanency, staff were placed in a position in which they needed to locate and move the subject child and her sibling to a placement option that would be permanent for her and her brother.  Further contributing to this pressure that staff felt was that the Judge granted a TPR in this case without having an identified permanency option and the county attorney did not want the case to go to trial.  Further impacting this change of placement and in order for it to occur quickly was that the current relative provider indicated to staff that they were going to be moving out of state in the near future and that they would not be able to take the children with them.  \\r\\n\\r\\nLastly, the older sibling in this case had many identified mental and behavioral health needs.  As a result this became staff\'s focus of attention and believed that a placement that could meet his complex mental and behavioral needs was critically important.   It was important for staff to keep both children together, and place with them with a relative that could be a permanency option for both of them.  Staff noted that the 10 best interest factors influenced this, in addition to identifying placements in which can support the children\'s needs.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"The decision to change placement was influenced by the need to find permanency for the identified child and her sibling.  Her current placement had indicated that they were not a permanency option for the subject child and her sibling.  Due to this and the fact that there are both state and federal pressures with statue and guidance to achieve timely permanency, staff were placed in a position in which they needed to locate and move the subject child and her sibling to a placement option that would be permanent for her and her brother.  Further contributing to this pressure that staff felt was that the Judge granted a TPR in this case without having an identified permanency option and the county attorney did not want the case to go to trial.  Further impacting this change of placement and in order for it to occur quickly was that the current relative provider indicated to staff that they were going to be moving out of state in the near future and that they would not be able to take the children with them.  \\r\\n\\r\\nIn cases such as this one, there is often a kinship worker, ongoing case worker, and an adoption worker.  As a result of the need to achieve timely (within 12 months) permanency, things were happening very quickly in this case This efficiency pressure impacted communication between all of the staff and left staff feeling like important information was not communicated amongst one another about the case.  Additionally impacting staff\'s ability to communicate effectively and thoroughly about this case was having staff located so far away from one another and staff not having a space where they are readily available to communicate on cases such as this one that involved multiple workers. \\r\\n\\r\\nThis efficiency pressure impacted communication between all of the staff and left staff feeling like important information was not communicated amongst one another about the case.  Additionally impacting staff\'s ability to communicate effectively and thoroughly about this case was having staff located so far away from one another and staff not having a space where they are readily available to communicate on cases such as this one that involved multiple workers. This, in addition to the pressure felt to make decisions quickly in this case, the case transfer process was impacted and staff where not able to sit down all together as a team and talk through placement decisions together.\",\"Multiple_Choice__362\":\"2\",\"Free_Text__363\":\"This is also influenced by not having enough foster care homes for children.  The non-emergency route to get a relative licensed can also feel daunting to a relative provider.\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"In cases such as this, the staff are likely to use the emergency placements process\\/paperwork for a change of placement when it\'s not an emergency.  It was staff\'s perception that this could more quickly get a relative licensed as the formal licensing process at the local agency is impacted by the amount of time the licensing  process can take at DHS.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,84,71,'2021-05-26 19:33:23','2021-06-01 18:58:07',NULL,'Arianna Lane Hunziker'),(250,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Sarah Storm\",\"Date__293\":\"04\\/13\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Arielle\",\"Short_Answer__304\":\"Hammonds-Ford\",\"Date__305\":\"01\\/26\\/2018\",\"Date__307\":\"03\\/03\\/2018\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"SSIS surfaced as a systemic barrier to meet staffs need to document their work in child welfare\\/child protection cases and carry out safe work practices. Considering the complex family dynamics and roles for all the relationships and participants involved in this case, it was the local agency practice to assign the same worker to 2 separate work groups. This created an efficiency pressure on the staff, as the staff needed to duplicate the same information gathered and document it under each workgroup. This local agency utilizes the practice of opening work groups under the primary caregiver\'s name. In this case there were two separate primary caregivers to the victim children, so a companion case needed to be opened.\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"SSIS surfaced as a systemic barrier to meet staffs need to document their work in child welfare\\/child protection cases and carry out safe work practices. Considering the complex family dynamics and roles for all the relationships and participants involved in this case, it was the local agency practice to assign the same worker to 2 separate work groups. This created an efficiency pressure on the staff, as the staff needed to duplicate the same information gathered and document it under each workgroup. This local agency utilizes the practice of opening work groups under the primary caregiver\'s name. In this case there were two separate primary caregivers to the victim children, so a companion case needed to be opened.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"SSIS surfaced as a systemic barrier to meet staffs need to document their work in child welfare\\/child protection cases and carry out safe work practices. Considering the complex family dynamics and roles for all the relationships and participants involved in this case, it was the local agency practice to assign the same worker to 2 separate work groups. This created an efficiency pressure on the staff, as the staff needed to duplicate the same information gathered and document it under each workgroup. This local agency utilizes the practice of opening work groups under the primary caregiver\'s name. In this case there were two separate primary caregivers to the victim children, so a companion case needed to be opened.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 15:19:25',NULL,'Arielle Hammonds-Ford'),(251,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"09\\/27\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Asher\",\"Short_Answer__304\":\"Pierre Louis\",\"Date__305\":\"12\\/16\\/2019\",\"Date__306\":\"09\\/21\\/2019\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"TPR was filed in lieu of a CHIPS petition with compelling reasons.\",\"Free_Text__318\":\"The case was assigned to the worker on a Monday as this case came in over the weekend and the RRT worker initially got the case. A 72-hour hold had been put on the surviving siblings at the time the worker was assigned the case, which influenced the worker having a court consultation with the county attorney\'s office within 3 days of being assigned the case. During the court consult the position of the county attorney\'s office was to file a TPR. The worker, as well as some supervisors and managers did not want to file a TPR. Rather, the agency suggested filing a CHIPS petition and offering the family a case plan. Statute influenced the county attorney\'s office position to file a TPR as they referred to statute during the discussions the agency had with them as what supported their decision. The worker felt the agency didn\'t have a say in the decision and had no other option than to sign the TPR petition. The worker stated that she felt forced to take a stance she didn\'t agree with and would be labeled \\u00e2\\u20ac\\u0153problematic\\u00e2\\u20ac\\u009d had she not signed the petition. It was learned in the debriefings that this case was handled differently than how other cases have been handled and outside the norm of agency practice, as every decision on the case needed to go through the county attorney\'s office.\\r\\nThe agency held a Safe and Connected consultation to assist in planning for working with the family (i.e. offering a case plan) and when it was shared with the county attorney\'s office, the agency was told that a case plan would not be offered to the family, as well as a family group conference as these are case planning services and was told to remove the information from the file.\",\"Free_Text__319\":\"A TPR being filed in lieu of a CHIPS petition with compelling reason was influenced by the analysis of the critical incident. The analysis of the critical incident was impacted by the fact that criminal charges were filed against both parents, and also factors that the county attorney\'s office considers when filing a TPR versus a CHIPS with compelling reasons. There is a threshold that needs to be met in order for a CHIPS with compelling reasons to be filed by the county attorney\'s office rather than a TPR. In this case, from the county attorney\'s perspective, that threshold was not met. There was an egregious harm maltreatment finding in this case and it supported the county attorney\'s position to file a TPR as their interpretation of MN Statute regarding a TPR, which states that the child has been subjected to egregious harm as defined in section 260C.007, subd. 14., had been met. Additionally, consultations occurred between social services and the county attorney\'s office to discuss filing a TPR versus a CHIPS with compelling reasons, which identified differences in what constitutes compelling reasons, which further supported the county attorney\'s office position to file a TPR. Furthermore, the agency requires approval from two managers, as well as approval from the county attorney for a CHIPS with compelling reasons to be filed.\",\"Short_Answer__320\":\"The surviving siblings were separated for 4 days when they initially went into placement.\",\"Free_Text__321\":\"When the sibling children were initially placed in foster care, they went to St. Joe\'s shelter. Law enforcement did not want the family, including the parents, to know that the kids were going into placement, so when the sibling children were put on a 72-hour hold, they were placed at St. Joe\'s shelter and from there were placed in separate foster. A relative search did not occur when the siblings were placed in foster care as law enforcement didn\'t want the family to know that the sibling children were being placed in foster care.\",\"Free_Text__322\":\"The surviving siblings being separated for 4 days when they initially went into placement was influenced by the fact that law enforcement (LE) put the surviving siblings on a hold, placed them in shelter care, and requested that the agency not inform the parents that the kids were going into placement. Due to this request by LE, a kinship search did not occur because of the request to not inform the parents of the placement. This particular shelter care facility does their own search for foster homes and ended up finding different foster homes, separating the surviving siblings. It is also possible that the foster homes that were found by the shelter care facility had limits of their own (i.e. number of children, gender, etc.), which may contribute to the surviving siblings needing to be separated. Additionally, when law enforcement is involved in an investigation, the agency often times takes direction from them as to not interfere with the criminal investigation, which can support the agency feeling like their hands are tied and their ability to meet certain requirements of an investigation (i.e. interviews, face-to-face contact, kinship discussions, etc.) might be delayed. Furthermore, obtaining information from law enforcement while they still have an active criminal investigation may be difficult as this information is confidential.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"LP #1: \\r\\nThere is a threshold that needs to be met in order for a CHIPS with compelling reasons to be filed by the county attorney\'s office rather than a TPR. In this case, from the county attorney\'s perspective, that threshold was not met. \\r\\n\\r\\nAdditionally, consultations occurred between social services and the county attorney\'s office to discuss filing a TPR versus a CHIPS with compelling reasons, which identified differences in what constitutes compelling reasons, which further supported the county attorney\'s office position to file a TPR.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"LP #2:\\r\\nThe surviving siblings being separated for 4 days when they initially went into placement was influenced by the fact that law enforcement (LE) put the surviving siblings on a hold, placed them in shelter care, and requested that the agency not inform the parents that the kids were going into placement. Due to this request by LE, a kinship search did not occur because of the request to not inform the parents of the placement.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"LP #1:\\r\\nThere was an egregious harm maltreatment finding in this case and it supported the county attorney\'s position to file a TPR as their interpretation of MN Statute regarding a TPR, which states that the child has been subjected to egregious harm as defined in section 260C.007, subd. 14., had been met.\\r\\n\\r\\nLP #2:\\r\\nThis particular shelter care facility does their own search for foster homes and ended up finding different foster homes, separating the surviving siblings. \\r\\n\\r\\nAdditionally, when law enforcement is involved in an investigation, the agency often times takes direction from them as to not interfere with the criminal investigation, which can support the agency feeling like their hands are tied and their ability to meet certain requirements of an investigation (i.e. interviews, face-to-face contact, kinship discussions, etc.) might be delayed.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 15:22:42',NULL,'Asher Pierre Louis'),(252,22,84,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kelly Knutson\",\"Short_Answer__292\":\"Paul Lennander-CQI Redesign Pilot - Face to face (24 Hour) for all of Kandioyhi\",\"Multiple_Choice__294\":\"Other\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"5\",\"Multiple_Choice__301\":\"Kandiyohi\",\"Short_Answer__303\":\"Aubri\",\"Short_Answer__304\":\"Guerrero\",\"Multiple_Choice__308\":\"13 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Step Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Face to face contact with all alleged victims occurred beyond the 24 hour response timeframes-6 cases and 3 staff debriefed\",\"Free_Text__318\":\"Information learned during the debriefs (3 staff-6 cases):\\r\\nAfter hour\'s intake:\\r\\n\\u00e2\\u20ac\\u00a2\\tConsultation and deference to LE (good working relationship between CP and LE) safety planning occurred and assured together-no access to alleged offender\\r\\n\\u00e2\\u20ac\\u00a2\\tConsultation also occurred with on-call worker and supervisor \\r\\n\\u00e2\\u20ac\\u00a2\\tNo hold placed on the child(ren)\\r\\n\\u00e2\\u20ac\\u00a2\\tCooperative family-mother agreed to bring the child in first thing Monday am\\r\\nIntake for a Koran speaking family:\\r\\n\\u00e2\\u20ac\\u00a2\\tTransitioning from carrying ongoing cases to investigations-a lot to balance and prioritize\\r\\n\\u00e2\\u20ac\\u00a2\\tDocumented PM instead of AM\\r\\n\\u00e2\\u20ac\\u00a2\\tDelays occurred within timeframes due to difficult accessing an Interpreter and simultaneously coordinating  with LE\\r\\no\\tLimited Koran interpreters available\\r\\no\\tDad was reluctant to meet with CP and LE and LE wanted dot meet with dad before mom and the youngest-CP followed LE\'s lead\\r\\nIntake for complex case with significant history:\\r\\n\\u00e2\\u20ac\\u00a2\\tCross reporting did not occur from LE-CP found out about incident through a MDT meeting\\r\\n\\u00e2\\u20ac\\u00a2\\tDue to history and complexity was assigned to a staff that had previously worked with the family \\r\\no\\tSignificant history-mother was dangerous-complicated court history \\r\\no\\tMale victim of DV \\r\\n\\u00e2\\u20ac\\u00a2\\tThis staff was only carrying overflow cases since she was now h role in the agency and only took cases when the team needed help\\r\\n\\u00e2\\u20ac\\u00a2\\tThere was a delay in when the staff was notified of assignment.  Upon notification staff conducted first face to face within an hour.  \\r\\n\\u00e2\\u20ac\\u00a2\\tInterview with the first victim at the school took longer than anticipated (an hour and a half)  Alleged victim keep disclosing and then recanting-this influenced how much time CP had to see the other children \\r\\n\\u00e2\\u20ac\\u00a2\\tDifficulties reaching father-no current phone number.  \\r\\nIntake re: newborn baby to prior TPR:\\r\\n\\u00e2\\u20ac\\u00a2\\tScreening staff that day was not typically on the screening team-less familiar with the process and protocol for assignment\\r\\n\\u00e2\\u20ac\\u00a2\\tThere was a snowstorm that day and the Inv. Assigned had left a few hours early-so had not been notified of the case until the following day\\r\\n\\u00e2\\u20ac\\u00a2\\tCase was open to an ongoing worker that made arrangements with the hospital to separate the mother and child at birth and assure that the child remained in hospital-hospital was aware that the baby would be placed on a hold\\r\\n\\u00e2\\u20ac\\u00a2\\tChild was also born in a hospital two hours away\\r\\n\\u00e2\\u20ac\\u00a2\\tHospital was aware that mom was under a civil commitment as well\\r\\n\\u00e2\\u20ac\\u00a2\\tArrangements had been made by ongoing CP for the foster care to pick the child up from the hospital\\r\\nAlleged Sexual Abuse Intake 1\\r\\n\\u00e2\\u20ac\\u00a2\\tChild was not going to be available to interview until after timeframes\\r\\n\\u00e2\\u20ac\\u00a2\\tAlleged perpetrator was in jail\\r\\n\\u00e2\\u20ac\\u00a2\\tDANCO was already in place\\r\\nAlleged Sexual Abuse Intake 2\\r\\n\\u00e2\\u20ac\\u00a2\\tSaw sibling children within timeframes\\r\\n\\u00e2\\u20ac\\u00a2\\tAlleged victim was in another state (North Dakota) visiting grandparents and would not be back until the following week\\r\\n\\u00e2\\u20ac\\u00a2\\tContact was made with the County in ND where grandparents resided to conduct a curiosity face to face-they were unable to complete this due to the size of the county\\r\\nIntake Types:\\r\\n1)\\tAfterhours with LE response\\/AP went to Jail\\r\\n2)\\tNewborn child in hospital-safety assured\\r\\n3)\\tLanguage barrier case (delays, however made timelines)\\r\\n4)\\tComplex cases due to history-DV with male victim\\r\\n5)\\tSexual abuse where AP was not in the home\\r\\n6)\\tSexual abuse where AP was not in the home\",\"Free_Text__319\":\"Learning Point: Face to face did not occur with all alleged victims within the required 24 hour response timeframes \\r\\n\\r\\nThere were many influences to time contact with alleged victims of maltreatment in cases requiring a 24 hour timeline. First, difficulties in accessing alleged victims due to circumstances such as bad weather, lack of access to interpreters, and staff vacations surfaced as an influence to missed 24 hour face-to-face contacts. \\r\\n\\r\\nAdditionally, four recent changes to the child protection screening statutes and process in the state surfaced as an influence to timely face-to-face contact with alleged victims of maltreatment through the creation of additional demands on staff time and increased caseloads. Specifically, a statute regarding predatory offenders, which created a requirement of face-to-face contact with alleged victims within 24 hours even when the offender no longer has access to the alleged victim(s) increased the number of cases that required a 24 hour response for local agencies, increasing caseload demands. Other changes such as a requirement to screen 24\\/7 and increased documentation requirements in SSIS regarding intakes created additional requirements and demands on staff time. Finally, the use of fiscal withholds based on performance standards attached to recent increases in funds by the state legislature make it difficult for agencies to rely on and therefore use the funds to hire additional staff, offsetting the goal of reducing caseloads with the additional funds. These increased demands on staff time and caseloads influenced the need to prioritize cases other than the ones with the missed 24 hour timeline based on perceptions of safety in those cases. The presumption of safety was influenced by involvement by, and assessments of, safety from trusted partners such as local law enforcement and medical professionals. The presumption of safety was also influenced by the worker\'s knowledge of the alleged offender\'s access to the alleged victim.\\r\\n\\r\\nFace to face delays in contact were also commonly affected by delays in case assignment. In some cases, the new DHS requirement to do screening by a team led to the local agency deciding to pull in team members unfamiliar with the screening process which resulted in slower screening decisions because of the need to explain and talk through the screening decision with the newer screening team member. These delays influenced delays in case assignment which meant less time for the worker assigned to the case to make the initial face-to-face contact with the alleged victim.   Further contributing to reports being held up in the screening process include the time it takes to obtain identifiable information when it is not contained within the original child maltreatment report. Sometimes a reporter may not have all of the identifiable information necessary to screen in a report and the local agency will take some time to do follow up with collaterals. However, SSIS doesn\'t allow an agency to indicate the date and time when they have actually received the minimum information necessary for the report to be considered an accepted child maltreatment report in accordance with state statute (626). Instead, the only information available to calculate the time to first face-to-face contact is the date and time the intake was first opened. Therefore, it can appear that there was a delay in seeing the alleged victim when additional time was used to get the minimum information necessary to screen in the maltreatment report.   \\r\\nMulti-agency jurisdictional involvement of child protection reports can further delay face-to-face contact with alleged victims beyond required timeframes through the additional time that is involved in working with multiple partners.  Additionally, best practices set forth by the Department of Human Services encourages local agencies to coordinate efforts with all agencies involved with multi- jurisdictional child maltreatment reports, including deference to law enforcement agencies needs occasionally (e.g. a law enforcement request to delay contact with alleged victims as a result of a criminal investigation). The need for coordination between multiple agencies such as law enforcement can also influence the worker to delay contact with alleged victims when waiting on the other agency for a particular need. For example, the worker may need to partner with law enforcement to make the visit in cases where either the law enforcement agent or worker may feel that law enforcement is necessary to ensure safety of the worker. \\r\\n\\r\\nFinally, further supporting delays in making contact with alleged victims is the fact that SSIS now automates the intake transfer from a receiving agency to the agency with jurisdiction and the agency with jurisdiction won\'t see that new intake until the agency checks a log in SSIS. As a result, when an intake is transferred across agencies within SSIS, the county of jurisdiction could be unaware that this intake was received which influences delays in making timely face-to-face contact with alleged victims.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"2\",\"Free_Text__349\":\"Face to face delays in contact were also commonly affected by delays in case assignment. In some cases, the new DHS requirement to do screening by a team led to the local agency deciding to pull in team members unfamiliar with the screening process (when staff that were typically involved in these decisions were not available) which resulted in slower screening decisions because of the need to explain and talk through the screening decision with the newer screening team member. These delays influenced delays in case assignment which meant less time for the worker assigned to the case to make the initial face-to-face contact with the alleged victim.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"However, SSIS doesn\'t allow an agency to indicate the date and time when they have actually received the minimum information necessary for the report to be considered an accepted child maltreatment report in accordance with state statute (626). Instead, the only information available to calculate the time to first face-to-face contact is the date and time the intake was first opened. Therefore, it can appear that there was a delay in seeing the alleged victim when additional time was used to get the minimum information necessary to screen in the maltreatment report.   \\r\\n\\r\\nFinally, further supporting delays in making contact with alleged victims is the fact that SSIS now automates the intake transfer from a receiving agency to the agency with jurisdiction and the agency with jurisdiction won\'t see that new intake until the agency checks a log in SSIS. As a result, when an intake is transferred across agencies within SSIS, the county of jurisdiction could be unaware that this intake was received which influences delays in making timely face-to-face contact with alleged victims.\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"Multi-agency jurisdictional involvement of child protection reports can further delay face-to-face contact with alleged victims beyond required timeframes through the additional time that is involved in working with multiple partners.  Additionally, best practices set forth by the Department of Human Services encourages local agencies to coordinate efforts with all agencies involved with multi- jurisdictional child maltreatment reports, including deference to law enforcement agencies needs occasionally (e.g. a law enforcement request to delay contact with alleged victims as a result of a criminal investigation). The need for coordination between multiple agencies such as law enforcement can also influence the worker to delay contact with alleged victims when waiting on the other agency for a particular need. For example, the worker may need to partner with law enforcement to make the visit in cases where either the law enforcement agent or worker may feel that law enforcement is necessary to ensure safety of the worker.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Additionally, four recent changes to the child protection screening statutes and process in the state surfaced as an influence to timely face-to-face contact with alleged victims of maltreatment through the creation of additional demands on staff time and increased caseloads. Specifically, a statute regarding predatory offenders, which created a requirement of face-to-face contact with alleged victims within 24 hours even when the offender no longer has access to the alleged victim(s) increased the number of cases that required a 24 hour response for local agencies, increasing caseload demands. Other changes such as a requirement to screen 24\\/7 and increased documentation requirements in SSIS regarding intakes created additional requirements and demands on staff time. Finally, the use of fiscal withholds based on performance standards attached to recent increases in funds by the state legislature make it difficult for agencies to rely on and therefore use the funds to hire additional staff, offsetting the goal of reducing caseloads with the additional funds. These increased demands on staff time and caseloads influenced the need to prioritize cases other than the ones with the missed 24 hour timeline based on perceptions of safety in those cases. The presumption of safety was influenced by involvement by, and assessments of, safety from trusted partners such as local law enforcement and medical professionals. The presumption of safety was also influenced by the worker\'s knowledge of the alleged offender\'s access to the alleged victim.\\r\\nFace to face delays in contact were also commonly affected by delays in case assignment. In some cases, the new DHS requirement to do screening by a team led to the local agency deciding to pull in team members unfamiliar with the screening process which resulted in slower screening decisions because of the need to explain and talk through the screening decision with the newer screening team member. These delays influenced delays in case assignment which meant less time for the worker assigned to the case to make the initial face-to-face contact with the alleged victim.   Further contributing to reports being held up in the screening process include the time it takes to obtain identifiable information when it is not contained within the original child maltreatment report. Sometimes a reporter may not have all of the identifiable information necessary to screen in a report and the local agency will take some time to do follow up with collaterals.\\r\\n\\r\\n.  Additionally, best practices set forth by the Department of Human Services encourages local agencies to coordinate efforts with all agencies involved with multi- jurisdictional child maltreatment reports, including deference to law enforcement agencies needs occasionally (e.g. a law enforcement request to delay contact with alleged victims as a result of a criminal investigation). The need for coordination between multiple agencies such as law enforcement can also influence the worker to delay contact with alleged victims when waiting on the other agency for a particular need. For example, the worker may need to partner with law enforcement to make the visit in cases where either the law enforcement agent or worker may feel that law enforcement is necessary to ensure safety of the worker.\",\"Multiple_Choice__360\":\"3\",\"Free_Text__361\":\"Additionally, four recent changes to the child protection screening statutes and process in the state surfaced as an influence to timely face-to-face contact with alleged victims of maltreatment through the creation of additional demands on staff time and increased caseloads. Specifically, a statute regarding predatory offenders, which created a requirement of face-to-face contact with alleged victims within 24 hours even when the offender no longer has access to the alleged victim(s) increased the number of cases that required a 24 hour response for local agencies, increasing caseload demands. Other changes such as a requirement to screen 24\\/7 and increased documentation requirements in SSIS regarding intakes created additional requirements and demands on staff time. Finally, the use of fiscal withholds based on performance standards attached to recent increases in funds by the state legislature make it difficult for agencies to rely on and therefore use the funds to hire additional staff, offsetting the goal of reducing caseloads with the additional funds. These increased demands on staff time and caseloads influenced the need to prioritize cases other than the ones with the missed 24 hour timeline based on perceptions of safety in those cases.  (Prescribed practice is connected to an increase in production of caseload tasks creating production\\/efficiency pressures for staff)\\r\\n\\r\\nFace to face delays in contact were also commonly affected by delays in case assignment. In some cases, the new DHS requirement to do screening by a team led to the local agency deciding to pull in team members unfamiliar with the screening process which resulted in slower screening decisions because of the need to explain and talk through the screening decision with the newer screening team member. These delays influenced delays in case assignment which meant less time for the worker assigned to the case to make the initial face-to-face contact with the alleged victim.   Further contributing to reports being held up in the screening process include the time it takes to obtain identifiable information when it is not contained within the original child maltreatment report. Sometimes a reporter may not have all of the identifiable information necessary to screen in a report and the local agency will take some time to do follow up with collaterals. \\r\\n\\r\\nAdditionally, best practices set forth by the Department of Human Services encourages local agencies to coordinate efforts with all agencies involved with multi- jurisdictional child maltreatment reports, including deference to law enforcement agencies needs occasionally (e.g. a law enforcement request to delay contact with alleged victims as a result of a criminal investigation). The need for coordination between multiple agencies such as law enforcement can also influence the worker to delay contact with alleged victims when waiting on the other agency for a particular need. For example, the worker may need to partner with law enforcement to make the visit in cases where either the law enforcement agent or worker may feel that law enforcement is necessary to ensure safety of the worker.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"These increased demands on staff time and caseloads influenced the need to prioritize cases other than the ones with the missed 24 hour timeline based on perceptions of safety in those cases. The presumption of safety was influenced by involvement by, and assessments of, safety from trusted partners such as local law enforcement and medical professionals. The presumption of safety was also influenced by the worker\'s knowledge of the alleged offender\'s access to the alleged victim.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,84,81,'2021-05-26 19:33:23','2021-05-26 15:23:33',NULL,'Aubri Guerrero'),(253,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tracy Nielsen\",\"Date__293\":\"06\\/26\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Sherburne\",\"Short_Answer__303\":\"Averie\",\"Short_Answer__304\":\"Ellingson\",\"Date__305\":\"03\\/08\\/2010\",\"Date__307\":\"04\\/15\\/2019\",\"Multiple_Choice__308\":\"9 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Step-Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:25:49',NULL,'Averie Ellingson'),(254,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Jennifer Carlson\",\"Date__293\":\"02\\/14\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Bengsu\",\"Short_Answer__304\":\"Lee\",\"Date__305\":\"04\\/27\\/2017\",\"Date__307\":\"02\\/02\\/2018\",\"Multiple_Choice__308\":\"10 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Grandmother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:26:29',NULL,'Bengsu Lee'),(255,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"09\\/06\\/2016\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"3\",\"Multiple_Choice__301\":\"Crow Wing\",\"Short_Answer__303\":\"Bethany\",\"Short_Answer__304\":\"Bakke\",\"Date__305\":\"10\\/12\\/2011\",\"Date__307\":\"07\\/04\\/2016\",\"Multiple_Choice__308\":\"4 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Maternal Uncle\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Child observation did not occur within 24-hours.\",\"Free_Text__318\":\"No human factors debriefing occurred due to the learning point being identified by the mapping team.  There was representation from multiple areas of the system and the mapping team felt a map could be developed with those at the mapping; therefore, the mapping team proceeded without a human factors debriefing.\",\"Free_Text__319\":\"Minnesota Statute 626.556 dictates State policy and guidance regarding 24-hour face-to-face timelines with an alleged victim. Not meeting face-to-face timelines results in financial withholdings to the agency by DHS, which influences the local agency\'s need to meet these timelines despite challenges of limited resources. The child observation not occurring within 24-hours was influenced by the distance between the local agency and the hospital where the child was admitted, making it difficult for the local agency to meet the required timelines.  This extensive distance supported the agency\'s decision to request another agency closer in proximity to the child to conduct a courtesy face-to-face with the child to meet the 24-hour requirements. Reduced staff within the agency of jurisdiction during the holiday resulted in high task load for remaining staff, which further supported the agency to request a face-to-face from an agency closer to the child.  Following the request for the local agency to conduct the face to face, no further action was deemed necessary because of the perception that the proximal agency would conduct the child observation within 24-hours following the formal request to that agency.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"Reduced staff within the agency of jurisdiction during the holiday resulted in high task load for remaining staff.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"The extensive distance between the local agency and the hospital where the child was admitted, supported the agency\'s decision to request another agency closer in proximity to the child to conduct a courtesy face-to-face with the child to meet the 24-hour requirements.\\r\\nFollowing the request for the local agency to conduct the face to face, no further action was deemed necessary because of the perception that the proximal agency would conduct the child observation within 24-hours following the formal request to that agency.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"Reduced staff within the agency of jurisdiction during the holiday resulted in high task load for remaining staff.  Due to the high task load, remaining staff were not able to complete all of the tasks on each case.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 15:28:22',NULL,'Bethany Bakke'),(256,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Brenda Mahoney\",\"Date__293\":\"07\\/18\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Sherburne\",\"Short_Answer__303\":\"Billy\",\"Short_Answer__304\":\"Chapman\",\"Date__305\":\"10\\/30\\/2013\",\"Date__306\":\"08\\/30\\/2015\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s partner\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"1.\\tNo safety planning occurred for the remaining siblings of the subject child\",\"Free_Text__318\":\"The agency\'s on-call social worker took the initial call regarding the child\'s injuries. LE was at the hospital that night and conducted initial interviews. The next morning, she was assigned to the case and reached out to LE to coordinate the interviews she needed to do. She was able to speak with the child\'s mother and also biological father. The mother\'s friend, who was caring for the child, was hospitalized himself after hyper-ventilating when hearing of the child\'s injuries. The remaining children were not interviewed by LE the night of the child\'s injuries, but did occur later in conjunction with the CP investigation interviews. The CP worker tended to the mother\'s needs during the child\'s treatment at the hospital, indicating this was very important. The child died the night after the worker made contact at the hospital. The remaining children were not identified as needing to be placed on a 72 hour hold by LE. The worker indicated that when children are not placed on a 72 hour hold by law enforcement, parents can make arrangements for the care of their children. Safety planning specific to the remaining children did not occur in this case after the children went with the grandparent. She reported that when discussing the family arrangement, it was agreed that the maternal grandmother would be the most stable location for the kids to be. She indicated that due to the children being in a stable place, her focus was turned to finding out who had injured the subject child. The worker further shared that at the time of the child\'s death, the norms were that they would make their safety assessment at the time of the hold\\/family arrangement and then allow that placement to take place. Any safety planning would have been informal\\/verbal in nature at that time. \\r\\n\\r\\nAfter interviews with the remaining children, there were significant discrepancies between their statements and the mother\'s friend\'s statements and interviews with other possible caregivers did not indicate that they were the source of the child\'s injuries. \\r\\nA significant issue in the investigation of the case was identified by the worker as being the conflicting opinions on medical professionals (child abuse specialist and ME) regarding timing of the injuries as well as the nature in which the injuries were sustained. While both agreed it was a homicide, the ME believed that the brain injury could have been a result of a fall off a couch. The agency made the maltreatment determination against the mother\'s friend as interviews indicated that prior caregivers were not the source of the child\'s injuries, as well as the medical professionals indicating the injuries that the child sustained were inflicted by another person. Delays in making the maltreatment determination were in part due to the time it took to see if the medical professionals would find agreement.\\r\\n\\r\\nAdditional barriers to completing work tasks included her caseload, which was over 60 investigations at the time. There were three investigators then and that was not enough to cover the number of assessments assigned. Additional barriers noted were limited amount of time available for case consultation (both of the worker and supervisor) as well as a general sense in the agency that when there are \\u00e2\\u20ac\\u0153big\\u00e2\\u20ac\\u009d cases, that there is no chatter going on about them, that it was the worker\'s issue to work it out.\",\"Free_Text__319\":\"Child protection investigation safety planning norms influenced the child protection worker\'s decision to not conduct safety planning for the sibling children at the time the family arrangement was made by law enforcement. Common practice in this agency are for child protection workers to trust law enforcement\'s assessment of safety as law enforcement are the only ones able to place children on hold, which guides the need for the agency to conduct safety planning. The social worker presumed the grandmother was a safe caregiver as the family arrangement with the grandmother, who lived 2 hours away, had already been decided as safe by law enforcement for the sibling children. Additionally, it is common practice to not safety plan when the perpetrator does not reside in the same home since the perpetrator does not have access to the child(ren).\\r\\nThere were changes in government regulation, such as the implementation of the Governor\'s Task Force recommendations and Governor\'s Order (directive), which had recently been put into practice. These directives included implementation of a Rapid Consultation line and creation of a DHS CP Screen-out Review Team. This screening oversight by DHS resulted in increased screened in reports by the agency and thus, an increase in worker caseloads. This increase resulted in prioritization of case duties other than safety planning in this case, as safety had already been assessed by law enforcement In addition to this, there was heightened media coverage on DHS policy changes, influencing defensive practices by the agency which likely supported the agency in screening in cases out of fear of liability. \\r\\nFurther influencing the worker to not safety plan was that during this time, limited funding for CP positions impacted the local agency\'s overall staffing levels. This led to an increase in caseload for staff resulting in the investigator carrying 60 open cases during this timeframe.  As a result, the worker prioritized other case duties over safety planning. The high level of case tasks required for each case impacts the ability to close cases, which compounds the amount of case tasks. This further decreased the amount of time the worker had available to complete all the necessary case tasks on each investigation. Additionally, the worker had limited availability for supervisor consultation as the supervisor was working cases as well. This reduced time available to consult regarding case duties, such as safety planning. Peer consultation is usually available on cases, but with egregious cases, chatter between coworkers is limited, so peer consultation is limited. This limited peer consultation also impacts the worker\'s ability to get feedback on case planning\\/duties etc.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"Common practice in this agency are for child protection workers to trust law enforcement\'s assessment of safety as law enforcement are the only ones able to place children on hold, which guides the need for the agency to conduct safety planning. The social worker presumed the grandmother was a safe caregiver as the family arrangement with the grandmother, who lived 2 hours away, had already been decided as safe by law enforcement for the sibling children.\",\"Multiple_Choice__348\":\"2\",\"Free_Text__349\":\"These directives included implementation of a Rapid Consultation line and creation of a DHS CP Screen-out Review Team. This screening oversight by DHS resulted in increased screened in reports by the agency and thus, an increase in worker caseloads. This increase resulted in prioritization of case duties other than safety planning in this case, as safety had already been assessed by law enforcement In addition to this, there was heightened media coverage on DHS policy changes, influencing defensive practices by the agency which likely supported the agency in screening in cases out of fear of liability.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"Further influencing the worker to not safety plan was that during this time, limited funding for CP positions impacted the local agency\'s overall staffing levels.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"2\",\"Free_Text__365\":\"Additionally, the worker had limited availability for supervisor consultation as the supervisor was working cases as well.\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:32:25',NULL,'Billy Chapman'),(257,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"JoLynn Sundstrom\",\"Date__293\":\"06\\/05\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Washington\",\"Short_Answer__303\":\"Blake\",\"Short_Answer__304\":\"Holmquist\",\"Date__305\":\"01\\/12\\/2016\",\"Date__306\":\"06\\/03\\/2017\",\"Date__307\":\"05\\/11\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s significant other\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"Delay in child protection receiving records in order to understand risk the biological non-custodial father posed when being considered as a placement preference.\",\"Free_Text__318\":\"When children were placed in out of home care due to concerns for the mother\'s ability to protect, a background check found the biological father had harmed a child badly in the state of Wisconsin. The extent of the harm what not clear, and what type of contact between the father and the child was to happen (if at all) was not clear. The mother and grandmother knew of the harm to the WI child and believed visitation between the child and the biological father was ok. The mother was not disclosing the concerns. \\r\\nSafety planning\\/visitation and using family\\/biological parents as a placement preference first was considered, however, because the investigation was not open for concerns around the father\'s unsafe harm to the WI child, the hospital who examined the WI child from 2014, would not release records regarding the extent of the child\'s injuries, or recommendations for contact between the alleged offender and the children. Specifically the hospital stated the Statute governing Child Protection Investigation data was \\u00e2\\u20ac\\u02dcnot broad enough to release data for another child\'s injuries\'.  The hospital requested a court order be signed by a judge for them to release the records. A judge did grant this request and the agency was eventually able to access the records, however there was significant delay. A criminal complaint was accessed from the state of Wisconsin. There was difficulty in obtaining the CP records as the mother had since moved into a different Minnesota county. There is difficulty for CP investigators accessing information about non-custodial parents due to limitations defined in various legislative statutes, and the impact this has on CP investigations, the difficulty is exacerbated due to the urgency of the information needed during an investigation in order to ensure safety of children.\",\"Free_Text__319\":\"Contributing to the delay in child protection receiving medical records was that the staff sought to exhaust all options when evidence gathering prior to requesting a court order to obtain the records. Staff decided to seek clarifying collateral knowledge when sources of information presented conflicting perspectives regarding the safety and risk regarding the bio father harming a child in the state of WI.  Considering the preferred preference is to place children with parents, as well as to engage fathers, the staff needed time to resolve and clarify the goal conflict between prioritizing engaging the non-custodial father and erroring on the side of safety to ensure child protection by not allowing contact. However, the immediacy of the placement did not allow for time, and during a background check the staff found criminal charges about the non-custodial father harming a child in the state of Wisconsin, yet the extent of the harm was not known and caregivers\' statements regarding the Wisconsin charges suggested contact would be okay, and they did not have safety concerns for the non-custodial father being considered as a placement preference. \\r\\nNeeded time to resolve and clarify the goal conflict again, delay to receiving the records was influenced by the complexity of a MN hospital not being able to release medical records immediately regarding a non-related child without a court order. The hospitals interpretation of statute governing Child Protection Investigation data was not broad enough to release data for another non-related child\'s injuries, including MN Statute 626.556 Sub. 10 (i) 3 & Statutes 13.384 and 144.291 to 144.298, and other relevant data privacy laws like HIPAA. The hospital was not able to make recommendations for what contact\\/visitation between the non-custodial biological father and the child, as the information in their records was protected.\\r\\nWI\'s interpretation of data privacy also contributed to staff not being able to readily receive records. A difficulty exists in accessing information about non-custodial parents due to limitations defined in various legislative statutes and data privacy laws. The limitations impact child welfare practice, specifically in CP investigations when the delay in receiving records is not aligned with the urgency information is needed during an investigation to ensure safety of children.\",\"Short_Answer__320\":\"Interviews regarding child death investigation were conducted separately by law enforcement and child protection\",\"Free_Text__321\":\"The critical incident occurred after 4:30pm. A contracted agency who provides after hours coverage responded to the hospital where law enforcement had also responded.  The after-hours worker made timely face to face with the alleged victim child, and prepared a report of their response and safety assessment to pass on to the investigator to be assigned in the morning. Law enforcement completed many interviews for their criminal investigation that evening, and a neurologist evaluating the child, had also worked a case in 2014 which had profound similarities to the injuries of this child\'s case. Ironically the alleged offender of the 2014 case was the same alleged offender in this case. A thorough CP investigation was completed with including many adult, child, and collateral interviews. An opportunity to interview with child protection was provided to the alleged offender which he declined. Law enforcement and Child protection accessed and shared investigative reports with one another, and telephone calls occurred between the agencies as they spoke about how to proceed, and sharing information learned, highlighting key concerns, and any topics that they could assist one another with, or request information or questions be asked based on scheduled interviews yet to occur prior to them happening. The interviews were conducted separate and apart from one another because of the dynamics of this case. The role of child protection being different than that of law enforcement for this case was especially noted. Circumstances, such as the incident occurring after hours, it wasn\'t a sexual abuse case, child protection focused more on the physical and mental health of the mother, and the impact around the subject child\'s worsening physical condition\\/impending death. The consideration for safety and risk assessment interviews needing to take more time than what law enforcement would need, and joining for investigation interviews would not benefit law enforcement. The trajectory of law enforcement\'s investigation and the trajectory of the child protection investigation unfolded as each discipline gathered relevant information particular to their work areas purpose. Child Protection prioritized being trauma informed and client centered and solution focused for the mother, surviving child, and tending to the grief and loss around the end of life decision the mother was facing at the moment in time. Also noted was the cautiousness around reliability of information the mother could reasonably provide to the agency and\\/or information the mother would be able to process from the agency. It was important to use engagement skills in order to resonate a balanced working relationship between child protection and the mother, as she was carrying shock, denial, anger, fear, and resentment towards child protection during her grief stricken emotional state. The agency approached the CP investigation in a non-punitive way with regard to ensuring child safety of the surviving child and assisting the mother and surviving child with supports and coping with grief and loss. A CHIPS opened in Juvenile Court, not to be punitive, but rather to be supportive of the mother and her decisions.  The agency norms of collaborating with law enforcement varies case by case, depending on many variables and dynamics.  In this case, the process of the investigation went as expected due to the nature of how each agency\'s work with the participants in the family unfolded over time, and the communication that was shared between each agency.\",\"Free_Text__322\":\"Contributing to interviews being conducted separate by the child protection staff and the law enforcement investigator was that the child fatality occurred after hours, where a contracted after hours child protection crisis response staff responded to the hospital where law enforcement was at the time. The role of the after-hours staff was to respond and observe the victim child, assess safety and risk, and develop a safety plan with the non-offending caregiver. The after- hours crisis response protocol met the local agencies developed and established protocol for reports that come in to child protection after hours, Department of Human Services guidance around 24\\/7 coverage, and mandate in Statute for 24\\/7 child protection coverage, that require an immediate\\/24 hour response in order to meet face to face timeline. The role of the crisis response staff was not to coordinate a joint investigation with law enforcement. The role of after-hours staff was to document the face to face contact with the alleged victim child, and to develop a safety plan, making safety plan decisions with the non-offending parent for the daytime child protection investigator to review and follow up with the family when assigned to the case the next day in the morning. \\r\\n Statutory language in 626.556 allows child protection to use law enforcement\'s investigative data in their child protection investigation. Collaboration between law enforcement and child protection occurred in the days after immediate response to the child death. Child protection and law enforcement exchanged information they each had learned in their separate interviews conducted. Because child protection interviews take more time when a child death occurs, a sensitive approach is used. Priority is given to the trauma the non-offending caregiver is experiencing, and the same priority is given when making contact with collateral contacts. The broader topics covered in child protection interviews required to complete the child protection investigation are perceived as not being efficient or beneficial for the purpose of law enforcement\'s investigation. There is a perception that child protection\'s purpose and role is different than law enforcement\'s purpose and role at the time of first response to a child death, in addition to each work disciplines role and purpose that occurs the next day and thereafter following the immediate response. Law Enforcement\'s role is to take the lead in the child death investigation the moment a child death is learned. Law enforcement\'s purpose is to seek evidence to understand what happened and who committed the crime and time is of the essence to ensure public safety.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"LP2: The broader topics covered in CP interviews required to complete the CP investigation are perceived as not being efficient or beneficial for the purpose of law enforcement\'s investigation.\\r\\nLP2: There is a perception that child protection\'s purpose and role is different than law enforcement\'s purpose and role at the time of first response to a child death, in addition to each work disciplines role and purpose that occurs the next day and thereafter following the immediate response. Law Enforcement\'s role is to take the lead in the child death investigation the moment a child death is learned. Law enforcement\'s purpose is to seek evidence to understand what happened and who committed the crime and time is of the essence to ensure public safety. The role of the after-hours CP staff is to respond and observe the victim child, assess immediate safety and risk concerns, and develop a safety plan with the non-offending caregiver. It is not to coordinate future joint investigative efforts with law enforcement\",\"Multiple_Choice__348\":\"1\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"LP1: Contributing to the delay in child protection receiving medical records was that the staff sought to exhaust all options when evidence gathering prior to requesting a court order to obtain the records.\\r\\nLP1:Needed time to resolve and clarify the goal conflict again, delay to receiving the records was influenced by the complexity of a MN hospital not being able to release medical records immediately regarding a non-related child without a court order. The hospitals interpretation of statute governing Child Protection Investigation data was not broad enough to release data for another non-related child\'s injuries, including MN Statute 626.556 Sub. 10 (i) 3 & Statutes 13.384 and 144.291 to 144.298, and other relevant data privacy laws like HIPAA. The hospital was not able to make recommendations for what contact\\/visitation between the non-custodial biological father and the child, as the information in their records was protected.\\r\\nWI\'s interpretation of data privacy also contributed to staff not being able to readily receive records. A difficulty exists in accessing information about non-custodial parents due to limitations defined in various legislative statutes and data privacy laws. The limitations impact child welfare practice, specifically in CP investigations when the delay in receiving records is not aligned with the urgency information is needed during an investigation to ensure safety of children.\\r\\nLP2: Contributing to interviews being conducted separate by the CP staff and the LE investigator was that the child fatality occurred after hours, where a contracted after hours CP crisis response staff responded to the hospital where law enforcement was at the time. The after-hours crisis response protocol met the mandate in Statute for 24\\/7 CP coverage and DHS guidance around 24\\/7 coverage, and was the local agencies developed and established protocol for reports that come in to CP after hours and require an immediate\\/24 hour response in order to meet face to face timeline. The role of the after-hours staff was to respond and observe the victim child, assess safety and risk, and develop a safety plan with the non-offending caregiver. It was not to coordinate a joint investigation with law enforcement. The after-hours staff documented the face to face contact with the alleged victim child, and the decision making that went into the developed safety plan with the non-offending parent for the daytime CP investigator to review when assigned to the case in the morning.\\r\\nThere is a perception that child protection\'s purpose and role is different than law enforcement\'s purpose and role at the time of first response to a child death, in addition to each work disciplines role and purpose that occurs the next day and thereafter following the immediate response. Law Enforcement\'s role is to take the lead in the child death investigation the moment a child death is learned. Law enforcement\'s purpose is to seek evidence to understand what happened and who committed the crime and time is of the essence to ensure public safety. The role of the after-hours CP staff is to respond and observe the victim child, assess immediate safety and risk concerns, and develop a safety plan with the non-offending caregiver. It is not to coordinate future joint investigative efforts with law enforcement, as there is statutory language in 626.556 which allows CP to use law enforcement\'s investigative data in their CP investigation.  \\r\\nNoting that CP interviews take more time when a child death occurs, and a sensitive approach is used, prioritizing the trauma the non-offending caregiver is experiencing, as well as when making contact with collateral contacts. The broader topics covered in CP interviews required to complete the CP investigation are perceived as not being efficient or beneficial for the purpose of law enforcement\'s investigation. Collaboration between Law Enforcement and Child Protection occurred in the days after immediate response to the child death, sharing information with one another learned in each of their separate interviews conducted.\",\"Multiple_Choice__356\":\"2\",\"Free_Text__357\":\"Contributing to the delay in child protection receiving medical records was that the staff sought to exhaust all options when evidence gathering prior to requesting a court order to obtain the records. Staff decided to seek clarifying collateral knowledge when sources of information presented conflicting perspectives regarding the safety and risk regarding the bio father harming a child in the state of WI.  Considering the preferred preference is to place children with parents, as well as to engage fathers, the staff needed time to resolve and clarify the goal conflict between prioritizing engaging the non-custodial father and erroring on the side of safety to ensure child protection by not allowing contact. However, the immediacy of the placement did not allow for time, and during a background check the staff found criminal charges about the non-custodial father harming a child in the state of Wisconsin, yet the extent of the harm was not known and caregivers\' statements regarding the Wisconsin charges suggested contact would be okay, and they did not have safety concerns for the non-custodial father being considered as a placement preference.\",\"Multiple_Choice__368\":\"3\",\"Free_Text__369\":\"Needed time to resolve and clarify the goal conflict again, delay to receiving the records was influenced by the complexity of a MN hospital not being able to release medical records immediately regarding a non-related child without a court order. The hospitals interpretation of statute governing Child Protection Investigation data was not broad enough to release data for another non-related child\'s injuries, including MN Statute 626.556 Sub. 10 (i) 3 & Statutes 13.384 and 144.291 to 144.298, and other relevant data privacy laws like HIPAA. The hospital was not able to make recommendations for what contact\\/visitation between the non-custodial biological father and the child, as the information in their records was protected.\\r\\nWI\'s interpretation of data privacy also contributed to staff not being able to readily receive records. A difficulty exists in accessing information about non-custodial parents due to limitations defined in various legislative statutes and data privacy laws. The limitations impact child welfare practice, specifically in CP investigations when the delay in receiving records is not aligned with the urgency information is needed during an investigation to ensure safety of children.\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"LP1: Staff decided to seek clarifying collateral knowledge when sources of information presented conflicting perspectives regarding the safety and risk regarding the bio father harming a child in the state of WI during the CP investigation. Considering the preferred preference is to place children with parents, as well as to engage fathers, the staff needed time to resolve and clarify the goal conflict between prioritizing engaging the non-custodial father and erroring on the side of safety to ensure child protection by not allowing contact. However, the immediacy of the placement did not allow for time, and during a background check the staff found criminal charges about the non-custodial father harming a child in the state of Wisconsin, yet the extent of the harm was not known and caregivers\' statements regarding the Wisconsin charges suggested contact would be okay, and they did not have safety concerns for the non-custodial father being considered as a placement preference. Staff needed time to resolve and clarify the goal conflict, delay to receiving the records was influenced by the complexity of a MN hospital not being able to release medical records immediately regarding a non-related child without a court order. The hospitals interpretation of statute governing Child Protection Investigation data was not broad enough to release data for another non-related child\'s injuries, including MN Statute 626.556 Sub. 10 (i) 3 & Statutes 13.384 and 144.291 to 144.298, and other relevant data privacy laws like HIPAA. The hospital was not able to make recommendations for what contact\\/visitation between the non-custodial biological father and the child, as the information in their records was protected.\\r\\nWI\'s interpretation of data privacy also contributed to staff not being able to readily receive records. A difficulty exists in accessing information about non-custodial parents due to limitations defined in various legislative statutes and data privacy laws. The limitations impact child welfare practice, specifically in CP investigations when the delay in receiving records is not aligned with the urgency information is needed during an investigation to ensure safety of children.\\r\\nLP2:  Contributing to interviews being conducted separate by the CP staff and the LE investigator was that the child fatality occurred after hours, where a contracted after hours CP crisis response staff responded to the hospital where law enforcement was at the time. The after-hours crisis response protocol met the mandate in Statute for 24\\/7 CP coverage and DHS guidance around 24\\/7 coverage, and was the local agencies developed and established protocol for reports that come in to CP after hours and require an immediate\\/24 hour response in order to meet face to face timeline. The role of the after-hours staff was to respond and observe the victim child, assess safety and risk, and develop a safety plan with the non-offending caregiver. It was not to coordinate a joint investigation with law enforcement. The after-hours staff documented the face to face contact with the alleged victim child, and the decision making that went into the developed safety plan with the non-offending parent for the daytime CP investigator to review when assigned to the case in the morning.\\r\\nLP2: Best Practice guidance to conduct joint LE and CP investigation is in conflict with 626.556\'s language which allows CP to use LE\'s investigative reports.  Contributing to interviews being conducted separate by the CP staff and the LE investigator was that the child fatality occurred after hours, where a contracted after hours CP crisis response staff responded to the hospital where law enforcement was at the time. The after-hours crisis response protocol met the mandate in Statute for 24\\/7 CP coverage and DHS guidance around 24\\/7 coverage, and was the local agencies developed and established protocol for reports that come in to CP after hours and require an immediate\\/24 hour response in order to meet face to face timeline. The role of the after-hours staff was to respond and observe the victim child, assess safety and risk, and develop a safety plan with the non-offending caregiver. It was not to coordinate a joint investigation with law enforcement. The after-hours staff documented the face to face contact with the alleged victim child, and the decision making that went into the developed safety plan with the non-offending parent for the daytime CP investigator to review when assigned to the case in the morning.\\r\\nThere is a perception that child protection\'s purpose and role is different than law enforcement\'s purpose and role at the time of first response to a child death, in addition to each work disciplines role and purpose that occurs the next day and thereafter following the immediate response. Law Enforcement\'s role is to take the lead in the child death investigation the moment a child death is learned. Law enforcement\'s purpose is to seek evidence to understand what happened and who committed the crime and time is of the essence to ensure public safety. The role of the after-hours CP staff is to respond and observe the victim child, assess immediate safety and risk concerns, and develop a safety plan with the non-offending caregiver. It is not to coordinate future joint investigative efforts with law enforcement, as there is statutory language in 626.556 which allows CP to use law enforcement\'s investigative data in their CP investigation.  \\r\\nNoting that CP interviews take more time when a child death occurs, and a sensitive approach is used, prioritizing the trauma the non-offending caregiver is experiencing, as well as when making contact with collateral contacts. The broader topics covered in CP interviews required to complete the CP investigation are perceived as not being efficient or beneficial for the purpose of law enforcement\'s investigation. Collaboration between Law Enforcement and Child Protection occurred in the days after immediate response to the child death, sharing information with one another learned in each of their separate interviews conducted.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"LP2: There is a perception that child protection\'s purpose and role is different than law enforcement\'s purpose and role at the time of first response to a child death, in addition to each work disciplines role and purpose that occurs the next day and thereafter following the immediate response. Law Enforcement\'s role is to take the lead in the child death investigation the moment a child death is learned. Law enforcement\'s purpose is to seek evidence to understand what happened and who committed the crime and time is of the essence to ensure public safety. The role of the after-hours CP staff is to respond and observe the victim child, assess immediate safety and risk concerns, and develop a safety plan with the non-offending caregiver. It is not to coordinate future joint investigative efforts with law enforcement, as there is statutory language in 626.556 which allows CP to use law enforcement\'s investigative data in their CP investigation.  \\r\\nNoting that CP interviews take more time when a child death occurs, and a sensitive approach is used, prioritizing the trauma the non-offending caregiver is experiencing, as well as when making contact with collateral contacts. The broader topics covered in CP interviews required to complete the CP investigation are perceived as not being efficient or beneficial for the purpose of law enforcement\'s investigation. Collaboration between Law Enforcement and Child Protection occurred in the days after immediate response to the child death, sharing information with one another learned in each of their separate interviews conducted.\",\"Multiple_Choice__362\":\"2\",\"Free_Text__363\":\"LP1: Contributing to the delay in child protection receiving medical records was that the staff sought to exhaust all options when evidence gathering prior to requesting a court order to obtain the records. Staff decided to seek clarifying collateral knowledge when sources of information presented conflicting perspectives regarding the safety and risk regarding the bio father harming a child in the state of WI.  Considering the preferred preference is to place children with parents, as well as to engage fathers, the staff needed time to resolve and clarify the goal conflict between prioritizing engaging the non-custodial father and erroring on the side of safety to ensure child protection by not allowing contact. However, the immediacy of the placement did not allow for time, and during a background check the staff found criminal charges about the non-custodial father harming a child in the state of Wisconsin, yet the extent of the harm was not known and caregivers\' statements regarding the Wisconsin charges suggested contact would be okay, and they did not have safety concerns for the non-custodial father being considered as a placement preference.\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"LP2: Contributing to interviews being conducted separate by the CP staff and the LE investigator was that the child fatality occurred after hours, where a (Washington County) contracted after hours CP crisis response staff responded to the hospital where law enforcement was at the time. The after-hours crisis response protocol met the mandate in Statute for 24\\/7 CP coverage and DHS guidance around 24\\/7 coverage, and was the local agencies developed and established protocol for reports that come in to CP after hours and require an immediate\\/24 hour response in order to meet face to face timeline. The role of the after-hours staff was to respond and observe the victim child, assess safety and risk, and develop a safety plan with the non-offending caregiver. It was not to coordinate a joint investigation with law enforcement. The after-hours staff documented the face to face contact with the alleged victim child, and the decision making that went into the developed safety plan with the non-offending parent for the daytime CP investigator to review when assigned to the case in the morning.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 15:36:18',NULL,'Blake Holmquist'),(258,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Fintan Moore\",\"Date__293\":\"01\\/02\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Brandi\",\"Short_Answer__304\":\"Bell\",\"Date__305\":\"07\\/23\\/2017\",\"Date__306\":\"12\\/03\\/2017\",\"Multiple_Choice__308\":\"4 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Face to face contact with alleged victims did not occur within 5 day response timeframe\",\"Free_Text__318\":\"Worker indicated that the case was not assigned to her by her supervisor until 5 days after the intake disposition. She reported that at this time, there was a significant backlog of cases in Hennepin County in addition to the annual influx on Ed. Neglect cases that come at the end of the school year. As a result of the backlog, they were triaging the cases on how\\/when to assign them. Cases would be screened and if screened in, intake worker would identify which unit it would be assigned to and then send the cases to the unit supervisor to then assign to a specific worker. The worker described lower urgency being placed on this assessment response for a couple reasons. First being that it had taken 5 days to even get the case to her and secondly, that the child was staying with the mother and was no longer with the alleged perpetrators. Addition information learned that she reported as complicating the process was that she had been with Hennepin County for approx.. 6 months, she had a brand new worker from the Induction Unit shadowing her, they were in a transition where they were adding new staff to the unit, the supervisor was new and she had a couple days of vacation in the week following her assignment to the case.\",\"Free_Text__319\":\"Face to face contact not occurring in the 5 day response timeline was influenced by a delay in the worker being assigned the case, caseload demands, and legislation. During this time period, the agency was trying to work through 200-400 pending cases that hadn\'t been assigned. This resulted from changes in government regulation, such as the implementation of the Governor\'s Task Force recommendations. These recommendations created changes to the Intake, Screening and Response Path guidelines, further increasing the number of 24 hour response cases the agency needed to respond to. Additionally, there was an influx of Educational Neglect cases from schools during this time period (spring), which were lower priority cases. Supervisors needed to triage cases and prioritize those needing a 24 hour response, resulting in a delay in assignment of 5 day response cases. This, coupled with the TSO system (technology used by local agency for distribution of cases to units) and the time it takes to review and assign cases, further impacted supervisor workload, which delayed the cases being assigned.  Supervisor workload was also adversely impacted by having 10 staff to supervise with high turnover rates for those staff.  Also, induction staff was not being trained in the investigation response, resulting in a larger learning curve for those coming from the induction unit and responding to child protection assessments and investigations.  \\r\\n\\r\\nThe worker assigned to the case identified the case as lower priority as well because the child was no longer in the care of the alleged offender. When attempting to schedule a face to face visit with the family, which was difficult due to workload levels, the worker did safety plan with the child\'s mother via phone. The workload which made it difficult for scheduling included the worker training a new staff and the number of checklists needing to be completed for each case. Further supporting staff\'s need to prioritize immediate response cases is that Minnesota State Statute 626.556, subd. 10(j) governs immediate response timeframes for predatory offenders and is based on allegations versus actual risk to the alleged victim.  As a result of this statute and since funding is tied to compliance with this measure, staff don\'t have discretion to respond to alleged victims based upon actual risk and are forced to respond based on allegation type and need to prioritize these cases over ones that come in as a 5 day response which may actually be at greater risk in some cases.\\r\\nFurther influencing the delay in contact was the interpretation of guidance and statute that CP can delay contact with alleged victims in 5 day response cases if directed by law enforcement such as in this case.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"The worker assigned to the case identified the case as lower priority as well because the child was no longer in the care of the alleged offender.\",\"Multiple_Choice__348\":\"2\",\"Free_Text__349\":\"The workload which made it difficult for scheduling included the worker training a new staff and the number of checklists needing to be completed for each case.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"This, coupled with the TSO system (technology used by local agency for distribution of cases to units) \\u00e2\\u20ac\\u201c add complexity to the system just for assigning cases.\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"2\",\"Free_Text__357\":\"Also, induction staff was not being trained in the investigation response, resulting in a larger learning curve for those coming from the induction unit and responding to child protection assessments and investigations\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"This resulted from changes in government regulation, such as the implementation of the Governor\'s Task Force recommendations. These recommendations created changes to the Intake, Screening and Response Path guidelines, further increasing the number of 24 hour response cases the agency needed to respond to.\\r\\n\\r\\nFurther supporting staff\'s need to prioritize immediate response cases is that Minnesota State Statute 626.556, subd. 10(j) governs immediate response timeframes for predatory offenders and is based on allegations versus actual risk to the alleged victim. As a result of this statute and since funding is tied to compliance with this measure, staff don\'t have discretion to respond to alleged victims based upon actual risk and are forced to respond based on allegation type and need to prioritize these cases over ones that come in as a 5 day response which may actually be at greater risk in some cases.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"During this time period, the agency was trying to work through 200-400 pending cases that hadn\'t been assigned.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"2\",\"Free_Text__365\":\"The time it takes to review and assign cases, further impacted supervisor workload, which delayed the cases being assigned.  Supervisor workload was also adversely impacted by having 10 staff to supervise with high turnover rates for those staff.\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:36:57',NULL,'Brandi Bell'),(259,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tracy Nielsen\",\"Date__293\":\"12\\/09\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"5\",\"Multiple_Choice__301\":\"Des Moines Valley\",\"Short_Answer__303\":\"Brexlee\",\"Short_Answer__304\":\"Thammalong\",\"Date__305\":\"10\\/07\\/2016\",\"Date__306\":\"12\\/09\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Face to face contact with sibling child (alleged victim) did not occur\",\"Free_Text__318\":\"Agency staff shared that through consultation with a supervisor and county attorney, it was discussed that they didn\'t want to cause any more trauma to the family than they had already experienced. As a result of this feeling, it was decided that the staff would not go out to interview the surviving sibling. After being released from the hospital (child had two broken legs), the sibling was released to his grandmother through a family arrangement. Agency staff did make contact with both the grandmother (caring for the child) and the school to follow up on how he was doing. Both reported that the child was doing well and there was a presumption of safety for the remaining sibling child.\",\"Free_Text__319\":\"The agency not making face to face contact with the sibling to the subject child was influenced by a presumption of safety as well as not wanting to cause additional trauma to the child. There has been a national push for evidence-based trauma informed practice and thus a push by the State for the same. As a result, there is hyper-vigilance on the trauma impact on children by local agency staff. There was a time lapse of a couple months between an initial screened-out report and subsequent screened-in report on the incident as it took time for the State Patrol to complete their investigation and release information on the incident. By the time the agency initiated a CP FI, the child had already been released from the hospital and was in the care of his grandmother. The hospital staff that released the child to the grandmother never reported to the agency any concerns with the family arrangement. The agency followed up with the child\'s grandmother and also school staff regarding the child\'s welfare. Both reported the child was doing well. This information, coupled with the time lapse from the incident and the information from the State Patrol, resulted in the agency not wanting to re-traumatize the child by interviewing him about the incident as they had the information they needed. Also, the alleged perpetrator to the maltreatment determination (mother) was deceased, contributing to the presumption of safety. \\r\\nAlso noted was that in situations similar to this, there can be complications with attaining reliable information from child interviews with serious injuries as the injuries may impact their ability to recall\\/share the information. Distance and weather conditions can also inhibit contact as children are often times transported to metro-area hospitals and the agency is in rural Minnesota.\",\"Multiple_Choice__346\":\"3\",\"Free_Text__347\":\"The hospital staff that released the child to the grandmother never reported to the agency any concerns with the family arrangement. The agency followed up with the child\'s grandmother and also school staff regarding the child\'s welfare. Both reported the child was doing well. This information, coupled with the time lapse from the incident and the information from the State Patrol, resulted in the agency not wanting to re-traumatize the child by interviewing him about the incident as they had the information they needed. Also, the alleged perpetrator to the maltreatment determination (mother) was deceased, contributing to the presumption of safety. \\r\\nAlso noted was that in situations similar to this, there can be complications with attaining reliable information from child interviews with serious injuries as the injuries may impact their ability to recall\\/share the information.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"There has been a national push for evidence-based trauma informed practice and thus a push by the State for the same. As a result, there is hyper-vigilance on the trauma impact on children by local agency staff.\\r\\n\\r\\nThis information, coupled with the time lapse from the incident and the information from the State Patrol, resulted in the agency not wanting to re-traumatize the child by interviewing him about the incident as they had the information they needed.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:37:51',NULL,'Brexlee Thammalong'),(260,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Kari Rude\",\"Date__293\":\"03\\/01\\/2017\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"3\",\"Multiple_Choice__301\":\"Otter Tail\",\"Short_Answer__303\":\"Bryson\",\"Short_Answer__304\":\"Totland\",\"Date__305\":\"11\\/30\\/2015\",\"Date__307\":\"01\\/19\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s boyfriend\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Family Assessment determined child protection services needed, case management closed without child protection services provided to the mother.\",\"Free_Text__318\":\"Normally the agency drafts a CHIPS petition in a narrative form, explaining why court ordered services are being requested of the court. Explanation of which parties they are requesting to be in court, and they email the CHIPS petition to their County Attorney\'s office. \\r\\nUnlike other cases that get \\u00e2\\u20ac\\u0153log jammed\\u00e2\\u20ac\\u009d in the county attorney\'s office, for example, on cases where paternity is not established, those cases can get held up before moving to get on the courts calendar.  \\r\\nIt was noted that in this case the petition was assigned fairly quickly. Worker wasn\'t what timeframes apply in court for CHIPS cases, just that they would not start until the petition had admit\\/deny hearing. \\r\\nPrior to the CHIPS petition being filed, both parents knew that it was going to be filed in Juvenile court, and both parents would be required to work with social services case plan. CP mentioned that the father did not have any tasks to complete per say for the case plan, it was mostly going to be structured around the risk to the child and the concerns surrounding deficits in mother\'s protective capacities.\\r\\nIn 2014 the agency had two staff positions unfilled, so 7 staff we running the CP unit, carrying both investigations, family assessments, child welfare services cases, and CP case management types of cases.  One worker was assigned to minor parent services.  PSOP is contracted out.\\r\\nA change in the unit dynamic occurred when four new positions were funded.  A decision was made by the CP supervisor and CP unit, that instead of professionals carrying mixed caseloads, professionals would work one or the other, either investigations or case management, not both.\\r\\nIt was further explained that the work is different for each of these types of cases, and carrying both affected how the professionals could complete the work required for both types of cases, and the demands and tasks are different. \\r\\n\\r\\nWorker noted that their court system feels unpredictable to their CP unit. It is normal that the expectation of safety for children is not consistent or predictable. It is the norm to see family court default to the CHIPS and social services case, but it is more complex even more now days that it was back in 2014.\\r\\nWorker learned about the family court order after it occurred. Identified communication challenges within the systems child protection, child support, county attorney for the CHIPS and family court system; two court jurisdictions.   \\r\\n\\r\\nAt the end of this case, it didn\'t feel \\u00e2\\u20ac\\u0153Final\\u00e2\\u20ac\\u009d.  Mother didn\'t have custody but the concerns were still there. She wasn\'t complying without a formal CHIPS but the order from the child support case trumped the CHIPS. Father was on the CHIPS, but he was and wasn\'t going to be doing the parenting full time.  His mother, paternal grandmother, stepped in while he was stationed out of state in his place. So they were told by social services that it would be considered failure to protect should they allow mother to have unsupervised contact, since she has not received services yet. Mother struggled to parent safely and adequately.  It is the expectation that the father will protect since social services is out.  Should mother come back into the picture, she would need to work services again. \\r\\nMother was not having contact with the child per the temporary family court order, when CP closed the case.\\r\\nDuring 01\\/20\\/2017 NF investigation this sibling sister was having contact with mother. Worker wasn\'t sure what happened, but it appeared Family court order may have been modified allowing mother to have contact or there was subjectivity on the father to decide when it was safe for visitation to occur between the mother and the child. Yet still mother never received the requested CP services that were determined to be needed at completion of the CP Assessment in 09\\/30\\/2014.\\r\\nWorker expressed frustration with circumstances of this case and having many consults with county attorney that did not meet the definition of neglect. Worker had no authority to make mother engage in services, and she would do as little as possible. \\r\\n\\r\\nWorker also noted there are not enough services available for minor parents. Example: 45 min home visit with a mother parenting her infant is not enough to learn how to parent.\",\"Free_Text__319\":\"The decision for child protection to close the case management workgroup without providing services to the mother was supported by a family court proceeding in a different county jurisdiction granting temporary physical custody to the father at the same time when the local Child Protection agency prepared a Child in Need of Protection and\\/or Services (CHIPS) petition and submitted it to their County Attorney\'s office.  Unaware of family court involvement in the neighboring county, or strategically using a \\u00e2\\u20ac\\u02dcwait and see\' approach, the County Attorney\'s Office reviewed the CHIPS petition, contemplating evidence required to meet the burden of proof standard for the requested CHIPS action. The neighboring county\'s family court proceeding occurred as scheduled, and resulted in a stipulated agreement by the parties.  The stipulated agreement impacted the course of action the County Attorney\'s Office was allowed to take by law, as criteria and evidence to prove child at risk or in danger was no longer met after the neighboring county\'s family court granted temporary physical custody of the child to the father. When co-occurring court proceedings take place, it is common practice for the court in which the social services agency requested CHIPS to retain venue for the case. However, under the Minnesota Rules of Juvenile Protection Procedure, Rule 23. INTERVENTION, other options exists should certain scenarios arise. Due to the child\'s circumstances and family participants coming to an agreement, the family court found that it was in the best interest of the child to allow the father to intervene using the family court venue, and granted the change of the child\'s physical residence to the father\'s home. The father was not an alleged offender and had been assessed by the child protection agency under the open case.  Safety and Decision Making Tools determined the child\'s change in residence to the father\'s home was safe and had low risk. Accordingly, the mother did not have the child in her care after the family court order, which changed the criteria under which child protection could be involved. Child protection had no legal jurisdiction to continue working with the mother, as there was no longer an unsafe child in her care. This additionally dismissed the need to pursue a CHIPS. The mother\'s minimal engagement in previous family based preventative services, further supported the agency\'s decision to close the case management workgroup without providing voluntary case management services to the mother.\",\"Multiple_Choice__346\":\"1\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"Court district communication  challenge, two counties (Becker and Otter Tail) and two courts systems (Family and Juvenile Courts), each within a different county jurisdiction.\\r\\nTwo County attorney offices. No method exists to allow sharing of information between Juvenile and Family courts when cases overlap in neighboring counties.\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"The court district communication challenge was complicated by timing of petitions being filed in two separate counties managing different paths of court intervention services for the family (juvenile court in Otter Tail County, and family court in Becker County). The two courts systems\' geographical location limited teamwork and interaction when no method of communication exists for knowledge regarding their work with the family to be shared between them. \\r\\nUnder the Minnesota Rules of Juvenile Protection Procedure, Rule 23. INTERVENTION, other options exists should certain scenarios arise, making an exception to the general rule that the court in which the social services agency requested CHIPS retain venue for the case. \\r\\nOnce it was learned by the social services agency in Otter Tail Co. that family court in Becker County granted a stipulated agreement, allowing the father to intervene using the family court venue, and the child\'s physical residence be moved to the father home, their involvement to provide CP services to the mother was limited.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Burden of Proof standards in Juvenile Court and Family Court systems are different and were conflicting.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 15:38:55',NULL,'Bryson Totland'),(261,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Date__293\":\"01\\/04\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"2\",\"Multiple_Choice__301\":\"Carlton\",\"Short_Answer__303\":\"Cassiopeia\",\"Short_Answer__304\":\"Mendoza\",\"Date__305\":\"08\\/01\\/2018\",\"Date__307\":\"11\\/05\\/2018\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Father\",\"Short_Answer__311\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:39:51',NULL,'Cassiopeia Mendoza'),(262,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage\",\"Date__293\":\"02\\/19\\/2020\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Cayden\",\"Short_Answer__304\":\"Moore\",\"Date__305\":\"01\\/01\\/2020\",\"Date__307\":\"02\\/19\\/2020\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Unknown offender\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:58:17',NULL,'Cayden Moore'),(263,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"03\\/08\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Washington\",\"Short_Answer__303\":\"Chase\",\"Short_Answer__304\":\"Reger\",\"Date__305\":\"10\\/21\\/2017\",\"Date__307\":\"02\\/22\\/2018\",\"Multiple_Choice__308\":\"4 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 15:42:08',NULL,'Chase Reger'),(264,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Tiffany Kacir\",\"Date__293\":\"09\\/28\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"2\",\"Multiple_Choice__301\":\"St. Louis\",\"Short_Answer__303\":\"Chase\",\"Short_Answer__304\":\"Rumpel\",\"Date__305\":\"12\\/04\\/2011\",\"Date__307\":\"08\\/28\\/2018\",\"Multiple_Choice__308\":\"7 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"The caregiver father was not involved in safety planning.\",\"Free_Text__318\":\"Debrief #1 with staff:\\r\\n\\u00e2\\u20ac\\u00a2\\tStaff were aware of the family and chronic pattern of reports made for neglect \\u00e2\\u20ac\\u201c inadequate supervision. There was constant work being done with the family for the same issue. \\r\\no\\tInitial perception was that neighbors did not like the family and were making reports.\\r\\no\\tFamily lived in a home in the outskirts of the city, a location where child protection reports are not commonly received by the agency. \\r\\no\\tFamily had some support from grandmothers, but were mostly isolated from supports\\r\\n\\u00e2\\u20ac\\u00a2\\tDuring the Family Assessment safety planning was more informal versus formal. \\r\\no\\tSafety planning with the father was difficult to complete due to his lack of investment in and unwillingness to participate in contacts with child protection staff. \\r\\no\\tThe father was difficult to engage (i.e. would not answer the door, did not trust law enforcement or social services, etc).\\r\\no\\tWhen contact was made with the father he denied\\/ minimized the allegation, blamed neighbors for targeting him, etc.\\r\\no\\tStaff utilized family assessment approach, letters, phone calls, leaving business card in door at the home, make contact with children at the school\\r\\no\\tThe chronic neglect allegation did not have the urgency like other allegations where immediate danger exists and staff need to involve law enforcement in the moment and not leave until contact made with the caregivers and put eyes on the children. \\r\\n\\u00e2\\u20ac\\u00a2\\tStaff prioritized putting in safety measures\\r\\no\\tPurchasing and installing of child window and door locks and alarms.\\r\\no\\tKept case open longer in assessment to monitor effectiveness of safety plan and parents\' capacity to use the safety measure and follow the safety plan. \\r\\n\\u00ef\\u201a\\u00a7\\tParents protective capacities to manage the children\'s behaviors was being monitored, as was the parents\' mentality to enforce the safety measures\\r\\n\\u00e2\\u20ac\\u00a2\\tThe parents would \\u00e2\\u20ac\\u02dcdo their own thing\' and the children would be allowed to \\u00e2\\u20ac\\u02dcdo what they wanted\'.  \\r\\n\\u00ef\\u201a\\u00a7\\tAware of older 14 year old sibling babysitting the children, where she reported no concerns for inadequate supervision at the time. \\r\\n\\u00ef\\u201a\\u00a7\\tDidn\'t provide any services or interventions to parents for this at the time.\\r\\n\\u00e2\\u20ac\\u00a2\\tThe local agency initiative was to use Signs of Safety and Safety Organized Practice.\\r\\no\\tSafety organized practice safety planning is more focused on participation, follow through by the family and workers; More accountability for all.\\r\\n\\u00e2\\u20ac\\u00a2\\tAt the time, the staff was most senior worker on the team (3 years of experience)\\r\\no\\tHigher caseload of 30-40 cases\\r\\n\\u00ef\\u201a\\u00a7\\tMost of the staff\'s cases were Investigations (sex abuse, egregious harm, birth matches) requiring 24-hour response\\r\\n\\u00e2\\u20ac\\u00a2\\tThis was FA and chronic neglect- shaped perception that not as high risk and had to prioritize investigations with 24 hour response\\/higher risk \\r\\n\\u00e2\\u20ac\\u00a2\\tOutside pressure from two major hospitals in the county on multiple birth match cases to have discharge safety plans established for newborns right away.\\r\\no\\tNew influx of new hire staff joining the workforce\\r\\n\\u00ef\\u201a\\u00a7\\tAs an experienced staff, the staff was providing on the on the job training for new hires\\r\\no\\tCases were assigned based by workers volunteering to take them from screeners\\r\\n\\u00ef\\u201a\\u00a7\\tMore experienced staff take complex case assignments \\r\\n\\u00ef\\u201a\\u00a7\\tStaff would take cases in which she was familiar with the family\\r\\n\\u00e2\\u20ac\\u00a2\\tLess time reviewing history since aware of it\\r\\n\\u00e2\\u20ac\\u00a2\\tNew hires not assigned complex cases; since staff had more experience it made sense for the staff to take this case due to her knowing the complex chronic neglect history and family dynamics involved\\r\\nDebrief #2 with supervisor: \\r\\n\\u00e2\\u20ac\\u00a2\\tSupervisor was not able to remember much of her involvement working with this family. Her mental model is shaped mostly in remembering the critical incident case and there being a history of involvement for inadequate supervision concerns, and chemical dependency concerns. \\r\\no\\tRecalls the agency focus being on engaging the family in safety planning and the rejuvenation efforts to use Signs of Safety and Safety Organized Practice initiatives. \\r\\n\\u00ef\\u201a\\u00a7\\tLots of tools available for staff and challenge in understanding how to use them.\\r\\n\\u00ef\\u201a\\u00a7\\tEfforts made to educate caregivers about the danger associated with the inadequate supervision allegation.\\r\\n\\u00ef\\u201a\\u00a7\\tMonitoring the family\'s ability to help resolve safety concerns and enforce safety plan.\\r\\n\\u00ef\\u201a\\u00a7\\tStaff conduct safety planning in the field, talk about bottom lines with caregivers, what the worries are, and who is responsible to address concerns.\\r\\n\\u00ef\\u201a\\u00a7\\tStaff discuss support networks with the families in the field.\\r\\n\\u00e2\\u20ac\\u00a2\\tIn this case father had chemical use concern, and it would likely be stated in a safety plan to not leave him in a caregiving role. \\r\\no\\tSometimes formal safety planners can be brought in at time of intake as a \\u00e2\\u20ac\\u0153rapid response\\u00e2\\u20ac\\u009d to high risk cases.  \\r\\n\\u00ef\\u201a\\u00a7\\t2 staff work this role for all children and families services provided by the agency.\\r\\n\\u00ef\\u201a\\u00a7\\tReferrals for utilizing safety planner is informal, request a meeting and is based on availability of the safety planners\\r\\n\\u00ef\\u201a\\u00a7\\tThere is not an established protocol when to request a safety planner, more upon a staff\'s request.\",\"Short_Answer__320\":\"At close of family assessment, result of risk assessment was \\u00e2\\u20ac\\u02dchigh\', and ongoing CP case management was marked not needed\\/family support services were not requested.\",\"Free_Text__321\":\"Debrief #1 with staff:\\r\\n\\u00e2\\u20ac\\u00a2\\tLot of changes occurring in the agency at that time\\r\\no\\t3 different directors in the previous year \\r\\n\\u00ef\\u201a\\u00a7\\tBrought about a lot of changes to agency initiatives\\r\\n\\u00e2\\u20ac\\u00a2\\tFocus at the time was to focus on child safety and engagement\\/ working with the family to establish safety plans, and for staff to monitor the parents enforcing of the developed safety plan over time, and its effectiveness.\\r\\no\\tInflux in hiring new staff from new sources of funding\\r\\n\\u00ef\\u201a\\u00a7\\tHiring of several new staff (8-9) to Investigation\\/Assessment unit\\r\\n\\u00ef\\u201a\\u00a7\\tMany of them had to attend CORE training first 2-3 months and not available to take cases\\r\\n\\u00ef\\u201a\\u00a7\\tStaff serving as peer mentor and only had 3 years of experience\\r\\no\\tUnit was spilt up and had 2 supervisors, one supervisor was new\\r\\no\\tSupervisors were being pulled away for agency meetings and were less available for direct consulting\\r\\n\\u00ef\\u201a\\u00a7\\tPeer to peer consulting occurred most often versus supervisor consults \\r\\no\\tHigh caseloads\\r\\n\\u00ef\\u201a\\u00a7\\tEfficiency trade-off for closing cases: only looked at bare minimum of why case was brought in and if safety issues were \\u00e2\\u20ac\\u0153remedied\\u00e2\\u20ac\\u009d\\r\\n\\u00e2\\u20ac\\u00a2\\tFamily Support Services were in place already when staff completed some family assessments with the family. \\r\\n\\u00ef\\u201a\\u00a7\\tHigh risk cases were staffed with the supervisor and County Attorney but was difficult to do at this time due to limited availability of new supervisors and all the changes.\\r\\n\\u00ef\\u201a\\u00a7\\tSupervisors were scrambling to prioritize all their own workloads\\r\\n\\u00e2\\u20ac\\u00a2\\tThere was a less formal process in how to staff high risk cases with County Attorney during this time period than currently (agency has weekly time held for County Attorney consults for staffing high risk cases). \\r\\n\\u00e2\\u20ac\\u00a2\\tSolo staffing with County Attorney happened \\u00e2\\u20ac\\u0153on the fly\\u00e2\\u20ac\\u009d. Staff was allowed to close the FA following consult as the case didn\'t meet the threshold for Court intervention \\u00e2\\u20ac\\u201c CHIPS.\\r\\no\\tStaff was not as aware or did not possess the same knowledge possesses now about the whole \\u00e2\\u20ac\\u0153child protection process\\u00e2\\u20ac\\u009d, from intake, assessment\\/investigation, case management.\\r\\n\\u00ef\\u201a\\u00a7\\tHow to \\u00e2\\u20ac\\u0153set up a case\\u00e2\\u20ac\\u009d for ongoing case management services and safety planning resources available, what services are available and how to refer for services\\r\\n\\u00ef\\u201a\\u00a7\\tWhat resources are available for safety planning through formal court intervention\\r\\n\\u00ef\\u201a\\u00a7\\tStaff noted that the \\u00e2\\u20ac\\u0153root of the family issues were not able to get solved\\u00e2\\u20ac\\u009d and identifying the \\u00e2\\u20ac\\u0153right intervention, resources, consults needed, and understand the family\'s ability to follow through\\u00e2\\u20ac\\u009d wasn\'t able to happen at the time.\\r\\nDebrief #2 with supervisor:\\r\\n\\u00e2\\u20ac\\u00a2\\tLot of changes occurring in the agency during this time, and it was a very overwhelming time for the supervisor.\\r\\no\\tSupervisor had 7 \\u00c2\\u00bd years work experience in the intake\\/screening area, time in adoptions and then left the agency for 2 years. \\r\\no\\tUpon return to the agency, so much had changed. Recalls there being so much turnover. \\r\\n\\u00e2\\u20ac\\u00a2\\tSupervisor transitioning adoptions caseload while taking on new Supervisor role. \\r\\no\\tSupervising high number of staff, averaging 15 per supervisor\\r\\no\\tIn charge of coordination efforts with law enforcement and Children and Family Services Clerical support (clerk) staff, and triaging intake and screening needs. \\r\\n\\u00e2\\u20ac\\u00a2\\tHiring new staff was constant\\r\\no\\tSenior workers were moving into different positions\\r\\no\\tHad to hire new staff, fill 8-9 positions due to increase agency received in funding at this time to increase workforce capacity.\\r\\n\\u00ef\\u201a\\u00a7\\tHad to use Merit system and as new supervisor had to learn all the regulations and rules to follow and how to navigate the Merit System, along with the local agencies the civil system (two systems to navigate). \\r\\n\\u00e2\\u20ac\\u00a2\\tThere was no training for this. \\r\\n\\u00ef\\u201a\\u00a7\\tSpent a lot of time interviewing for new hires\\r\\n\\u00ef\\u201a\\u00a7\\tTook time away from being available to staff for consulting\\r\\n\\u00e2\\u20ac\\u00a2\\tWhen did meet with staff it was briefer check-ins \\r\\n\\u00e2\\u20ac\\u00a2\\tOften felt \\u00e2\\u20ac\\u0153triaging\\u00e2\\u20ac\\u009d situations and making decisions quickly\\r\\n\\u00e2\\u20ac\\u00a2\\tAlways feeling the need for more 1 on 1 time with staff and wanting to be more available to consult on cases.\\r\\n\\u00ef\\u201a\\u00a7\\tWent 7 months without a clerk \\r\\n\\u00e2\\u20ac\\u00a2\\tLead to inefficiencies routing calls into the agency\\r\\n\\u00e2\\u20ac\\u00a2\\tBecame issue for supervisor to resolve \\u00e2\\u20ac\\u201c took more attention away from supervising.\\r\\no\\tStaff was (currently is) supervising 15 staff\\r\\n\\u00ef\\u201a\\u00a7\\tLittle time available for regular one to one supervision\\r\\n\\u00ef\\u201a\\u00a7\\tRecognizes the nature of the job creates environment for high burnout of employees and is always trying to combat this, and nurture them so they will stay.\\r\\n\\u00ef\\u201a\\u00a7\\tGrateful the agency created lead worker position and this bringing the supervisor some support in supervising staff\\r\\no\\tStaff carrying high caseloads\\r\\n\\u00ef\\u201a\\u00a7\\tDoubled the number of intakes during that time\\r\\n\\u00e2\\u20ac\\u00a2\\tImpacted by new and changes to screening guidance\\r\\n\\u00e2\\u20ac\\u00a2\\tMore 24 hour responses\\r\\n\\u00ef\\u201a\\u00a7\\tStaff would normally consult Supervisor on high risk cases before closure.\\r\\n\\u00e2\\u20ac\\u00a2\\tConsulting County Attorney was not always necessary and was not normative practice.\\r\\no\\tModerate or high risk cases not always meet threshold for CP ongoing case management. \\r\\no\\tWhen caregivers are not motivated to comply, making them with a court order can result in minimal engagement. \\r\\n\\u00ef\\u201a\\u00a7\\tAdditionally formal court intervention not always the best option, because when threshold is not met after starting CHIPS process, and case gets dismissed anyways, there are no grounds to work with the family, and have to close the case.  \\r\\no\\tBetter to strategize how to get family buy in to be more involved in safety planning and working collaboratively with child protection without court intervention (i.e. voluntarily). \\r\\no\\tFamily has a choice to engage. \\r\\n\\u00e2\\u20ac\\u00a2\\tSupervisor didn\'t have a lot of time to review cases for closure especially balancing the demand of onboarding so many new staff \\r\\no\\tRequested creation of lead staff \\r\\n\\u00e2\\u20ac\\u00a2\\tSupervisor had discretion, interpretation of case dynamics from staff consults and reviewed results of SDM tools.\\r\\n\\u00ef\\u201a\\u00a7\\tMany cases were not transitioned into ongoing case management\\/ family support services.\",\"Yes_or_No__370\":\"No\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 15:41:35',NULL,'Chase Rumpel'),(265,22,91,NULL,13,NULL,NULL,NULL,NULL,0,1,91,91,'2021-05-26 19:33:23','2021-05-26 20:18:51',NULL,'Chasity Bland'),(266,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"07\\/14\\/2017\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Chassidy\",\"Short_Answer__304\":\"Vang\",\"Date__305\":\"12\\/01\\/2014\",\"Date__307\":\"06\\/18\\/2017\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 15:52:09',NULL,'Chassidy Vang'),(267,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"JoLynn Sundstrom\",\"Date__293\":\"07\\/31\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Colton\",\"Short_Answer__304\":\"Senogles\",\"Date__305\":\"06\\/08\\/2017\",\"Date__306\":\"03\\/20\\/2018\",\"Multiple_Choice__308\":\"9 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Legally Unlicensed Child Care Provider\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"A maltreatment determination was made against the legally unlicensed child care provider for the same allegation by two local agencies regarding the subject child\'s fatality.  Additionally, communication did not occur between the two local agencies regarding the maltreatment determination against the legally unlicensed child care provider.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:00:47',NULL,'Colton Senogles'),(268,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Date__293\":\"04\\/17\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Anoka\",\"Short_Answer__303\":\"Cora\",\"Short_Answer__304\":\"Verke\",\"Date__305\":\"09\\/26\\/2017\",\"Date__306\":\"10\\/26\\/2017\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:01:31',NULL,'Cora Verke'),(269,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"12\\/27\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Cruz\",\"Short_Answer__304\":\"Devitt\",\"Date__305\":\"11\\/18\\/2019\",\"Date__306\":\"12\\/27\\/2019\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Input this data for tracking purposes for maltreatment determined sleep related infant death. The mother had taken approx 10 pills of prescribed lorazepam.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:02:15',NULL,'Cruz Devitt'),(270,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Jennifer Carlson\",\"Date__293\":\"09\\/03\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Derrick\",\"Short_Answer__304\":\"Johnson Jr.\",\"Date__305\":\"06\\/25\\/2019\",\"Date__306\":\"09\\/03\\/2019\",\"Multiple_Choice__308\":\"2 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:02:54',NULL,'Derrick Johnson Jr.'),(271,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Lynn Shafer\",\"Date__293\":\"07\\/23\\/2017\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Chisago\",\"Short_Answer__303\":\"Desiree\",\"Short_Answer__304\":\"Miller\",\"Date__305\":\"04\\/22\\/2001\",\"Date__307\":\"06\\/07\\/2017\",\"Multiple_Choice__308\":\"16 Years\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Delays in achieving permanency for the subject child and her siblings.\",\"Free_Text__318\":\"The subject child spent a majority of her life in out-of-home placement with her maternal grandmother.  Prior to the agency getting involved with the family, the subject child and her 11-year old and 14-year old siblings had spent approximately 261 days in out-of-home placement in a different county.  When the agency got involved with the family, the children were immediately placement with their maternal grandmother due to a violation of the No Contact Order between the children and the mother\'s boyfriend.  The maternal grandmother completed the licensing process through Chisago County.  Upon receiving the case, the agency\'s initial thoughts were that this was going to be an automatic Termination of Parental Rights based on the length of time the children had already been in out-of-home placement and permanency timelines.  The worker consulted with her supervisor as to why they were going to make the mother \\u00e2\\u20ac\\u0153jump through hoops\\u00e2\\u20ac\\u009d if the children were already at permanency.  The plan was for the agency to develop case plans for each of the parents and work towards reunification with the mother.  The concurrent permanency plan for the subject child was for a Transfer of Legal and Physical Custody to the maternal grandmother and if that was not possible, then a Transfer of Legal and Physical Custody to the paternal grandmother.  The concurrent permanency plan for the 11-year old and the 14-year old was for a Transfer of Legal and Physical Custody to their father.\\r\\n\\r\\nAfter reviewing the previous county\'s case plans and engagement with the family, the agency felt the family was not given an opportunity to work a case plan and felt the family deserved a chance at reunification.  Knowing the children were at permanency, the agency began working towards reunification.  There were numerous conversations with the mother about transferring custody of the children to their concurrent permanency options, but the mother was resistant.  The mother agreed to transfer custody of the subject child to the maternal grandmother, but the near fatal incident occurred and that took priority.  The agency had frequent conversation about filing a Termination of Parental Rights; however wanted to wait until the mother completed a psychological evaluation and they received the results, which occurred in March 2017 and the results were received in April 2017.\\r\\n\\r\\nThe worker talked with the subject child about where she would like to live in the event she couldn\'t be reunified and she identified her paternal grandmother (which ultimately occurred) because she didn\'t think her maternal grandmother could care for her to due to her own health issues.  Even though there were delays in permanency for the children, the agency acknowledges that the children are in the most appropriate settings.\",\"Free_Text__319\":\"Delays in achieving permanency was influenced by the local agency\'s requirement to exhaust relative placement options that would preserve the subject child\'s placement with her siblings.  Further influencing delays in achieving permanency was the local agency\'s requirement to follow the 10 Best Interest Factors defined in MN State Statute 260C.212 subd. 2 (b) for the placement of the subject child and her siblings.  Specifically. this was evidenced by the subject child\'s significant mental health needs and the agency\'s need to prioritize a relative placement option that could meet the high needs of the subject child while also being the subject child\'s placement preference as required in the 10 best interest factor considerations.\\r\\n\\r\\nDelays to achieve the permanency preference was influenced by the fact the permanency option lived in a different county and needed to be licensed by that county.  Additionally, staffing limitations existed in the agency responsible for licensing the permanency option, which delayed permanency for the subject child. \\r\\n\\r\\nThe agency\'s need to balance the multiple competing priorities of relative placement, sibling preservation, the 10 Best Interests Factors, and permanency timelines also contributed to the delays in achieving permanency.\\r\\n\\r\\nFurther contributing to permanency delays was that the burden of proof criteria under 260C.301 to meet the requirements to terminate parental rights and move towards permanency for the subject child and her siblings had not been met when the case came into the second county of jurisdiction.  The second county wanted to give the family an opportunity to work the case plan towards reunification and wanted to complete a case plan with the subject child\'s father as this had not been previously done in the first county of jurisdiction.  \\r\\n\\r\\nLastly, the near fatal critical incident itself further contributed to delays in permanency due to the local agency prioritizing the subject child\'s mental health needs over the achievement of permanency.  This included placing the child in a residential treatment facility to ensure the subject child\'s safety and meet her high level of mental health needs.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"Delays to achieve the permanency preference was influenced by the fact the permanency option lived in a different county and needed to be licensed by that county.  Additionally, staffing limitations existed in the agency responsible for licensing the permanency option, which delayed permanency for the subject child.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Further contributing to permanency delays was that the burden of proof criteria under 260C.301 to meet the requirements to terminate parental rights and move towards permanency for the subject child and her siblings had not been met when the case came into the second county of jurisdiction.  The second county wanted to give the family an opportunity to work the case plan towards reunification and wanted to complete a case plan with the subject child\'s father as this had not been previously done in the first county of jurisdiction.\\r\\n\\r\\nThe agency\'s need to balance the multiple competing priorities of relative placement, sibling preservation, the 10 Best Interests Factors defined in MN State Statute 260C.212 subd. 2 (b), and permanency timelines also contributed to the delays in achieving permanency.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:03:40',NULL,'Desiree Miller'),(272,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Paul Lennander\",\"Date__293\":\"11\\/15\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Anoka\",\"Short_Answer__303\":\"Drake\",\"Short_Answer__304\":\"Oliva\",\"Date__305\":\"10\\/15\\/2014\",\"Date__306\":\"11\\/08\\/2016\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Mother\'s boyfriend\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Interpreter not used during visit with the family\",\"Free_Text__318\":\"During the debriefing, the caseworker stated that interpreters were used during all contacts with Law Enforcement and that the LE agency had been the one to coordinate that interpreter. Additionally, all court proceedings utilized an interpreter provided by the court. During visits that were not with LE or at court, the agency utilized an interpreter service that contracts with the County. The worker stated that obtaining an interpreter was quite easy and that an interpreter was generally always available if given 24 hour notice of when\\/where it would be needed. \\r\\n\\r\\nRegarding the Key Observation, the worker stated that not utilizing an interpreter during the one visit with extended family was due to two things. Primarily it was that the meeting time with family members was not scheduled as the family was traveling to Minnesota from Texas and they were unable to give the worker a time of arrival. For this reason, she was unable to schedule an interpreter due to the uncertainty of the meeting time. A bilingual family member was used during that meeting to interpret. She noted that the meeting took place to make sure that they were in agreement on a case plan, which they had already been made aware of and she just needed to ensure this. The bilingual family member had told the worker that the family wasn\'t understanding all of her translations so the worker answered their questions and left it at that.\",\"Free_Text__319\":\"An interpreter not being used during a meeting with a prospective kin placement option for the subject child\'s sibling was influenced by the worker not knowing when this family was arriving from another state. While interpreter services could be made available on an as-needed basis, typically the contracted interpreters preferred 24 hour notice. As a result, the worker believed that 24 hour notice was necessary when scheduling interpreter services. Due to there being an open criminal investigation, agency practice was that they would defer to the law enforcement (LE) investigation. All prior contact with the family was facilitated by LE, therefore LE provided all interpreter services through their investigation resulting in the worker not having to coordinate that activity. Additionally, the investigator was assisting the ongoing worker with facilitating the court process as there was an agency need to get cases transitioned to case management so the ongoing worker could assume the case management duties. This resulted in additional case responsibilities due to the worker needing to complete her investigation as well as also assist the ongoing worker with the court process. \\r\\nThe transition period between investigation and case management resulted in multiple workers and supervisors being involved in the case. This supported the worker\'s assumption that the family had already been informed of the purpose of the meeting as well as the information they were going to discuss. As a result, the investigator utilized a bilingual family member to translate during the meeting. \\r\\n\\r\\nWhen Out of Home Placement (OOHP) occurs, such as for the subject child\'s sibling in this case, there is a push by Local, State and Federal policies to place with kin whenever possible. Additionally, OHHP court cases are prioritized over not court cases by the local agency and require defined timelines for documentation as well as court scheduling. As a result and to ensure the agency was keeping the process moving, the worker was making the best of her circumstances to facilitate a meeting prior to the court hearing without an interpreter as the information needed to be conveyed to the prospective kin to secure the placement and ensure their understanding prior to court. Further impacting the worker moving forward was that the worker\'s understanding was that the family had already been told this information through an interpreter, facilitated by a co-worker, prior to the meeting before court.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"While interpreter services could be made available on an as-needed basis, typically the contracted interpreters preferred 24 hour notice. As a result, the worker believed that 24 hour notice was necessary when scheduling interpreter services.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"The transition period between investigation and case management resulted in multiple workers and supervisors being involved in the case. This supported the worker\'s assumption that the family had already been informed of the purpose of the meeting as well as the information they were going to discuss. As a result, the investigator utilized a bilingual family member to translate during the meeting.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Due to there being an open criminal investigation, agency practice was that they would defer to the law enforcement (LE) investigation. All prior contact with the family was facilitated by LE, therefore LE provided all interpreter services through their investigation resulting in the worker not having to coordinate that activity. - Refer to 626.556 Subd. 10 (5) to find this \\r\\n\\r\\nWhen Out of Home Placement (OOHP) occurs, such as for the subject child\'s sibling in this case, there is a push by Local, State and Federal policies to place with kin whenever possible. Additionally, OHHP court cases are prioritized over non-court cases by the local agency and require defined timelines for documentation as well as court scheduling. - Relative placement best practice vs. ensuring interpreters are available for the families\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"As a result and to ensure the agency was keeping the process moving, the worker was making the best of her circumstances to facilitate a meeting prior to the court hearing without an interpreter as the information needed to be conveyed to the prospective kin to secure the placement and ensure their understanding prior to court.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:04:20',NULL,'Drake Oliva'),(273,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"02\\/05\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Brown\",\"Short_Answer__303\":\"Dylan\",\"Short_Answer__304\":\"Rodriguez\",\"Date__305\":\"10\\/14\\/2017\",\"Date__306\":\"01\\/07\\/2018\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Alleged Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:05:57',NULL,'Dylan Rodriguez'),(274,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"07\\/24\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Insanti\",\"Short_Answer__303\":\"Eli\",\"Short_Answer__304\":\"Arispe-Hentges\",\"Date__305\":\"02\\/03\\/2017\",\"Date__306\":\"04\\/05\\/2017\",\"Multiple_Choice__308\":\"2 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Services to address concerns noted in the PSOP referral were not documented in the SSIS case file.\",\"Free_Text__318\":\"No human factors debriefing completed\",\"Free_Text__319\":\"The local agency\'s norm is to document at the bottom of the intake how the case met the eligibility requirements (i.e. identified risk factors) for PSOP services.  Specifically, the agency documented mental health concerns, chemical dependency needs, and concerns with the mother\'s parenting as eligibility requirements.  PSOP eligibility requirements do not dictate services provided due to risk factors not needing to be present at the time of the referral.  Impacting the agency not documenting services to address concerns noted in the PSOP referral were that the foster family did not indicate current chemical dependency concerns, the PSOP worker was unaware that the mother was actively using at the time of the referral, and the worker\'s mental model was such that public health was working with the mother to address parenting needs.  PSOP is also a client driven service and at the time of the referral, the mother only identified housing as the need, which further supported the worker focusing on the mother\'s self-identified need rather than the risk factors identified for eligibility.  The agency\'s normative practice of utilizing PSOP as an engagement strategy to voluntarily work with families further supported the worker prioritizing the mother\'s need for housing.  \\r\\n\\r\\nServices not being documented in the PSOP case file were influenced by the agencies need to prioritize working with involuntary cases over voluntary cases as a result of an overall increase in staff\'s caseload.  As a result of federal and state child protection mandates, involuntary cases take precedence over voluntary cases, which is normative practice for all counties in Minnesota.  The rise in caseload size has been impacted by the local agency receiving more child welfare reports resulting in an overall increase of screened in reports.  The surge in volume of calls, screened in reports, and increased case load size at the local agency has been effected by the recent revisions to the Minnesota Intake, Screening, and Response Path Guidelines.  These changes resulted from new legislation following the recommendations made by the Governor\'s Task Force on the Protection of Children.  Furthermore, staff turnover influenced the prioritization of involuntary cases over voluntary cases within the agency, such as PSOP cases which have fewer federal and state regulatory restrictions.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"PSOP is a client driven service and at the time of the referral, the mother only identified housing as the need, which further supported the worker focusing on the mother\'s self-identified need rather than the risk factors identified for eligibility.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"3\",\"Free_Text__351\":\"The local agency\'s norm is to document at the bottom of the intake how the case met the eligibility requirements (i.e. identified risk factors) for PSOP services.  Specifically, the agency documented mental health concerns, chemical dependency needs, and concerns with the mother\'s parenting as eligibility requirements.  PSOP eligibility requirements do not dictate services provided due to risk factors not needing to be present at the time of the referral.  Impacting the agency not documenting services to address concerns noted in the PSOP referral were that the foster family did not indicate current chemical dependency concerns, the PSOP worker was unaware that the mother was actively using at the time of the referral, and the worker\'s mental model was such that public health was working with the mother to address parenting needs.  PSOP is also a client driven service and at the time of the referral, the mother only identified housing as the need, which further supported the worker focusing on the mother\'s self-identified need rather than the risk factors identified for eligibility.  In addition, services not being documented in the PSOP case file were influenced by the agencies need to prioritize working with involuntary cases over voluntary cases as a result of an overall increase in staff\'s caseload.\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"PSOP cases have fewer federal and state regulatory restrictions.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"As a result of federal and state child protection mandates, involuntary cases take precedence over voluntary cases, which is normative practice for all counties in Minnesota.  The agency needed to prioritize working with involuntary cases over voluntary cases as a result of an overall increase in staff\'s caseload.  The rise in caseload size has been impacted by the local agency receiving more child welfare reports resulting in an overall increase of screened in reports.  The surge in volume of calls, screened in reports, and increased case load size at the local agency has been effected by the recent revisions to the Minnesota Intake, Screening, and Response Path Guidelines.  These changes resulted from new legislation following the recommendations made by the Governor\'s Task Force on the Protection of Children.  Furthermore, staff turnover influenced the prioritization of involuntary cases over voluntary cases within the agency, such as PSOP cases which have fewer federal and state regulatory restrictions.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:58:38',NULL,'Eli Arispe-Hentges'),(275,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Kelly Knutson\",\"Date__293\":\"01\\/04\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Elijah\",\"Short_Answer__304\":\"Johnson\",\"Date__305\":\"08\\/15\\/2017\",\"Date__306\":\"10\\/27\\/2017\",\"Multiple_Choice__308\":\"2 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Face to Face contact with alleged victim did not occur within the 5 day response time frame.\",\"Free_Text__318\":\"Working in Child Welfare in July 2016 presented different challenges for the local agency than today. Both the CP Supervisor and the CP Investigator spoke to practice being exceptionally overwhelming in 2016. It was a time driven by compliance with many newly passed legislative mandates and new DHS guidance. Specifically, the ICWA unit was being taxed more than ever before. The unit was seeing an extremely high amount of cases being screened in for assessment\\/investigation due to the Governor\'s Task Force and the 93 new recommendations and guidance from DHS.  \\r\\nThe ICWA unit was responsible for completing more CP Investigations and Assessments than any other unit at the agency. The unit received all ICWA cases, including cases with pending ICWA eligibility. In addition the local agency is considered to be one of the largest in the state; densely populated and a large geographic jurisdiction. The agency experienced change on a continual basis due to the Legislative Recommendations, the CP worker voiced the work environment to be in a \\u00e2\\u20ac\\u0153constant state of change\\u00e2\\u20ac\\u009d. \\r\\nIn 2016 media coverage was focused on child welfare, and the agency\'s County Attorney Office used a conservative approach, enforcing local agency policy. There was a heightened sense of needing to be cautious and aware of liability.  This defensive practice placed additional stress on CP workers in the agency for many reasons. The CP Worker stated he\\/she \\u00e2\\u20ac\\u0153felt they were staying involved with families for longer than they needed to\\u00e2\\u20ac\\u009d as a result of the defensive practice decisions made by the County Attorney Office.  \\r\\nIn 2016, the agency had one ICWA unit that was made up of 11 staff and two of those staff were assigned to a work crisis situations. Compared to 2016, the local agency now has two ICWA units, comprised of 8-9 staff within each unit for a total of 16-18 investigator\\/assessment workers. Caseload size was discussed to be approximately 20 open cases for the CP investigator in 2016 compared to the current (2018) caseload size of 8 open cases. It was expected that CP workers would receive 4-5 new cases a week in 2016, which i different from current assignments of 2-3 cases per week. \\r\\nWith less staff employed in 2016, and with the increase in the amount of screened in assessment\\/investigations coming in, the CP supervisor would \\u00e2\\u20ac\\u0153triage\\u00e2\\u20ac\\u009d the cases as they came in, as there were not enough staff to assign the volume of cases coming in for assignment.  There were no open positions to hire more staff into either. \\r\\nAnother impact on the workforce was more 24 hour response guidance issued by DHS. The direction given was for CP workers to prioritize 24 hour response cases. For example the predatory offender 24 hour response guidance. The CP worker spoke about unintended consequences that stem from all the mandates.  He\\/she indicated even if the child was safe and not in contact with the alleged offender, all other cases had to be put on hold so a case like this could have his\\/her primary attention. The worker expressed black and white guidance like this makes practice hard because child welfare is filled with a lot of gray circumstances. The CP worker was passionate about the purpose of her position and ensuring child safety.  She stated the purpose behind child welfare gets lost when mandates direct the work and take away flexibility of the worker being able to manage his\\/her caseload tasks.\\r\\nThe ICWA unit staff placed pressure on themselves too. They worried a lot about all the new guidance and how they would be able to keep up with the workload. It was a stressful time and staff worried they would not be able to meet every task timely, and the CP Supervisor worried that cases she could not get assigned had the potential for bad outcomes to happen. This impacted staff turnover.\\r\\nBoth the CP Supervisor and the CP worker debriefed spoke to times in 2016 as being \\u00e2\\u20ac\\u0153unmanageable\\u00e2\\u20ac\\u009d and \\u00e2\\u20ac\\u0153overwhelming\\u00e2\\u20ac\\u009d. Although we were not able to speak with the first CP worker who was originally assigned this case, after speaking to the CP supervisor and the CP worker, differences in CP practice were evident in 2016 compared to 2018. In 2016, there was an unsettled and defensive approach to child welfare practice, the agency was in a constant state of change along with overwhelming caseload sizes and increased tasks to be completed for each case. Turnover and stress was high. The first CP Worker assigned to make the face to face, was struggling to manage the high caseload and manage all the tasks associated with all the cases. He\\/she subsequently went out on a leave of absence and the 5 day response was not able to be met. The worker\'s caseload of approximately 20+ cases were distributed amongst the ICWA unit. Although not within the 5 day response, the second CP Assessment worker was assigned to this case met with the family and successfully assessed safety and addressed family needs.\",\"Free_Text__319\":\"Staffing resources impacted the initial face to face not being met within the 5 day timeframe  In July of 2016, the culture of Minnesota\'s child welfare system was defensive in nature, as evidenced by an influx in number of suspected child maltreatment reports being made into the system, which were also being screened in at a higher rate. The defensive practice occurred simultaneous in regard to media scrutiny regarding child welfare practices and following the Governor\'s Task Force on the Protection of Children releasing 93 recommendations for change to the system\'s practices. With the local agency having one of the largest populations of child welfare clients served in the state, the increased volume of reports flooding the agency\'s intake and screening unit was also complicated by continual changes being made to the Intake, Screening and Reponses Path Guidelines, by the Child Safety and Permanency Division\'s Safety and Prevention Unit. CSP\'s Safety and Prevention Unit was under pressure to develop implementation guidance based on the 93 Governor\'s Task Force recommendations. Guidance was also issued for the predatory offender statute put into law in 2012, which required agencies to prioritize making contact with alleged victims within 24 hours, even at times when the alleged victim was not alleged to be in contact with the alleged predatory offender and presumed safe, adding to the amount of reports and cases being assigned to staff of FA\\/FI units backlogs, trumping all other case assignments, as there was no discretion for the supervisor or staff regarding predatory offender reports. For staff, the frequent updates and changes to guidance added complexity, constraining staff to make goal conflict and trade off decisions as managed workload tasks like, prioritizing allegations screened in, making initial safety and risk decisions based on vulnerability of alleged victim children, and compliance metrics, as well as more work tasks and documentation requirements that needed to be completed for each case. This lead to more stress as staff were already managing high caseload sizes with limited staffing resources. During this time, the local agency saw high turnover as frontline staff prioritized their health and wellbeing over attempting to manage high caseload sizes. Further intensifying the staff available for case assignment was staff utilizing LOA to prioritize their health and wellbeing creating an unpredictability if staff out on leave of absence would return to work or not. When staff out on leave did not to return to their position, time was required to hire and onboard a new staff to fill their position, which placed even higher demand and stress on the staff taking on new case assignments, who were already managing high caseloads.\\r\\nThe local agency placed higher importance on meeting 24 hour face to face timelines over 5 day face to face timelines, which was a procedural adaptation made in effort to triage the volume of cases sitting in a backlog of 200-400 reports that were in pending screening and assignment to FA\\/FI units. Once assigned to FA\\/FI units, supervisors of each unit prioritized and made the decision for frontline staff to go beyond the 5 day face to face timeline based on the allegation(s) and safety\\/risk known at the time, such as in this case. There was higher demand and pressure on the local agency to meet compliance measures to avoid legislative withholds of money\\/funding that an agency would not receive when out of compliance.\\r\\n\\r\\nAt this time, the local agency also regionalized the geographic areas within their jurisdiction, and changed normative practice away from using zip codes. The local agency decision was to utilize one special unit to take on all potential qualifying ICWA FA\\/FI\'s, as an effort to comply with new ICWA and BIA regulations and provide consistent practices, especially for cases with known have previous history with Transfer of Legal Custody (TLC), as the County Attorney had a policy for CP staff to adhere to, further impacting the demand and pressure on the frontline staff working in this ICWA specialty unit.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"Staffing resources impacted the face to face not being met in this case. In July of 2016, the culture of the child welfare system was defensive in nature, as evidenced by an influx in number of reports being made into the CW system, which were being screened in at a higher rate. The defensive practice occurred simultaneous in regard to media scrutiny regarding child welfare practices and following the Governor\'s Task Force on the Protection of Children releasing 93 recommendations for change to the system\'s practices. With the local agency having one of the largest populations of child welfare clients served in the state, the increased volume of reports flooding the agency\'s intake and screening unit was also complicated by continual changes being made to the Intake, Screening and Reponses Path Guidelines, by the Child Safety and Permanency Division\'s Safety and Prevention Unit. CSP\'s Safety and Prevention Unit was under pressure to develop implementation guidance based on the 93 Governor\'s Task Force recommendations. Guidance was also issued for the predatory offender statute put into law in 2012, which required agencies to prioritize making contact with alleged victims within 24 hours, even at times when the alleged victim was not alleged to be in contact with the alleged predatory offender and presumed safe, adding to the amount of reports and cases being assigned to staff of FA\\/FI units backlogs, trumping all other case assignments, as there was no discretion for the supervisor or staff regarding predatory offender reports. For staff, the frequent updates and changes to guidance during this time added complexity, constraining staff to make goal conflict and trade off decisions as they needed to balance prioritizing allegation, alleged safety and risk, and compliance metrics, as well as more work tasks and documentation to be completed for each case. This lead to more stress as staff were already managing high caseload sizes with limited staffing resources. A demand \\u00e2\\u20ac\\u201c resource mismatch existed reinforcing a production pressure cycle of high caseload size, high stress for staff to manage, and staff turnover. During this time, the local agency saw high turnover as frontline staff prioritized their health and wellbeing over attempting to manage high caseload sizes. Further intensifying the staff available for case assignment was staff utilizing LOA to prioritize their health and wellbeing creating an unpredictability if staff out on leave of absence would return to work or not. When staff out on leave did not to return to their position, time was required to hire and onboard a new staff to fill their position, which placed even higher demand and stress on the staff taking on new case assignments, who were already managing high caseloads.  \\r\\nThere was higher demand and pressure on the local agency to meet compliance measures to avoid legislative withholds of money\\/funding that an agency would not receive when out of compliance. The local agency placed higher importance on meeting 24 hour face to face timelines over 5 day face to face timelines, which was a procedural adaptation made in effort to triage the volume of cases sitting in a backlog of 200-400 reports that were in pending screening and assignment to FA\\/FI units. Once assigned to FA\\/FI units, supervisors of each unit prioritized and made the decision for frontline staff to go beyond the 5 day face to face timeline based on the allegation(s) and safety\\/risk known at the time, such as in this case.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"1.) Maltreatment determined accidental sleep related child death; co-sleeping with parents.\\r\\nThere is absent, conflicting, or vague guidance regarding maltreatment determinations on fatalities related to unsafe sleep practices. \\r\\n2.) With the local agency having one of the largest populations of child welfare clients served in the state, the increased volume of reports flooding the agency\'s intake and screening unit was also complicated by continual changes being made to the Intake, Screening and Reponses Path Guidelines, by the Child Safety and Permanency Division\'s Safety and Prevention Unit. CSP\'s Safety and Prevention Unit was under pressure to develop implementation guidance based on the 93 Governor\'s Task Force recommendations. Guidance was also issued for the predatory offender statute put into law in 2012, which required agencies to prioritize making contact with alleged victims within 24 hours, even at times when the alleged victim was not alleged to be in contact with the alleged predatory offender and presumed safe.\\r\\n3.) At this time, the local agency also regionalized the geographic areas within their jurisdiction, and changed normative practice away from using zip codes. The local agency decision was to utilize one special unit to take on all potential qualifying ICWA FA\\/FI\'s, as an effort to comply with new ICWA and BIA regulations and provide consistent practices, especially for cases with known have previous history with Transfer of Legal Custody (TLC), as the County Attorney had a policy for CP staff to adhere to, further impacting the demand and pressure on the frontline staff working in this ICWA specialty unit.\",\"Multiple_Choice__360\":\"3\",\"Free_Text__361\":\"In July of 2016, the culture of the child welfare system was defensive in nature, as evidenced by an influx in number of reports being made into the CW system, which were being screened in at a higher rate. The defensive practice occurred simultaneous in regard to media scrutiny regarding child welfare practices and following the Governor\'s Task Force on the Protection of Children releasing 93 recommendations for change to the system\'s practices. With the local agency having one of the largest populations of child welfare clients served in the state, the increased volume of reports flooding the agency\'s intake and screening unit was also complicated by continual changes being made to the Intake, Screening and Reponses Path Guidelines, by the Child Safety and Permanency Division\'s Safety and Prevention Unit. CSP\'s Safety and Prevention Unit was under pressure to develop implementation guidance based on the 93 Governor\'s Task Force recommendations. Guidance was also issued for the predatory offender statute put into law in 2012, which required agencies to prioritize making contact with alleged victims within 24 hours, even at times when the alleged victim was not alleged to be in contact with the alleged predatory offender and presumed safe, adding to the amount of reports and cases being assigned to staff of FA\\/FI units backlogs, trumping all other case assignments, as there was no discretion for the supervisor or staff regarding predatory offender reports. For staff, the frequent updates and changes to guidance during this time added complexity, constraining staff to make goal conflict and trade off decisions as they needed to balance prioritizing allegation, alleged safety and risk, and compliance metrics, as well as more work tasks and documentation to be completed for each case. This lead to more stress as staff were already managing high caseload sizes with limited staffing resources. A demand \\u00e2\\u20ac\\u201c resource mismatch existed reinforcing a production pressure cycle of high caseload size, high stress for staff to manage, and staff turnover. During this time, the local agency saw high turnover as frontline staff prioritized their health and wellbeing over attempting to manage high caseload sizes. Further intensifying the staff available for case assignment was staff utilizing LOA to prioritize their health and wellbeing creating an unpredictability if staff out on leave of absence would return to work or not. When staff out on leave did not to return to their position, time was required to hire and onboard a new staff to fill their position, which placed even higher demand and stress on the staff taking on new case assignments, who were already managing high caseloads.  \\r\\nThere was higher demand and pressure on the local agency to meet compliance measures to avoid legislative withholds of money\\/funding that an agency would not receive when out of compliance. The local agency placed higher importance on meeting 24 hour face to face timelines over 5 day face to face timelines, which was a procedural adaptation made in effort to triage the volume of cases sitting in a backlog of 200-400 reports that were in pending screening and assignment to FA\\/FI units. At this time, the local agency also regionalized the geographic areas within their jurisdiction, and changed normative practice away from using zip codes. The local agency decision was to utilize one special unit to take on all potential qualifying ICWA FA\\/FI\'s, as an effort to comply with new ICWA and BIA regulations and provide consistent practices, especially for cases with known have previous history with Transfer of Legal Custody (TLC), as the County Attorney had a policy for CP staff to adhere to, further impacting the demand and pressure on the frontline staff working in this ICWA specialty unit.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"3\",\"Free_Text__365\":\"Once assigned to FA\\/FI units, supervisors of each unit prioritized and made the decision for frontline staff to go beyond the 5 day face to face timeline based on the allegation(s) and safety\\/risk known at the time, such as in this case.\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"Once assigned to FA\\/FI units, supervisors of each unit prioritized and made the decision for frontline staff to go beyond the 5 day face to face timeline based on the allegation(s) and safety\\/risk known at the time, such as in this case.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:07:14',NULL,'Elijah Johnson'),(276,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Brenda Mahoney\",\"Date__293\":\"10\\/01\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Insanti\",\"Short_Answer__303\":\"Elijah\",\"Short_Answer__304\":\"Kohl\",\"Date__305\":\"01\\/18\\/2018\",\"Date__307\":\"08\\/12\\/2019\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Unknown\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"The licensing agency was not notified by the placing agency when the sibling child was placed.\",\"Free_Text__318\":\"The licensing agency was aware of the placing agency\'s intention to place the sibling child with the relatives and at the time the sibling child was born, placement in relative foster care with the subject child had already been determined to be in the sibling child\'s best interest by the placing agency. Supporting the placement of the sibling child with the relatives was the fact that the subject child was placed with them and the relatives were willing to take the sibling child. Additionally, there was general pressure to place siblings together. The Sibling Bill of Rights had been introduced within the placing agency around the same time as the sibling child\'s birth, further influencing the pressure to place with siblings whenever possible.\\r\\n\\r\\nThe placing agency put an emphasis on the relative search process as it is important to those working within the county, as well as, the judges who oversee these cases in court. The placing agency has a JTST (preplacement) process they bring case information to in order to make decisions on a case. Specifically, this team met frequently through this case to discuss relative placement options for the children. The worker felt the support of this team and stated every decision was made as a team. Additionally, the placing agency had a worker dedicated to relative search efforts, which took the responsibility of locating relatives off of the worker on the case. \\r\\n\\r\\nOnce the placing agency learned that the mother was pregnant, the worker on the case had a conversation with the licensing agency about the new baby coming and the intention to place the new baby (sibling child) with the relatives at the time of his birth. The focus of the worker\'s attention was put on supporting the relatives in caring for 1 biological child and these 2 siblings, 3 years old and younger. The worker indicated that the placing agency went above and beyond to support the relative in preparing them to care for the 3 children. Additionally, the worker shared that they didn\'t have a lot of situations where children needed to be placed outside of their county.\\r\\n\\r\\nAdditional information shared by the worker was that the relatives were doing everything they needed to do in order to become licensed and the feedback that was received from the licensing agency and other collateral contacts was that the relatives were completing tasks and paperwork and cooperating with services. The relatives had an extensive support system and were invested in doing what needed to be done to care for the children.\",\"Free_Text__319\":\"The licensing agency not being notified by the placing agency when the sibling child was placed was influenced by staff\'s perception that notification had been given, as the worker previously informed the licensing agency of the intention to place the sibling child with the relatives. Given the circumstances of the case, multiple workers had been assigned to the case (licensing worker, Family Investigation (FI) and Family Assessment (FA) worker, and an adoption worker) which contributed to role ambiguity regarding placement decisions on the case. There was also an assumption made by the FI worker that notice was given by the current worker. Additionally, the agency was put in a position to assign multiple workers to manage the case due to state and federal requirements relating to placement, permanency, and adoption. These requirements place agencies in a position to need specialized workers to fulfill the multiple requirements of these statutes. Furthermore, the number of federal and state documentation requirements within SSIS related to permanency\\/adoption cases such as this, place staff in a position to balance multiple competing tasks and documentation requirements further impacting the licensing agency not being notified by the placing agency when the sibling child was placed. \\r\\n\\r\\nGiven the staff\'s limited time at the agency, staff did not have prior experience and knowledge of placement requirements when cross jurisdictional placements occur, further influencing the licensing agency not being notified when the sibling child was placed. The limitations and knowledge regarding this were impacted by the agency\'s ability to teach staff everything they need to know about placement requirements. The perceived lack of clarity on guidance and direction regarding emergency and non-emergency placements has an effect on the agency\'s ability to teach these requirements; therefore impacting staff\'s knowledge on such requirements. The number of requirements in child welfare can also make it difficult to teach staff everything they need to know. Further influencing the licensing agency not being notified was staff\'s focus of attention on supporting the relative\'s ability to care for 3 children, ages 3 years and younger. The need to provide a high level of support was influenced by state statute requirements to place siblings together (260C.212 subd. 2d) and relative placement (260C.221) to make sure the relatives were able to maintain the placement.\\r\\n\\r\\nFurther influencing the licensing agency not being notified by the placing agency when the sibling child was placed was the relationship between the licensing worker and the foster care parents (relatives), as the foster care parents would likely have informed the licensing worker that the sibling child had been placed, which influenced the perception that notification was given.\",\"Short_Answer__320\":\"The siblings were separated.\",\"Free_Text__321\":\"No debrief occurred on this learning point as it came out at the mapping.\",\"Free_Text__322\":\"The siblings being separated was supported by the recommendation from the sibling separation evaluation which suggested that the siblings remain in their respective homes. The agency\'s practice to seek outside consultation when siblings are separated coupled with concerns about disrupting the sibling\'s attachments, further supported the agency\'s decision for outside consultation. Influencing the agency\'s practice to seek outside consultation was the requirement to look at the best interests of both children and to make an individual determination regarding each child. \\r\\n\\r\\nAdditionally, the subject child had significant medical needs and the sibling child\'s foster care provider stated they could not care for the subject child. Because of the ambivalence the agency perceived that if they placed the subject child with the sibling child\'s foster parents, it placed both placements at risk of disruption; therefore, the agency made the decision to not place the subject child with the sibling child\'s foster parents.\",\"Multiple_Choice__346\":\"3\",\"Free_Text__347\":\"Learning point #1:\\r\\nThe licensing agency not being notified by the placing agency when the sibling child was placed was influenced by staff\'s perception that notification had been given, as the worker previously informed the licensing agency of the intention to place the sibling child with the relatives.\\r\\n\\r\\nThere was also an assumption made by the FI worker that notice was given by the current worker.\\r\\n\\r\\nFurther influencing the licensing agency not being notified by the placing agency when the sibling child was placed was the relationship between the licensing worker and the foster care parents (relatives), as the foster care parents would likely have informed the licensing worker that the sibling child had been placed, which influenced the perception that notification was given.\\r\\n\\r\\nLearning point #2:\\r\\nThe subject child had significant medical needs and the sibling child\'s foster care provider stated they could not care for the subject child. Because of the ambivalence, the agency perceived that if they placed the subject child with the sibling child\'s foster parents, it placed both placements at risk of disruption; therefore, the agency made the decision to not place the subject child with the sibling child\'s foster parents.\",\"Multiple_Choice__348\":\"2\",\"Free_Text__349\":\"Learning point #1:\\r\\nThe limitations and knowledge regarding this were impacted by the agency\'s ability to teach staff everything they need to know about placement requirements. The perceived lack of clarity on guidance and direction regarding emergency and non-emergency placements has an effect on the agency\'s ability to teach these requirements; therefore impacting staff\'s knowledge on such requirements. The number of requirements in child welfare can also make it difficult to teach staff everything they need to know.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"2\",\"Free_Text__357\":\"Learning point #!:\\r\\nGiven the staff\'s limited time at the agency, staff did not have prior experience and knowledge of placement requirements when cross jurisdictional placements occur, further influencing the licensing agency not being notified when the sibling child was placed. The limitations and knowledge regarding this were impacted by the agency\'s ability to teach staff everything they need to know about placement requirements.\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Learning point #1:\\r\\nthe agency was put in a position to assign multiple workers to manage the case due to state and federal requirements relating to placement, permanency, and adoption. These requirements place agencies in a position to need specialized workers to fulfill the multiple requirements of these statutes. Furthermore, the number of federal and state documentation requirements within SSIS related to permanency\\/adoption cases such as this, place staff in a position to balance multiple competing tasks and documentation requirements further impacting the licensing agency not being notified by the placing agency when the sibling child was placed. \\r\\n\\r\\nFurther influencing the licensing agency not being notified by the placing agency when the sibling child was placed was the relationship between the licensing worker and the foster care parents (relatives), as the foster care parents would likely have informed the licensing worker that the sibling child had been placed, which influenced the perception that notification was given.\\r\\n\\r\\nLearning point #2:\\r\\nThe agency\'s practice to seek outside consultation when siblings are separated coupled with concerns about disrupting the sibling\'s attachments, further supported the agency\'s decision for outside consultation. Influencing the agency\'s practice to seek outside consultation was the requirement to look at the best interests of both children and to make an individual determination regarding each child.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:07:48',NULL,'Elijah Kohl'),(277,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Kari Rude\",\"Date__293\":\"08\\/27\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Ella\",\"Short_Answer__304\":\"Thao\",\"Date__305\":\"02\\/02\\/2018\",\"Date__306\":\"05\\/26\\/2018\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"Safety of surviving sibling infant child viewed as accident by law enforcement, however child protection requested 72 hour hold be done by LE to remove and place sibling child in out of home relative placement per their local agency protocol to remove and place first before assessing\\/ investigating.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Supporting the decision to make a maltreatment determination regarding failure to protect for unsafe sleep was supported by local agency practice that requires Substantiated maltreatment determinations when they had previously educated the family about unsafe sleep through working with the family in a opened case.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:15:07',NULL,'Ella Thao'),(278,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tom Sandberg\",\"Date__293\":\"03\\/14\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Elspeth\",\"Short_Answer__304\":\"Aldinger\",\"Date__305\":\"11\\/19\\/0217\",\"Date__307\":\"03\\/02\\/2018\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"No cross-report to LE made for 2\\/1 and 2\\/2\\/2017 screened-out CP reports\",\"Free_Text__318\":\"A debrief did not take place as the learning point was outside of the CW system.\",\"Free_Text__319\":\"Cross reporting to LE not occurring was influenced by LE coordination, workload and technology. It was learned that due to the size of the local agency and having multiple LE jurisdictions within it, there is often times uncertainty on jurisdictions and coverage for geographical areas. This makes it inherently difficult to identify where a report is supposed to be sent. This, coupled with the Governor\'s Task Force creating heightened expectations that screen-outs be cross-reported, led to staffing levels and capacity being an issue for LE to follow up on those cross-reports. Due to this reduction in capacity, some police departments were not assigning screened-out cross reports for follow up. Furthermore, LE indicated that they did not want them in the first place as their perception about screened out reports is that if CP doesn\'t take action, that LE won\'t either. This resulted in a lower priority being placed on these reports in general. \\r\\n\\r\\nStaffing levels at the local agency also impacted cross-reporting practices. Due to turnover and staffing levels, intake workers are often times working multiple intakes at a time. Each intake takes over 300 clicks to complete within SSIS and is very time consuming for intake staff. Prioritization for some intakes (more egregious) create the situation where staff are working different reports at the same time, thus increasing the risk of not being able to fulfill the cross-report mandate. Additionally, the agency prides itself on less than a 5 minute wait time for reporters as they want the community and mandated reports to continue making reports and not be discouraged when not being able to connect with an intake worker in a timely manner.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"Staffing levels at the local agency also impacted cross-reporting practices. Due to turnover and staffing levels, intake workers are often times working multiple intakes at a time.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"It was learned that due to the size of the local agency and having multiple LE jurisdictions within it, there is often times uncertainty on jurisdictions and coverage for geographical areas. This makes it inherently difficult to identify where a report is supposed to be sent.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Each intake takes over 300 clicks to complete within SSIS and is very time consuming for intake staff.\",\"Multiple_Choice__360\":\"3\",\"Free_Text__361\":\"This, coupled with the Governor\'s Task Force creating heightened expectations that screen-outs be cross-reported, led to staffing levels and capacity being an issue for LE to follow up on those cross-reports. Due to this reduction in capacity, some police departments were not assigning screened-out cross reports for follow up (Pressure for additional reports was from our system)\\r\\n\\r\\nPrioritization for some intakes (more egregious) create the situation where staff are working different reports at the same time, thus increasing the risk of not being able to fulfill the cross-report mandate. Additionally, the agency prides itself on less than a 5 minute wait time for reporters as they want the community and mandated reports to continue making reports and not be discouraged when not being able to connect with an intake worker in a timely manner.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:15:52',NULL,'Elspeth Aldinger'),(279,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"05\\/01\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Emersyn\",\"Short_Answer__304\":\"Morris\",\"Date__305\":\"03\\/23\\/2016\",\"Date__306\":\"08\\/13\\/2016\",\"Multiple_Choice__308\":\"4 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"1.) After receiving and screening in an initial CP intake\\/child maltreatment report regarding the critical incident, subsequent intakes regarding the critical incident (duplicates) were received by the local agency. These duplicate CP intakes\\/child maltreatment reports were screened out and referred to the staff working the CP investigation. Screening duplicate intakes out instead of screening them in was not in compliance with intake, screening and response path guidance at the time, however, was a modified practice the local agency had become accustomed to, as SSIS allowed this option in the dropdown for local agencies to choose disposition when screening.  The local agency choose SSIS option to Screen out with reason being: Duplicate report; physical abuse allegations are already being assessed.   \\r\\n\\r\\n2.)  The auto generated *CPS Summary Disposition Notice* letter sent to mandated reporters following the local agency\'s decision to screen out, which is found in SSIS under CP Intake chronology, documents -  read: \\r\\nAddressed to the mandated reporter,  \\r\\n\\u00e2\\u20ac\\u0153Thank you for providing your concerns of suspected maltreatment of ____Name included is of the mother - not the subject child____. We did not conduct an investigation because the information provided did not meet the definition of physical abuse, sexual abuse, or neglect under Child Protection Statutes. If you become aware of additional information regarding this situation please contact the agency again. \\r\\nThank you for your interest and concern for children. Please continue to report any situations of suspected child maltreatment to Hennepin County Human Services and Public Health Department at 612-348-3000.\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"State policy is that duplicate reports be screened in and referred to the already open assessment\\/investigation workgroup. Hennepin County\'s practice in this case was to screen out the duplicate reports. \\r\\nRelevant to multiple Child maltreatment reports that were screened out in this case, under the Dispositions\\/Screening decision reads: Screened out - duplicate report; physical abuse allegations are already being assessed.\\r\\nAfter receiving and screening in an initial CP intake\\/child maltreatment report regarding the critical incident, subsequent intakes regarding the critical incident (duplicates) were received by the local agency. These duplicate CP intakes\\/child maltreatment reports were screened out and referred to the staff working the CP investigation.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"Screening duplicate intakes out instead of screening them in was not in compliance with intake, screening and response path guidance at the time, however, was a modified practice the local agency had become accustomed to.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:16:40',NULL,'Emersyn Morris'),(280,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tracy Nielsen\",\"Date__293\":\"06\\/26\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Sherburne\",\"Short_Answer__303\":\"Evan\",\"Short_Answer__304\":\"Pishney\",\"Date__305\":\"06\\/03\\/2011\",\"Date__307\":\"04\\/15\\/2019\",\"Multiple_Choice__308\":\"7 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Step-Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:17:15',NULL,'Evan Pishney'),(281,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage review\",\"Date__293\":\"02\\/27\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Wright\",\"Short_Answer__303\":\"Freya\",\"Short_Answer__304\":\"Furzland\",\"Date__305\":\"08\\/17\\/2018\",\"Date__307\":\"01\\/11\\/2019\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:18:53',NULL,'Freya Furzland'),(282,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"11\\/16\\/2016\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Houston\",\"Short_Answer__303\":\"Fuschia\",\"Short_Answer__304\":\"Thomas\",\"Date__305\":\"04\\/04\\/2016\",\"Date__307\":\"11\\/16\\/2016\",\"Multiple_Choice__308\":\"7 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Remaining child not added to TPR petition\",\"Free_Text__318\":\"N\\/A - no debrief conducted\",\"Free_Text__319\":\"The remaining child not being added to the TPR petition was influenced by the agency considering best interests of the child, the child\'s healthy condition and also local and state guidance. When the subject child was seen for her critical incident, the hospital identified that this child needed immediate care or the child would die. As a result of this, the subsequent Child Protection (CP) report, and allegations, only pertained to the subject child. The resulting investigation then focused on the critically ill child. At the initial home visit done o asses and assure safety of the reaming child, it was staff\'s perception that this child was healthy Further  supporting the worker\'s assessment of safety for the sibling child was that Law Enforcement (LE) did not place that child on a hold, creating a presumption of safety for that child. \\r\\n\\r\\nDHS guidance, driven by state statues, provides direction for local agencies on practice standards related to reasonable efforts being made for reunification (Statute 260.012), application of best interest factors and also the goal of family preservation, when possible. This statute and guidance offers itself to varying interpretations and application of best interests for a child and was a consideration when satisfying reasonable efforts while engaging the family in the child protection process. Additionally, the local agency was balancing engaging the family and supporting their cultural needs by not adding the sibling child to the TPR petition given there were not any safety concerns for this child. \\r\\n\\r\\nFinally, Minnesota state statute 260C.503 provides guidance surrounding permanency hearings. This statute lends itself to interpretation as the statute indicates that the agency must only ask the county attorney to immediately file a TPR on a sibling child when the subject child was subject to egregious harm. This language results in varying application by county\\/county attorney for sibling children as some agencies file TPR\'s on all sibling children every time, while others do not.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"The remaining child not being added to the TPR petition was influenced by the agency considering best interests of the child, the child\'s healthy condition and also local and state guidance. When the subject child was seen for her critical incident, the hospital identified that this child needed immediate care or the child would die. As a result of this, the subsequent Child Protection (CP) report, and allegations, only pertained to the subject child. The resulting investigation then focused on the critically ill child. At the initial home visit done to assess and assure safety of the reaming child, it was staff\'s perception that this child was healthy. Further  supporting the worker\'s assessment of safety for the sibling child was that Law Enforcement (LE) did not place that child on a hold, creating a presumption of safety for that child.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"DHS guidance, driven by state statutes, provides direction for local agencies on practice standards related to reasonable efforts being made for reunification (Statute 260.012), application of best interest factors and also the goal of family preservation, when possible. This statute and guidance offers itself to varying interpretations and application of best interests for a child and was a consideration when satisfying reasonable efforts while engaging the family in the child protection process.\\r\\n\\r\\nMinnesota state statute 260C.503 provides guidance surrounding permanency hearings. This statute lends itself to interpretation as the statute indicates that the agency must only ask the county attorney to immediately file a TPR on a sibling child when the subject child was subject to egregious harm. This language results in varying application by county\\/county attorney for sibling children as some agencies file TPR\'s on all sibling children every time, while others do not.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:19:27',NULL,'Fuschia Thomas'),(283,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Date__293\":\"08\\/09\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Licensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Licensed\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Gabriel\",\"Short_Answer__304\":\"Cooper\",\"Date__305\":\"07\\/14\\/2016\",\"Date__306\":\"07\\/13\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Daycare provider\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"After receiving and screening in an intake after a critical incident, subsequent intakes regarding the critical incident (duplicates)  were screened out.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,71,'2021-05-26 19:33:23','2021-06-01 18:59:05',NULL,'Gabriel Cooper'),(284,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Paul Lennander\",\"Date__293\":\"12\\/05\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Genevieve\",\"Short_Answer__304\":\"Roach-Blose\",\"Date__305\":\"06\\/05\\/2016\",\"Date__306\":\"06\\/17\\/2016\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"There is absent, conflicting, or vague guidance regarding maltreatment determinations on fatalities related to unsafe sleep practices. Hennepin County will consider making a maltreatment determination for unsafe sleep when substances are known at time of the incident.  Autopsy states cause of death is positional asphyxia and manner as accident, with other significant conditions noted to be cosleeping on a couch with an intoxicated adult.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:20:47',NULL,'Genevieve Roach-Blose'),(285,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Tiffany Kacir\",\"Date__293\":\"09\\/05\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Licensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Licensed\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Washington\",\"Short_Answer__303\":\"Gus\",\"Short_Answer__304\":\"Hoisser\",\"Date__305\":\"11\\/27\\/2018\",\"Date__306\":\"04\\/30\\/2019\",\"Multiple_Choice__308\":\"5 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,71,'2021-05-26 19:33:23','2021-06-01 18:59:43',NULL,'Gus Hoisser'),(286,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Kari Rude\",\"Date__293\":\"08\\/30\\/2017\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"3\",\"Multiple_Choice__301\":\"Douglas\",\"Short_Answer__303\":\"Hayden\",\"Short_Answer__304\":\"Stricker\",\"Date__305\":\"03\\/12\\/2015\",\"Date__307\":\"06\\/27\\/2017\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Father\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"The sibling children were observed\\/interviewed two weeks before investigation closed.\",\"Free_Text__318\":\"Several factors influenced the sibling children being observed\\/interviewed two weeks before the CP investigation closed. Law enforcement had responded initially to the near fatal drowning scene and did not place the subject child or sibling children on a 72 hour hold. They were viewing this incident as a tragic accident and did not pursue criminal charges or open a criminal investigation. It was the perspective of the worker that law enforcement did not want to add \\u00e2\\u20ac\\u0153insult to injury\\u00e2\\u20ac\\u009d as no one knew if the subject child would survive influencing the decision to observed\\/interview the sibling children two weeks before CP investigation closed was that law enforcement had also not determined the maternal grandparents to be unsafe caregivers, therefore the sibling children were presumed safe with them.  There was no imminent reasons to \\u00e2\\u20ac\\u0153force\\u00e2\\u20ac\\u009d the family to have the sibling children interviewed\\/observed sooner.  By engaging the family at their pace and tone, CP was eventually at least able to get some information from the sibling.  Typically law enforcement is driving the CP investigations, but they were not in this case.  Since law enforcement had not placed a 72 hour hold on the children, allowed them to go with maternal grandparents, and that there was not a criminal investigation opened, understanding child protection\'s role was different for this case than normal and \\u00e2\\u20ac\\u0153harder to wrap his\\/her head around\\u00e2\\u20ac\\u009d. Not having law enforcement involvement in this case posed challenges in this CP investigation. Law enforcement told the parent\'s that they were not pursuing criminal charges on the scene, so when CP arrived at the hospital to interview and see the subject child, there was greater backlash from the parents. It was hard to explain to the family the role differences between CP and Law Enforcement and that although the standards for criminal charges had not been met, the standard for a child protection investigation for the suspected maltreatment had been met. \\r\\nSince there was not court involvement the investigators role became one of engaging the family in the \\u00e2\\u20ac\\u0153least invasive way possible\\u00e2\\u20ac\\u009d in order to gather the best information possible.  Engaging the family this way mitigated the risk of the family being non-cooperative and the local agency not having the authority to stay involved without a court order. \\r\\nThe parents were often traveling to hospitals outside of their county to be with the subject child, so they were not readily available or trusting of what was happening when they were not around.  The agency was also mindful that the parents were facing \\u00e2\\u20ac\\u0153end of life\\u00e2\\u20ac\\u009d decisions, and not knowing from day to day if the subject child was going to survive.  It was an intense reality for them and the local agency gave them time to work through that.\\r\\nRegarding the sibling children, the family was initially not compliant with allowing the local agency access to them for observation and interview. Child Protection used engagement strategies, and provided the family options for how the verbal sibling child could be interviewed, and infant be observed. The maternal grandparents and parents to the children did finally allow the interview and observation to take place, on the terms that the maternal grandfather would be allowed to sit in with the sibling child during the interview.\\r\\nThe CP investigator consulted with the supervisor at multiple points in the investigation. The supervisor was available when needed for consultation and the investigator felt safe in openly discussing the strengths and needs of the case with the supervisor. He\\/she trusted the advice and direction given by the supervisor. Maltreatment was determined for Neglect \\u00e2\\u20ac\\u201c Inadequate supervision to the subject child by the mother and father.  Maltreatment was also determined for an added allegation of Neglect - Failure to protect from serious endangerment to the subject child by his mother and father. Mother, father, and sibling child, expressed the mother and father were not present with the subject child when he experienced the near fatal drowning. The local agency decided to proceed in transitioning to case management from investigation by preparing a CHIPS petition, noting the determination of maltreatment, circumstances of the near fatal incident, and other risk factors, including the vulnerability of the subject child due to high medical needs.\",\"Free_Text__319\":\"The critical incident occurred during non-child protection office hours during the summer when school was not in session. The date and time of the critical incident influenced staff\'s ability to access the sibling children to observe\\/interview them without parental consent. First responders and law enforcement perceived the critical incident as accidental, and while on scene, communicated to the family that they were not pursuing criminal charges. Law enforcement did not perceive a need to cross report the accidental critical incident to child protection, nor did other mandated reporters who had contact with the family at the time of the incident. Law enforcement did not have safety concerns for the sibling children and they did not pursue an emergency 72 hour hold at the time of the critical incident. Law enforcement considered the grandparents to be safe caregivers and the sibling children were presumed safe in their care.\\r\\nDiffering perspectives exist between law enforcement and child protection about each of their roles at times when critical incidents occur. The two work disciplines follow different definitions of child safety and alleged neglect, based on MN state laws that govern and guide their individual work, influencing the frontline\'s mental models, depending on which code of law is being referenced, criminal or juvenile law. Additionally, the burden of proof standards are different for criminal law and child protection law. Law enforcement\'s standard of probable cause and beyond a reasonable doubt is a higher burden to meet than child protection\'s standard of preponderance of evidence and clear and convincing.\\r\\nThe parents, coping with trauma induced by hearing the hospital\'s knowledge of the subject child\'s near death condition, faced potential end of life decisions and travelled to be with the subject child who was transported to a hospital outside of the county\'s jurisdiction. The parents were not trusting of child protection\'s involvement when child protection made contact with the family, as their involvement was perceived as conflicting to what law enforcement had communicated to them about not opening a criminal investigation. When child protection staff attempted to engage with the family, they were met with resistance. The grandparents refused child protection access to the sibling children. Helping the family understand the role differences between child protection and law enforcement was difficult for the staff. The family\'s confusion and resistance impacted staff\'s ability to observe\\/interview the sibling children in a timely manner.\\r\\nUsing a least invasive approach with the family was used by staff to best reduce the risk of the family continuing to resist child protection involvement, and this approach also mitigated the barrier of not having a formal process (criminal charges and court involvement) available to support child protection involvement at the time. Strategically, the local agency prioritized giving the parent\'s time to work through the trauma of the critical incident, as there was no imminent concern for safety to the children per law enforcement\'s safety assessment of the children and family at the time they had contact during the critical incident. Considering the totality of the circumstances  , being sensitive to the family\'s traumatic reality was prioritized as a method of family engagement, and a tradeoff decision to not make timely face to face with the sibling children was made.\\r\\n\\r\\nUnderstanding differences exist across the state regarding culture within County Attorney Offices, including office size, caseloads size, attorneys available to work cases, individual attorney\'s methods used to practice law, (potentially anticipating case outcomes prior to filing petitions), and potentially serving multiple roles within their office, etc. The county attorney\'s office, also being influenced by county board decisions, further complicated the office\'s ability to communicate advice to child protection in a timely manner, contributing to the delay in observing\\/interviewing the sibling children.   Furthermore, staff did not know if their request to the county attorney\'s office to petition the court for a court order to observe\\/ interview the children would be filed by the county attorney, and\\/or if filed, granted by the court. Considering child protection\'s mental model shaped from past experience (to not get court orders granted which they had requested in the past), child protection staff utilized a workaround\\/adaptation to their approach used with the children and family in order to engage and assess the safety of the sibling children, contributing to staff observing\\/interviewing the sibling children two weeks before the investigation closed.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"Staff did not know if their request to the county attorney\'s office to petition the court for a court order to observe\\/ interview the children would be filed by the county attorney, and\\/or if filed, granted by the court. Considering child protection\'s mental model shaped from past experience (to not get court orders granted which they had requested in the past), child protection staff utilized a workaround\\/adaptation to their approach used with the children and family in order to engage and assess the safety of the sibling children, contributing to staff observing\\/interviewing the sibling children two weeks before the investigation closed.\",\"Multiple_Choice__348\":\"1\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"1.) CP and County Attorney Office and Judge barrier exists impacting CP\'s ability to make face to face with sibling children efficiently and timely. \\r\\nConsidering child protection\'s mental model shaped from past experience (to not get court orders granted which they had requested in the past), child protection staff utilized a workaround\\/adaptation to their approach used with the children and family in order to engage and assess the safety of the sibling children, contributing to staff observing\\/interviewing the sibling children two weeks before the investigation closed. \\r\\n2.)  Impact to trajectory of CP practice was evidenced significantly by LE not cross reporting the critical incident to CP. \\r\\nLaw enforcement did not perceive a need to cross report the accidental critical incident to child protection, nor did other mandated reporters who had contact with the family at the time of the incident. Law enforcement did not have safety concerns for the sibling children and they did not pursue an emergency 72 hour hold at the time of the critical incident. Law enforcement considered the grandparents to be safe caregivers and the sibling children were presumed safe in their care. Differing perspectives exist between law enforcement and child protection about each of their roles at times when critical incidents occur. The two work disciplines follow different definitions of child safety and alleged neglect, based on MN state laws that govern and guide their individual work, influencing the frontline\'s mental models, depending on which code of law is being referenced, criminal or juvenile law. Additionally, the burden of proof standards are different for criminal law and child protection law. Law enforcement\'s standard of probable cause and beyond a reasonable doubt is a higher burden to meet than child protection\'s standard of preponderance of evidence and clear and convincing. \\r\\n\\r\\nThe parents were not trusting of child protection\'s involvement when child protection made contact with the family, as their involvement was perceived as conflicting to what law enforcement had communicated to them about not opening a criminal investigation. When child protection staff attempted to engage with the family, they were met with resistance. The grandparents refused child protection access to the sibling children. Helping the family understand the role differences between child protection and law enforcement was difficult for the staff. The family\'s confusion and resistance impacted staff\'s ability to observe\\/interview the sibling children in a timely manner.\",\"Multiple_Choice__356\":\"2\",\"Free_Text__357\":\"Law enforcement did not perceive a need to cross report the accidental critical incident to child protection, nor did other mandated reporters who had contact with the family at the time of the incident. Law enforcement did not have safety concerns for the sibling children and they did not pursue an emergency 72 hour hold at the time of the critical incident. Law enforcement considered the grandparents to be safe caregivers and the sibling children were presumed safe in their care.\\r\\nDiffering perspectives exist between law enforcement and child protection about each of their roles at times when critical incidents occur. The two work disciplines follow different definitions of child safety and alleged neglect, based on MN state laws that govern and guide their individual work, influencing the frontline\'s mental models, depending on which code of law is being referenced, criminal or juvenile law. Additionally, the burden of proof standards are different for criminal law and child protection law. Law enforcement\'s standard of probable cause and beyond a reasonable doubt is a higher burden to meet than child protection\'s standard of preponderance of evidence and clear and convincing.\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"1.) The two work disciplines follow different definitions of child safety and alleged neglect, based on MN state laws that govern and guide their individual work, influencing the frontline\'s mental models, depending on which code of law is being referenced, criminal or juvenile law. Additionally, the burden of proof standards are different for criminal law and child protection law. Law enforcement\'s standard of probable cause and beyond a reasonable doubt is a higher burden to meet than child protection\'s standard of preponderance of evidence and clear and convincing.\\r\\n\\r\\n2.) Using a least invasive approach with the family was used by staff to best reduce the risk of the family continuing to resist child protection involvement, and this approach also mitigated the barrier of not having a formal process (criminal charges and court involvement) available to support child protection involvement at the time. Strategically, the local agency prioritized giving the parent\'s time to work through the trauma of the critical incident, as there was no imminent concern for safety to the children per law enforcement\'s safety assessment of the children and family at the time they had contact during the critical incident. Considering the totality of the circumstances, being sensitive to the family\'s traumatic reality was prioritized as a method of family engagement, and a tradeoff decision to not make timely face to face with the sibling children was made.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"2\",\"Free_Text__363\":\"Using a least invasive approach with the family was used by staff to best reduce the risk of the family continuing to resist child protection involvement, and this approach also mitigated the barrier of not having a formal process (criminal charges and court involvement) available to support child protection involvement at the time.\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"Strategically, the local agency prioritized giving the parent\'s time to work through the trauma of the critical incident, as there was no imminent concern for safety to the children per law enforcement\'s safety assessment of the children and family at the time they had contact during the critical incident. Considering the totality of the circumstances, being sensitive to the family\'s traumatic reality was prioritized as a method of family engagement, and a tradeoff decision to not make timely face to face with the sibling children was made.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:22:39',NULL,'Hayden Stricker'),(287,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Date__293\":\"05\\/18\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Isabella\",\"Short_Answer__304\":\"Davis\",\"Date__305\":\"03\\/11\\/2016\",\"Date__306\":\"08\\/22\\/2016\",\"Multiple_Choice__308\":\"5 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"After receiving and screening in an intake after a critical incident, subsequent intakes regarding the critical incident (duplicates) were screened out.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:23:21',NULL,'Isabella Davis'),(288,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Jess J. VanKuyk\",\"Date__293\":\"02\\/18\\/2020\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"5\",\"Multiple_Choice__301\":\"Kandiyohi\",\"Short_Answer__303\":\"Isabella\",\"Short_Answer__304\":\"Quam\",\"Date__305\":\"01\\/13\\/2020\",\"Date__307\":\"01\\/13\\/2020\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"3\",\"Free_Text__351\":\"When information is accessible and shared amongst all county and tribal jurisdictions, local agencies can make more informed decisions, as the knowledge of prior work completed with children\\/families is requisite. Contracted programs\\/services, such as Project child in this case or contracted PSOP work, were examples the mapping team voiced that surface most often as being absent in documentation. \\r\\nThere is an impact on trajectory of case practice with children\\/families because of how local agency\'s practice in documenting contracted service providers\' work or not. When there is no documented contract work accessible, child welfare\\/social services continuity of care\\/work with children and families, is not supported adequately. The systemic limitation surfaced as an inconsistency across county\\/tribe jurisdictions, noting that SSIS database also contributes varied methods when documentation does occur in the database.\",\"Multiple_Choice__352\":\"3\",\"Free_Text__353\":\"Access to screened out report was learned not to be accessible using State Search in SSIS. This technology barrier impacts local agency\'s ability to carry out safe work practices when screening decisions can incorporate prior screen outs.  Not bein gable to access of have knowledge of prior Screen Out reports was considered a significant system issue, and this information was shared with the SSIS Business Operations work area for them to diagnose and address with SSIS developers\\/design team.  \\r\\n\\r\\nCoupled with the absent guidance, SSIS surfaced as a barrier in how local agencies can document contracted provider work. Many agencies have adopted their own methods when documenting contract provider work in SSIS.  Statewide policy or practice guidance is absent regarding how local agencies document work that is completed using a local agency contract providers who complete services and programs with children and families. Some agencies upload contract provider work with children in families by opening a workgroup in SSIS, while other agencies may not document contract providers\' work at all. The absence of guidance surfaced during this review and mapping team discussed there being inconsistency in how each local agency documents contracted work by non-government service providers.\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"When information is accessible and shared amongst all county and tribal jurisdictions, local agencies can make more informed decisions, as the knowledge of prior work completed with children\\/families is requisite.  Statewide policy or practice guidance is absent regarding how local agencies document work that is completed using contracted providers, who complete services and programs with children and families. Some agencies upload contract provider work with children in families by opening a workgroup in SSIS, while other agencies may not document contract providers\' work at all. The absence of guidance surfaced during this review and mapping team discussed there is inconsistency in how each local agency documents contracted work, by non-government service providers. Contracted programs\\/services, such as Project child in this case or contracted PSOP work, were examples the mapping team voiced that surface most often as being absent in documentation in SSIS. There is an impact on trajectory of case practice with children\\/families because of the absent guidance for local expectation of local agency practice when to document contracted provider work with children and families and when to not.  When there is no documented contracted service work accessible, child welfare and other social services work is not supported adequately.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:31:23',NULL,'Isabella Quam'),(289,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Jennifer Carlson\",\"Date__293\":\"01\\/24\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Isatoria\",\"Short_Answer__304\":\"Kerkulah\",\"Date__305\":\"02\\/14\\/2017\",\"Date__306\":\"07\\/22\\/2018\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:31:59',NULL,'Isatoria Kerkulah'),(290,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage team\",\"Date__293\":\"07\\/10\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"3\",\"Multiple_Choice__301\":\"Otter Tail\",\"Short_Answer__303\":\"Izaya\",\"Short_Answer__304\":\"VaTreece\",\"Date__305\":\"09\\/23\\/2017\",\"Date__307\":\"06\\/11\\/2018\",\"Multiple_Choice__308\":\"9 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:32:33',NULL,'Izaya VanTreece'),(291,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"02\\/10\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Legally Unlicensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Legally Unlicensed\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Ja\'Mir\",\"Short_Answer__304\":\"Dunagan\",\"Date__305\":\"08\\/20\\/2016\",\"Date__306\":\"01\\/28\\/2017\",\"Multiple_Choice__308\":\"5 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Unlicensed child daycare provider\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"1\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"1\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,71,'2021-05-26 19:33:23','2021-06-01 19:00:21',NULL,'Ja\'Mir Dunagan'),(292,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"10\\/11\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"2\",\"Multiple_Choice__301\":\"St. Louis\",\"Short_Answer__303\":\"Jace\",\"Short_Answer__304\":\"Marshall\",\"Date__305\":\"11\\/01\\/2017\",\"Date__307\":\"06\\/14\\/2018\",\"Multiple_Choice__308\":\"7 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:34:37',NULL,'Jace Marshall'),(293,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Karilee Pietz\",\"Date__293\":\"02\\/12\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Jamario\",\"Short_Answer__304\":\"Taylor\",\"Date__305\":\"10\\/19\\/2017\",\"Date__307\":\"11\\/19\\/2017\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:35:37',NULL,'Jamario Taylor'),(294,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Date__293\":\"07\\/17\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Jamayah\",\"Short_Answer__304\":\"Williams-Roberts\",\"Date__305\":\"12\\/23\\/2016\",\"Date__306\":\"04\\/22\\/2017\",\"Multiple_Choice__308\":\"4 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:36:39',NULL,'Jamayah Roberts'),(295,22,84,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kelly Knutson\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"11\\/22\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Jamie\",\"Short_Answer__304\":\"Soe\",\"Date__305\":\"07\\/13\\/2016\",\"Date__306\":\"10\\/16\\/2016\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,84,81,'2021-05-26 19:33:23','2021-05-26 16:37:16',NULL,'Jamie Soe'),(296,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Sarah Storm\",\"Date__293\":\"10\\/03\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Jamir\",\"Short_Answer__304\":\"Brown\",\"Date__305\":\"10\\/12\\/2018\",\"Date__307\":\"08\\/30\\/2019\",\"Multiple_Choice__308\":\"10 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"1\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Medical staff tested a newborn\'s meconium without known risk criteria of substance abuse exposure. The reason for the test being ordered could not be identified. The mother and subject child are Black African American.  Due to the subjectivity in the medical field guidance and standards in prescribed department of health practice, it appears inequitable testing occurred. Considering the impact on children and families in the Black African American community, and the trajectory that mandated reporting positive test results to child protection, there is an influence of Black African American children and families being subjected to child protection services at an inequitable rate, due to the matter of fact, that a positive meconium test will nearly always be a screened in CP report for neglect - prenatal exposure to controlled substance. This inequity of testing a newborns meconium when there are no risk indicators or criteria known or observed in the mother or newborn does not adequately support the ethics and purpose of child welfare and child protection work. A positive test result does not adequately or automatically identify a parents capacity to be a protective parent and keep their child safe.\\r\\n\\r\\nHospital made decision to test newborn meconium, which appears to fall outside of expected practice per state statute.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:38:02',NULL,'Jamir Brown'),(297,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Tiffany Kacir\",\"Date__293\":\"09\\/28\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"2\",\"Multiple_Choice__301\":\"St. Louis\",\"Short_Answer__303\":\"Jaxen\",\"Short_Answer__304\":\"Rumpel\",\"Date__305\":\"05\\/28\\/2013\",\"Date__307\":\"08\\/28\\/2018\",\"Multiple_Choice__308\":\"4 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"N\\/A Documented under Jaxen Rumpel\",\"Yes_or_No__370\":\"No\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:39:34',NULL,'Jaxen Rumpel'),(298,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"08\\/20\\/2020\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Jayden\",\"Short_Answer__304\":\"Asfaw\",\"Date__305\":\"04\\/14\\/2020\",\"Date__307\":\"06\\/25\\/2020\",\"Multiple_Choice__308\":\"2 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"Child was seen in ER for going unresponsive. When at the ER, the child became responsive. No medical testing was completed on the subject child at that time. \\r\\n\\r\\nBoth parents stated that they have noticed the subject child having \\\"twitching\\\" episodes in which he was seen by medical professionals last month the emergency room and the child\'s primary care provider, and there were no findings. In June of 2020, the subject child presented to a metro children\'s hospital with a diagnosis of BRUE (brief, resolved, unexplained event). During that incident the child was not responsive for a few minutes at home, went to the hospital, and became conscious upon arrival, and no additional testing was recommended by the doctors.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"1\",\"Multiple_Choice__356\":\"1\",\"Multiple_Choice__368\":\"1\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:41:37',NULL,'Jayden Asfaw'),(299,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Jennifer Carlson\",\"Date__293\":\"10\\/12\\/2016\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Jayden\",\"Short_Answer__304\":\"Omar\",\"Date__305\":\"06\\/12\\/2014\",\"Date__307\":\"10\\/08\\/2016\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Father not interviewed during Child Protection Family Assessment response.\",\"Free_Text__318\":\"The worker reported that she had difficulty getting a hold of the mother by phone after the report came in and ended up doing a drop-in visit. Due to this, the worker had to balance making timelines with ensuring all parties were present for a visit. Worker stated that the mother and the three children were at the home, however the father was not home at the initial visit. Five days later, a new CP report dated 7\\/29\\/2016 came in. As a result of this domestic violence incident, the father to the Subject Child was arrested. The worker sent letters to the Subject Child\'s mother and father. The letter to the father requested that he call the worker back to discuss the two CP reports. The worker reported that by the time she was able to have a face to face with the Subject Child\'s mother again regarding the new CP report, the father had been released from jail and his whereabouts were unknown. The Subject Child\'s mother reported that she and the Subject Child\'s father were not together. The Subject Child\'s mother also reported that he did not have a cell phone that she could reach him at. The worker also asked the Subject Child\'s mother to have the father get a hold of her.\\r\\n\\r\\nThe worker had many years of experience and history working with domestic violence cases. This experience found the worker needing to reconcile truths about the DV incident, resulting in the worker making a trade-off between developing and supporting engagement with the mother of the children while working to ensure the children\'s well-being and continuing to locate and meet with the father.\",\"Free_Text__319\":\"The worker was unable to interview the father in response to a domestic violence family assessment response. The worker received the case appointment a day after it was screened in and 4 days after the incident occurred. The worker was unsuccessful in her initial reach out to the mother by phone after receiving the case, requiring her to make an unannounced visit in order to meet the 5 day response guidelines, which are mandated by MN Statute 626.556 as well as DHS guidance. This trade off resulted in the worker prioritizing the face to face contact with the mother to ensure she met timelines with the alleged victims and, thus, being unable to coordinate having both the mother and father present at the visit. Legislatively mandated withhold funds further influenced the worker making that trade-off decision. Within days of the first visit with the mother, another DV related report came in and the father was arrested. The worker sent letters to both the mother and the father and again the worker had to make an unannounced visit to the home at which time the father had already been released from jail and his whereabouts were unknown. This, coupled with the fact that the father didn\'t have a cell phone, made it extremely difficult for the worker to make any type of contact with him. \\r\\n\\r\\nThe State of Minnesota\'s Federal Program Improvement Plan (PIP) prioritizes both family engagement as well as engaging fathers when working with children and families. In this case, these two priorities were in conflict. Specifically, the nature of domestic violence cases such as this, creates conflict as the worker is placed in a position to decide between engagement and relationship building with the mother, in addition to ensuring child safety, versus putting continued resources into locating and engaging the father, when his whereabouts are unknown. Normative practice in this agency further supported the worker not putting additional resources into locating and meeting with the father as the multiple letters that were sent and the several attempts to call the father were sufficient to fulfill the agency\'s obligation to engage him. Within three weeks, the child protection assessment was transitioned to case management services, which is much quicker than usual. As a result, the assessment worker assumed that additional resources to engage the father would be undertaken by the case management worker.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"Within three weeks, the child protection assessment was transitioned to case management services, which is much quicker than usual. As a result, the assessment worker assumed\\r\\nthat additional resources to engage the father would be undertaken by the case management worker\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Specifically, the nature of domestic violence cases such as this, creates conflict as the worker is placed in a position to decide between engagement and relationship building with the mother, in addition to ensuring child safety, versus putting continued resources into locating and engaging the father, when his whereabouts are unknown. Reference: Family Assessment Response Best Practice Guidance, DV Guidance, Engaging Fathers\\r\\n\\r\\nThe worker was unsuccessful in her initial reach out to the mother by phone after receiving the case, requiring her to make an unannounced visit in order to meet the 5 day response guidelines, which are mandated by MN Statute 626.556 as well as DHS guidance. This trade off resulted in the worker prioritizing the face to face contact with the mother to ensure she met timelines with the alleged victims and, thus, being unable to coordinate having both the mother and father present at the visit. Legislatively mandated withhold funds further influenced the worker making that trade-off decision.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"No\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:42:16',NULL,'Jayden Omar'),(300,22,84,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kelly Knutson\",\"Short_Answer__292\":\"Paul Lennander\",\"Multiple_Choice__294\":\"Other\",\"Yes_or_No__295\":\"Yes\",\"Multiple_Choice__296\":\"Other Tribe\",\"Short_Answer__297\":\"Sisseton-Wahpeton\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Licensed\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Jenecio\",\"Short_Answer__304\":\"Prentice\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Grandfather\",\"Multiple_Choice__316\":\"3\",\"Short_Answer__317\":\"Placement occurred when licensing concerns were noted\",\"Free_Text__318\":\"The human factors debriefing information was not documented at the request of the local agency due to pending litigation.  All of the local rationality information is captured in the narrative.\",\"Free_Text__319\":\"The decision to place the child in a home when licensing concerns were noted was influenced by federal, state, and local agency policies that prioritize the placement of children with relative caregivers and siblings whenever possible.  Minnesota State Statues 260C.212; 260C.221 and Stat. \\u00c2\\u00a7 260C.212, subd. 2 requires additional due diligence beyond the federal requirements with regards to locating and placing children with relatives as well as placing children with their siblings whenever possible.  Further placing pressure on staff to place children with relatives in cases like this is the metric of relative placement in which is set at 35.7% for agencies to achieve. This placement was not only a relative provider but also had the child\'s siblings in his care as well.  Additionally, there were no other relatives available to take the subject child and this relative care provider was excited to take the child when he was born and wanted the child in his care.  \\r\\nFurther supporting the agency\'s decision to place the child in this home was that this child was Native American and the child\'s Tribe was recommending placement with this relative. Deferring to the child\'s Tribe and following their recommendation as well as placement preferences is shaped by both the Federal Indian Child Welfare Act as well as the Minnesota Indian Family Preservation Act.  As a result of this, the local agency\'s normative practice is to defer to the Tribe for placement options.  It was also staff\'s perception that placing with this relative would further preserve the relationship between the Tribe and the worker.  An additional influence into this placement occurring with this relative was that there was limited availability of Native American foster care homes for children qualifying under the ICWA.\",\"Short_Answer__320\":\"Placement with the relative provider occurred beyond capacity\",\"Free_Text__321\":\"The human factors debriefing information was not documented at the request of the local agency due to pending litigation.  All of the local rationality information is captured in the narrative\",\"Free_Text__322\":\"Influencing placing the subject child with the relative provider beyond the providers licensed capacity was the fact that this provider was both a relative placement and all of the child\'s siblings were placed with this relative.  Additionally, multiple workers were assigned to this case within the placing agency. The multiple workers assigned to cases such as this has resulted in the agency\'s need to have specialized workers on a case that better support the agency being more child focused.  Having multiple workers on this case contributed to role confusion in providing services to this child and family.  This role confusion impacted communication between the placing worker and the licensing worker at the agency that was responsible for licensing the home.  As a result, communication barriers between the two agencies occurred around the licensing process; including notification of the child being placed in the home.  This further contributed to the placing agency not being aware that the home was only licensed for 3 children, not 4.  Staff within this local agency also do not have offices and as a result, often work remotely and separate from one another.  The location of the multiple staff on the case within the agency also created communication barriers between staff. Further supporting this placement decision was staff\'s limited knowledge of all of the licensing requirements as child protection workers are not typically responsible for the licensing process with families.\",\"Short_Answer__323\":\"Services were not provided to the relative caregiver\",\"Free_Text__324\":\"The human factors debriefing information was not documented at the request of the local agency due to pending litigation.  All of the local rationality information is captured in the narrative\",\"Free_Text__325\":\"Services not being provided to the relative caregiver was influenced by the multiple workers and agencies involved with this case.  Having this many workers on one case impacted communication and consultation between the two agencies involved with regards to which agency was assessing and providing services to the relative caregiver. Furthermore, in relative foster care placements such as this, agencies are less likely to provide services to relative placements.  This was often supported by relative placement providers having and utilizing informal supports. It is also common in cases such as this that a history of mistrust exists between the family and the local agency, impacting the relative placement provider requesting services for support.  Furthermore, there are a lack of culturally appropriate services available for relative placement providers.  Lastly, staff perceived that this provider was getting all of the services he needed as it was common that he would reach out for basic need items and allowances for the children he was caring for.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"LP 1- It was also staff\'s perception that placing with this relative would further preserve the relationship between the Tribe and the worker.  \\r\\n\\r\\nLP 3-Lastly, staff perceived that this provider was getting all of the services he needed as it was common that he would reach out for basic need items and allowances for the children he was caring for.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"LP 2-Additionally, multiple workers were assigned to this case within the placing agency. The multiple workers assigned to cases such as this has resulted in the agency\'s need to have specialized workers on a case that better support the agency being more child focused.  Having multiple workers on this case contributed to role confusion in providing services to this child and family.  This role confusion impacted communication between the placing worker and the licensing worker at the agency that was responsible for licensing the home.  As a result, communication barriers between the two agencies occurred around the licensing process; including notification of the child being placed in the home.  This further contributed to the placing agency not being aware that the home was only licensed for 3 children, not 4.  Staff within this local agency also do not have offices and as a result, often work remotely and separate from one another.  The location of the multiple staff on the case within the agency also created communication barriers between staff. Further supporting this placement decision was staff\'s limited knowledge of all of the licensing requirements as child protection workers are not typically responsible for the licensing process with families.  \\r\\n\\r\\nLP 3-\\r\\nServices not being provided to the relative caregiver was influenced by the multiple workers and agencies involved with this case.  Having this many workers on one case impacted communication and consultation between the two agencies involved with regards to which agency was assessing and providing services to the relative caregiver.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"LP 1-The decision to place the child in a home when licensing concerns were noted was influenced by federal, state, and local agency policies that prioritize the placement of children with relative caregivers and siblings \\r\\nwhenever possible.  Minnesota State Statues 260C.212; 260C.221 and Stat. \\u00c2\\u00a7 260C.212, subd. 2 requires additional due diligence beyond the federal requirements with regards to locating and placing children with relatives as well as placing children with their siblings whenever possible.  Further placing pressure on staff to place children with relatives in cases like this is the metric of relative placement in which is set at 35.7% for agencies to achieve. This placement was not only a relative provider but also had the child\'s siblings in his care as well.  Additionally, there were no other relatives available to take the subject child and this relative care provider was excited to take the child when he was born and wanted the child in his care. \\r\\n\\r\\nFurther supporting the agency\'s decision to place the child in this home was that this child was Native American and the child\'s Tribe was recommending placement with this relative. Deferring to the child\'s Tribe and following their recommendation as well as placement preferences is shaped by both the Federal Indian Child Welfare Act as well as the Minnesota Indian Family Preservation Act.  As a result of this, the local agency\'s normative practice is to defer to the Tribe for placement options.  \\r\\n\\r\\nLP2-Influencing placing the subject child with the relative provider beyond the providers licensed capacity was the fact that this provider was both a relative placement and all of the child\'s siblings were placed with this relative.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"LP 2-Additionally, multiple workers were assigned to this case within the placing agency. The multiple workers assigned to cases such as this has resulted in the agency\'s need to have specialized workers on a case that better support the agency being more child focused.  Having multiple workers on this case contributed to role confusion in providing services to this child and family.  This role confusion impacted communication between the placing worker and the licensing worker at the agency that was responsible for licensing the home.  As a result, communication barriers between the two agencies occurred around the licensing process; including notification of the child being placed in the home.  This further contributed to the placing agency not being aware that the home was only licensed for 3 children, not 4.  Staff within this local agency also do not have offices and as a result, often work remotely and separate from one another.  The location of the multiple staff on the case within the agency also created communication barriers between staff. Further supporting this placement decision was staff\'s limited knowledge of all of the licensing requirements as child protection workers are not typically responsible for the licensing process with families.\",\"Multiple_Choice__362\":\"2\",\"Free_Text__363\":\"An additional influence into this placement occurring with this relative was that there was limited availability of Native American foster care homes for children qualifying under the ICWA.\\r\\n\\r\\nLP 3-Furthermore, there are a lack of culturally appropriate services available for relative placement providers.\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,84,71,'2021-05-26 19:33:23','2021-06-01 19:01:46',NULL,'Jenecio Prentice'),(301,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"02\\/26\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Joshua\",\"Short_Answer__304\":\"Lockhart\",\"Date__305\":\"02\\/03\\/2015\",\"Date__306\":\"02\\/12\\/2017\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s Significant Other\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"3\",\"Free_Text__353\":\"After receiving and screening in an initial CP intake\\/child maltreatment report regarding the critical incident, subsequent intakes regarding the critical incident (duplicates) were received by the local agency. These duplicate CP intakes\\/child maltreatment reports were screened out and referred to the staff working the CP investigation. Screening duplicate intakes out instead of screening them in was not in compliance with intake, screening and response path guidance at the time, however, was a modified practice the local agency had become accustomed to, as SSIS allowed this option in the dropdown for local agencies to choose disposition when screening.  The local agency choose SSIS option to Screen out with reason being: Duplicate report; physical abuse allegations are already being assessed.   \\r\\n\\r\\n2.)  The auto generated *CPS Summary Disposition Notice* letter sent to mandated reporters following the local agency\'s decision to screen out, which is found in SSIS under CP Intake chronology, documents -  read: \\r\\nAddressed to the mandated reporter,  \\r\\n\\u00e2\\u20ac\\u0153Thank you for providing your concerns of suspected maltreatment of ____Name included is of the mother - not the subject child____. We did not conduct an investigation because the information provided did not meet the definition of physical abuse, sexual abuse, or neglect under Child Protection Statutes. If you become aware of additional information regarding this situation please contact the agency again. \\r\\nThank you for your interest and concern for children. Please continue to report any situations of suspected child maltreatment to Hennepin County Human Services and Public Health Department at 612-348-3000.\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"State policy is that duplicate reports be screened in and referred to the already open assessment\\/investigation workgroup. Hennepin County\'s practice in this case was to screen out the duplicate reports. \\r\\nRelevant to multiple Child maltreatment reports that were screened out in this case, under the Dispositions\\/Screening decision reads: Screened out - duplicate report; physical abuse allegations are already being assessed.\\r\\nAfter receiving and screening in an initial CP intake\\/child maltreatment report regarding the critical incident, subsequent intakes regarding the critical incident (duplicates) were received by the local agency. These duplicate CP intakes\\/child maltreatment reports were screened out and referred to the staff working the CP investigation.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"Screening duplicate intakes out instead of screening them in was not in compliance with intake, screening and response path guidance at the time, however, was a modified practice the local agency had become accustomed to.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 16:43:23',NULL,'Joshua Lockhart'),(302,22,84,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kelly Knutson\",\"Short_Answer__292\":\"Collette Roseller\",\"Date__293\":\"11\\/17\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Jude\",\"Short_Answer__304\":\"Summers-Sandberg\",\"Date__305\":\"08\\/01\\/2012\",\"Date__306\":\"09\\/05\\/2017\",\"Multiple_Choice__308\":\"5 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Biological Mother\",\"Multiple_Choice__316\":\"3\",\"Short_Answer__317\":\"Contact did not occur with the father.\",\"Free_Text__318\":\"During the debrief, staff indicated that she was a new CP investigator when this case came in and this this was the first child fatality that she had experienced as a new worker.  She noted that this was a very difficult case given the circumstance and upon receiving the case, she was instructed to not make contact with anyone.  This included contact with the family and law enforcement.  The worker believed that this came from her supervisor who was directed by the program manager that staff should not make contact with anyone.  The staff was unclear as to why this was since she was new and still learning, however, thought that this was influenced by the fact that this case had received a lot of media attention.  The worker also noted that given the circumstances of the case, going to the father\'s home to talk with him about child protection\'s investigation would have been very difficult based on what occurred.  While the worker felt relieved to not have to speak with the father she also wondered if he had the necessary supports and resources available to him during this time.   \\r\\nThe supervisor that was debriefed indicated that during child protection investigations involving fatalities they rely on law enforcement\'s investigation, including the utilization of their interviews. As a result the supervisor assumed that an interview had been done with the father through law enforcements investigation.  She also noted that if contact was not made with a parent that this would need to be approved by the program manager.  Additionally, any cases that involve the media such as this case, it is common practice that supervisors and staff are instructed by program managers to \\u00e2\\u20ac\\u0153just wait\\u00e2\\u20ac\\u009d and to not do anything immediately with the case.  The supervisor also discussed the difficulty of this case especially being that this was the workers\' first child fatality.  When this case came into rotation, the supervisor was balancing the assignment of such a difficult case to a new staff given that this would be a very hard case to work while also recognizing that this would also be learning opportunity for her as a new worker.  The supervisor was also balancing being cognizant of not assigning this case to other staff that may have had recent egregious harm\\/fatal\\/or near fatal cases assigned to them.\",\"Free_Text__319\":\"Contact not being made with the father during this Child Protection (CP) investigation was influenced by this case being the first child fatality that the investigator had ever worked.  As a result she was still learning what to do when child fatalities occur.  In addition to this, the staff was a new CP worker and supervisors are cautious when assigning cases such as this one to new workers.  However, several competing priorities influenced this case being assigned to a new worker.  This included the increase of number of new cases coming into the unit and ensuring that there was equal case distribution occurring.  Additionally, when this case came into rotation, the supervisor was balancing the assignment of such a difficult case to a new staff given that this would be a very hard case to work while also recognizing that this would also be good learning opportunity as a new worker.  Furthermore, the supervisor was also being cognizant of not assigning this case to other staff that may have had recent egregious harm\\/fatal\\/or near fatal cases assigned to them.  \\r\\nFurther impacting contact not being made in this case was that the manager and supervisor on this case also instructed the investigator to not make contact with anyone.  This included both Law Enforcement (LE) and the family.  This instruction was influenced by heighted media coverage during this time and the varied response protocols and processes that have occurred over the years as a result of the changing guidance issued by DHS on the requirements when child fatalities and near fatalities occur.  In high profile cases such as this one that surface in the media it is common practice within the agency that supervisors and staff are instructed by program managers to \\u00e2\\u20ac\\u0153just wait\\u00e2\\u20ac\\u009d and to not do anything immediately with the case.  \\r\\n\\r\\nMinnesota State Statute 626.556 Subd. 10 (b) (5) also allows agencies to defer to LE during the course of child fatality investigations including the use of their interviews and information to supplement their CP investigations when fatalities occur.  As a result agency staff indicated that during child protection investigations involving fatalities they rely heavily on law enforcement\'s investigation, including the utilization of their interviews. Staff in this case also believed that an interview had been done with the father through the law enforcements investigation.  Lastly, given that this was a murder suicide, staff believed that making contact with dad would not only cause additional trauma for him but there were also no other surviving siblings to interview and the perpetrator (the subject child\'s mother) was deceased.\",\"Short_Answer__320\":\"Learning Point-Cross report to law enforcement did not occur\",\"Free_Text__321\":\"During the debrief, staff indicated that she was a new CP investigator when this case came in and this this was the first child fatality that she had experienced as a new worker.  She noted that this was a very difficult case given the circumstance and upon receiving the case, she was instructed to not make contact with anyone.  This included contact with the family and law enforcement.  The worker believed that this came from her supervisor who was directed by the program manager that staff should not make contact with anyone.  The staff was unclear as to why this was since she was new and still learning, however, thought that this was influenced by the fact that this case had received a lot of media attention.  The worker also noted that given the circumstances of the case, going to the father\'s home to talk with him about child protection\'s investigation would have been very difficult based on what occurred.  While the worker felt relieved to not have to speak with the father she also wondered if he had the necessary supports and resources available to him during this time.   \\r\\nThe supervisor that was debriefed indicated that during child protection investigations involving fatalities they rely on law enforcement\'s investigation, including the utilization of their interviews. As a result the supervisor assumed that an interview had been done with the father through law enforcements investigation.  She also noted that if contact was not made with a parent that this would need to be approved by the program manager.  Additionally, any cases that involve the media such as this case, it is common practice that supervisors and staff are instructed by program managers to \\u00e2\\u20ac\\u0153just wait\\u00e2\\u20ac\\u009d and to not do anything immediately with the case.  The supervisor also discussed the difficulty of this case especially being that this was the workers\' first child fatality.  When this case came into rotation, the supervisor was balancing the assignment of such a difficult case to a new staff given that this would be a very hard case to work while also recognizing that this would also be learning opportunity for her as a new worker.  The supervisor was also balancing being cognizant of not assigning this case to other staff that may have had recent egregious harm\\/fatal\\/or near fatal cases assigned to them.\",\"Free_Text__322\":\"A cross report to Law Enforcement (LE) not occurring in this case was influenced by the fact that LE was already involved with the incident and making a report would have been duplicative since they were already aware of the incident.  Additionally, staff were instructed to not contact LE supporting the decision to not cross report this incident to LE.  Furthermore, there were no other surviving siblings in this case influencing the decision to not cross report this incident to law enforcement.\",\"Short_Answer__323\":\"Learning Point-Cross report to child protection did not occur\",\"Free_Text__324\":\"A human factors debrief did not occur as this learning point surfaced in the mapping process.\",\"Free_Text__325\":\"Law Enforcement (LE) not cross reporting the critical incident was influenced by law enforcement\'s perception of the murder\\/suicide incident and that child protection did not need to be involved given the suspected perpetrator was deceased.  Further impacting the child protection report not being made was varied cross reporting practices exist by the multiple law enforcement jurisdictions within the county based upon thee populations within each jurisdiction.  For example, if an incident like this occurs in Champlin, it is likely not going to be reported to CP.  However, if the incident occurs in Minneapolis it is likely going to be reported to CP.  \\r\\nCross reporting between the local agency and LE is further impacted by the changes in relationship that occur between CP and LE over the years.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"LP 1-Staff in this case also believed that an interview had been done with the father through the law enforcements investigation. Lastly, given that this was a murder suicide, staff believed that making contact with dad would not only cause additional trauma for him but there were also no other surviving siblings to interview and the perpetrator (the subject child\'s mother) was deceased.\\r\\n\\r\\nLP 3-\\r\\nLaw Enforcement (LE) not cross reporting the critical incident was influenced by law enforcement\'s perception of the murder\\/suicide incident and that child protection did not need to be involved given the suspected perpetrator was deceased. Further impacting the child protection report not being made was that varied cross-reporting practices exist by the multiple law enforcement jurisdictions within the county based upon the populations within each jurisdiction. For example, if an incident like this occurs in Champlin, it is likely not going to be reported to CP. However, if the incident occurs in Minneapolis it is likely going to be reported to CP.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"LP 3-Cross reporting between the local agency and LE is further impacted by the changes in relationship that occur between CP and LE over the years.\",\"Multiple_Choice__356\":\"2\",\"Free_Text__357\":\"LP 1-Contact not being made with the father during this Child Protection (CP) investigation was influenced by this case being the first child fatality that the investigator had ever worked. As a result she was still learning what to do when child fatalities occur. In\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"LP 1-In high profile cases such as this one that surface in the media it is common practice within the agency that supervisors and staff are instructed by program managers to \\u00e2\\u20ac\\u0153just wait\\u00e2\\u20ac\\u009d and to not do anything immediately with the case.\\r\\n\\r\\nMinnesota State Statute 626.556 Subd. 10 (b) (5) also allows agencies to defer to LE during the course of child fatality investigations and also allows the use of their interviews and information to supplement their CP investigations when fatalities occur. As a result, agency staff indicated that during child protection investigations involving fatalities, they rely heavily on law enforcement\'s investigation, including the utilization of their interviews.\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"LP 1- However, several competing priorities influenced this case being assigned to a new worker. This included an increase in the number of new cases coming into the unit and ensuring that there was equal case distribution occurring. Additionally, when this case came into rotation, the supervisor was balancing the assignment of such a difficult case to a new staff given that this would be a very hard case to work, while also recognizing that this would also be a good learning opportunity as a new worker. Furthermore, the supervisor was also being cognizant of not assigning this case to other staff that may have had recent egregious harm\\/fatal\\/or near fatal cases assigned to them.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"LP 1-In high profile cases such as this one that surface in the media it is common practice within the agency that supervisors and staff are instructed by program managers to \\u00e2\\u20ac\\u0153just wait\\u00e2\\u20ac\\u009d and to not do anything immediately with the case.\\r\\n\\r\\nLP2-\\r\\nAdditionally, staff were instructed to not contact LE supporting the decision to not cross report this incident to LE.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,84,81,'2021-05-26 19:33:23','2021-05-26 16:44:07',NULL,'Jude Summers-Sandberg'),(303,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"JoLynn Sundstrom\",\"Date__293\":\"12\\/04\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"MN Prairie\",\"Short_Answer__303\":\"Julianna\",\"Short_Answer__304\":\"Krause\",\"Date__305\":\"09\\/01\\/2011\",\"Date__307\":\"09\\/27\\/2018\",\"Multiple_Choice__308\":\"7 Years\",\"Multiple_Choice__309\":\"3\",\"Short_Answer__310\":\"Adoptive Mother\",\"Short_Answer__311\":\"Adoptive Father\",\"Short_Answer__312\":\"Unknown Offender\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:44:59',NULL,'Julianna Krause'),(304,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Tiffany Kacir\",\"Date__293\":\"02\\/15\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Legally Unlicensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Legally Unlicensed\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Dakota\",\"Short_Answer__303\":\"Justin\",\"Short_Answer__304\":\"Lin\",\"Date__305\":\"05\\/10\\/2017\",\"Date__307\":\"02\\/05\\/2018\",\"Multiple_Choice__308\":\"9 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Legally unlicensed care provider\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,71,'2021-05-26 19:33:23','2021-06-01 19:02:19',NULL,'Justin Lin'),(305,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Paul Lennander\",\"Date__293\":\"01\\/11\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Anoka\",\"Short_Answer__303\":\"Kaidyn\",\"Short_Answer__304\":\"Troy\",\"Date__305\":\"03\\/16\\/2004\",\"Date__307\":\"01\\/11\\/2018\",\"Multiple_Choice__308\":\"13 Years\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Father\",\"Short_Answer__311\":\"Father\'s partner\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Child protection report met screen in criteria for Neglect according to the Intake, Screening, and Response Path Guidelines, however, the child protection report was screened out\",\"Free_Text__318\":\"Anoka County\'s Child Protection Screening area has team of four screeners during their traditional daytime hours and rely on one another for consultation and decision making. The decisions made during the screening of this case were done in consultation with one another. The first call about the subject child\'s condition came from the Father of the children, who reported allegations of inadequate supervision and medical neglect.  The Father had made allegations that his girlfriend was using drugs and that had left a child on his own while out selling drugs. The Father had reported that the hospital was going to make a report of medical neglect, but the screener said the report was not received. \\r\\n\\r\\nThe screeners initial impression was that this case was one of \\u00e2\\u20ac\\u0153back and forth retaliation\\u00e2\\u20ac\\u009d between the parents.  Consultation occurred with the other screeners and with law enforcement who was with the subject child\'s mother at the hospital.  They also believed this to be a report made out of retaliation which supported the decision to screen the report out.  \\r\\n\\r\\nFurther influencing the decision to screen the report out, was that the report did not have any documentation which supported the medical neglect or the inadequate supervision. \\r\\n\\r\\nThe screener also stated that they generally have some discretion with taking allegations of medical neglect and following up of medical providers, but that they do rely on medical documentation when screening the report. If they do have unanswered questions, they can follow up with either extended screening (health and welfare checks or follow up with reporters and professionals). In this situation, due to the impression that this was a divorce\\/retaliation situation, they did not follow up with the medical provider.\",\"Free_Text__319\":\"The CP report being screened-out even though it met screening guidelines was influenced by the agency\'s perception that the report was not credible and that the worker felt safe with the screening decision. Agency staff reported that there is considerable complexity in screening guidelines surrounding medical neglect and neglect \\u00e2\\u20ac\\u201c failure to provide adequate care. There is a general expectation that all information needs to be in the report to make a screening decision, and the perception of not enough evidence included in the report to screen-in influenced the decision to screen the report out. In addition to this, the agency had a history of receiving these types of reports (diabetes related), which are difficult to screen due to the complexity of the disease process and the child\'s condition (they often lend themselves to alternative explanations) so external consultation occurs often with law enforcement (LE) in these cases. The LE agency was aware of the situation and never made a CP report or signed a hold for the children after their involvement (there is reliance on LE for initial safety assessment when they are involved) further dampening the credibility of the report. In this case, the report was made by the child\'s father against his estranged girlfriend which additionally led the screener to question the credibility of the report. \\r\\nDHS also had issued guidance around the utilization of a screening team when making screening decisions. After the group consultation, that included consideration of their history of receiving these types of reports and the absence of documented LE or hospital concerns or reports, staff believed that the report did not meet the screen in criteria.\",\"Multiple_Choice__346\":\"2\",\"Free_Text__347\":\"The CP report being screened-out even though it met screening guidelines was influenced by the agency\'s perception that the report was not credible and that the worker felt safe with the screening decision. \\r\\n\\r\\nIn addition to this, the agency had a history of receiving these types of reports (diabetes related), which are difficult to screen due to the complexity of the disease process and the child\'s condition (they often lend themselves to alternative explanations) so external consultation occurs often with law enforcement (LE) in these cases. The LE agency was aware of the situation and never made a CP report or signed a hold for the children after their involvement (there is reliance on LE for initial safety assessment when they are involved) further dampening the credibility of the report.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Agency staff reported that there is considerable complexity in screening guidelines surrounding medical neglect and neglect \\u00e2\\u20ac\\u201c failure to provide adequate care.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:46:38',NULL,'Kaidyn Troy'),(306,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Date__293\":\"07\\/05\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Kal\",\"Short_Answer__304\":\"Vang\",\"Date__305\":\"07\\/14\\/2016\",\"Date__306\":\"10\\/22\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Uncle\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:47:16',NULL,'Kal Vang'),(307,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"09\\/21\\/2020\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"1\",\"Multiple_Choice__301\":\"Polk\",\"Short_Answer__303\":\"Kash\",\"Short_Answer__304\":\"Cole\",\"Date__305\":\"09\\/21\\/2020\",\"Date__307\":\"09\\/23\\/2020\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:47:57',NULL,'Kash Cole'),(308,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Kimette Almon\",\"Date__293\":\"11\\/06\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Keyaris\",\"Short_Answer__304\":\"Samuels\",\"Date__305\":\"09\\/23\\/2010\",\"Date__306\":\"05\\/16\\/2018\",\"Multiple_Choice__308\":\"7 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"MIFPA notices were not sent after the subject child\'s father identified a possibility of Native American Heritage.\",\"Free_Text__318\":\"The case was assigned to the ICWA unit due to a conflict of interest in another unit. The worker had 6 years of experience working as a CP investigator in the ICWA unit. The worker described feeling uncomfortable having to contact the family after everything that had transpired (child fatality) and explain child protection\'s role is in the investigation. The worker\'s focus of attention was on talking with the detective to coordinate efforts during the investigation. Case notes indicated that the subject child\'s father initially denied American Indian heritage in a previous case and during the 10\\/22\\/2018 CP investigation he stated potential American Indian heritage. The father was not able to provide additional information and denied any tribal affiliation. From the worker\'s perspective, if a parent states they have American Indian heritage, a notice is completed and sent to the tribe, a phone call to the tribe is made, and this information is documented in SSIS in case notes and in tabs under each child. The worker stated that if a parent says they are Cherokee, Ojibwe, etc., the worker would send notice to all of the Cherokee tribes or all of the Ojibwe tribes, follow up with a phone call, and document the info in SSIS. In situations where a parent is not sure or states possible American Indian heritage and cannot provide any information regarding a tribe, would typically not be considered ICWA and notice would not be sent. \\r\\n\\r\\nThe worker stated that she felt personally protective of the family because of what they had experienced and felt pressure when DHS called shortly after the critical incident occurred and asked whether or not the agency was planning to place the surviving siblings out of the home.\",\"Free_Text__319\":\"MIFPA notices not being sent after the subject child\'s father identified a possibility of Native American Heritage was influenced by the perception that there was no tribal affiliation or heritage due to the subject child\'s father not being able to provide information about a specific tribe. Agency practice supported notices not being sent when a family member states a possibility of Native American Heritage and is unable to provide information regarding a specific tribe. Further influencing the perception that there was no tribal affiliation or heritage was the fact that the father had previously denied Native American Heritage during prior involvement with the agency, which also supported staff identifying follow up with the father regarding possible Native American Heritage being lesser of a priority.\\r\\n\\r\\nIn addition, confusion exists about what notices need to be sent, as well as when and by whom, which contributes to inconsistent practice among workers and as a result, influences MIFPA notices not being sent. State and local guidance was unclear and supported inconsistent practice among workers as it was not as clear on steps that needed to take place to ensure policy\\/statute was followed. State and local guidance is shaped by ICWA and MIFPA requirements that notices be sent to the BIA by a social services agency if a tribe is unknown. Furthermore, these ICWA and MIFPA requirements, coupled with changes to the AFCARS requirements, influenced the development of tabs in SSIS used for guiding ICWA related work. These tabs were not fulling developed at the time, which contributed to state and local guidance being unclear.\\r\\n\\r\\nFurthermore, in a case involving a critical incident, law enforcement oftentimes take the lead and social service agencies are sometimes asked not to conduct further interviews until the law enforcement investigation is complete. This contributes to workers\' hesitancy to reach out to a family member to gain additional information, and follow-up with the father regarding Native American heritage not being prioritized and MIFPA notices not being sent.\",\"Multiple_Choice__346\":\"3\",\"Free_Text__347\":\"MIFPA notices not being sent after the subject child\'s father identified a possibility of Native American Heritage was influenced by the perception that there was no tribal affiliation or heritage due to the subject child\'s father not being able to provide information about a specific tribe. \\r\\n\\r\\nFurther influencing the perception that there was no tribal affiliation or heritage was the fact that the father had previously denied Native American Heritage during prior involvement with the agency, which also supported staff identifying follow up with the father regarding possible Native American Heritage being lesser of a priority.\\r\\n\\r\\nIn addition, confusion exists about what notices need to be sent, as well as when and by whom, which contributes to inconsistent practice among workers and as a result, influences MIFPA notices not being sent.\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"Furthermore, in a case involving a critical incident, law enforcement oftentimes take the lead and social service agencies are sometimes asked not to conduct further interviews until the law enforcement investigation is complete. This contributes to workers\' hesitancy to reach out to a family member to gain additional information, and follow-up with the father regarding Native American heritage not being prioritized and MIFPA notices not being sent.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Agency practice supported notices not being sent when a family member states a possibility of Native American Heritage and is unable to provide information regarding a specific tribe. \\r\\n\\r\\nState and local guidance was unclear and supported inconsistent practice among workers as it was not as clear on steps that needed to take place to ensure policy\\/statute was followed. State and local guidance is shaped by ICWA and MIFPA requirements that notices be sent to the BIA by a social services agency if a tribe is unknown. Furthermore, these ICWA and MIFPA requirements, coupled with changes to the AFCARS requirements, influenced the development of tabs in SSIS used for guiding ICWA related work. These tabs were not fulling developed at the time, which contributed to state and local guidance being unclear.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 16:48:37',NULL,'Keyaris Samuels'),(309,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Jennifer Droneck\",\"Date__293\":\"11\\/09\\/2016\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Stearns\",\"Short_Answer__303\":\"King\",\"Short_Answer__304\":\"Karon\",\"Date__305\":\"09\\/26\\/2014\",\"Date__307\":\"10\\/17\\/2015\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:49:28',NULL,'King Karon'),(310,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Tracy Nielsen\",\"Date__293\":\"02\\/09\\/2018\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Short_Answer__297\":\"Licensed\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__299\":\"Licensed\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Kristin\",\"Short_Answer__304\":\"Nelson\",\"Date__305\":\"07\\/29\\/2016\",\"Date__306\":\"11\\/13\\/2017\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Licensed relative - Maternal Grandmother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"3\",\"Free_Text__355\":\"Maltreatment determination for natural sleep related death impacted work relationships between the local agency\'s licensing, adoptions, adn child protection units. \\r\\n\\r\\nAdoptions worker had trouble getting a hold of GAL. GAL did not attend meetings.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"SUID - Maltreatment determined, natural death that occurred in relative licensed family foster care provider\'s home. Child had been sick with a cold. Relative caregiver placed child down for rest; she was later found deceased. Cause of death possible croup laryngotracheobronchitis.\\r\\n\\r\\nLocal agency practice to remove all children from caregiver prior to assessing safety, and with DHS Licensing direction to the local agency\'s licensing unit, to issue a temporary immediate suspension when a child death occurred did not support the permanency pre-adoptive placement option for the surviving children.\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,71,'2021-05-26 19:33:23','2021-06-01 19:03:11',NULL,'Kristin Nelson'),(311,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Meg Carriveau\",\"Date__293\":\"09\\/27\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Lamel\",\"Short_Answer__304\":\"Stewart\",\"Date__305\":\"04\\/06\\/2015\",\"Date__306\":\"07\\/04\\/2015\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Mother\'s partner\",\"Multiple_Choice__316\":\"2\",\"Short_Answer__317\":\"24 hour Face to Face timelines not met after screen-in of 24 hour response sexual abuse allegations (Hennepin Co)\",\"Free_Text__318\":\"Information obtained during the debrief was minimal due to the length of time that has passed since those events occurred. However, it was noted by one of the staff debriefed that it was a difficult time due to having multiple high-profile cases and upwards of 25 investigations\\/assessments on their caseload. The child was also no longer in the care of his father when either of the sexual abuse reports were made and screened in (with grandmother for the 8\\/15\\/15 report and at a residential treatment center at the time of the 2\\/10\\/16 report). Additionally, at the time that the 2\\/10\\/16 report was forwarded to the investigator, she had seen the child just 3 days prior.\",\"Free_Text__319\":\"The agency staff not making 24 hour face to face timelines was influenced by the worker already having an open case at the time. When the new report came in, the worker had seen the child just 3 days prior. The child was identified as safe at the time and additionally, the child was not with the alleged perpetrator and thus in no imminent harm. Also, the child\'s location was a significant distance from the staff\'s office, further supporting the decision to not go back out to the child\'s home to make timelines. Due to the nature of the child\'s injury, multiple law enforcement agencies were involved resulting in additional coordination time being needed to move through the investigation. Law enforcement\'s homicide unit was also involved and the agency was asked to not interview the child. As a result of the implementation of the Governor\'s Task Force recommendations, there was increased media coverage and a subsequent public perception that the child protection system failed. This perception led to staff movement within the agency and also increased turnover. This turnover and staff movement increased caseload levels, further impacting the worker needing to prioritize other cases in which safety and risk concerns were more imminent, especially given that the staff had just seen the child 3 days prior. \\r\\nAs a consequence of heightened media coverage, there was additional oversight by DHS on high profile cases and thus, more oversight by the local agency administration (managers, supervisors, County Attorney\'s, etc.). This additional oversight then resulted in more consult time needed as there were more people involved in high profile cases. The additional time needed for this further exacerbated the worker\'s ability to complete case duties.  As a result, staff needed to prioritize their time to best meet the needs of the families they were working with, and since the worker had seen the child just 3 days earlier, and identified the child as safe, the worker prioritized other more pressing caseload demands rather than going out again to make timelines.\",\"Short_Answer__320\":\"Family Assessment was not closed within the 45 day timeframe (Anoka Co)\",\"Free_Text__321\":\"Staff identified that the amount of paperwork needed to complete an assessment influences delays in getting workgroups closed. This paperwork includes writing assessment summaries for every assessment or investigation that is completed, and often times these take considerable amount of time to complete. SSIS is also cumbersome, with a lot of clicks to complete everything needed to work on and subsequently close an assessment. During the time that the worker was working with the family on the CP Assessment (FA), an additional CP intake was received that was screened in for CP Family Investigation (FI) response. Due to the worker having an open assessment with the family, the case was assigned to this same worker for the Family Investigation. The worker reported that the FI response took precedence while the FA stayed open. Both were closed at essentially the same time in mid-October. Lastly, the worker shared that when completing an assessment with a family, knowing that Case management services will not be necessary, staff will often do case management-like services with the family and keep the assessment open a little longer to provide the family with what they need to ensure safety. It was also shared that the Agency has a philosophy that you serve and provide the family with what they need, even if that means that the assessment is open longer than the 45 day timeframe.\",\"Free_Text__322\":\"The family assessment not closing within 45 day timelines was influenced by the amount of work needed to complete assessments, SSIS functions, prioritization of cases and family-centered work. Agency staff primarily identified that the amount of work to close assessment cases was a contributing factor in this assessment not closing on time. Both paper and SSIS tasks were stated to be barriers as SSIS requires many clicks to complete an assessment, including redundancies, such as ICWA documentation and limitations within the system such as FA and FI workgroups not being allowed to exist together (within one workgroup). This results in duplication of work as an FA and FI were both being worked by the same staff and separate case summaries to be written on each workgroup. Within this, the worker was prioritizing the FI work in order to meet the more pressing issues that arose within the FI workgroup. \\r\\nAlso, the Federal PIP (Program Improvement Plan) requirements and State CFSR reviews resulted in the local agency having additional requirements needing to be completed to close out cases, including those contained within the PIP that resulted from the state CFSR\'s agency review. Recent high profiles cases had also increased the amount of work needed to close out cases. The increased media coverage due to high profile cases (including subsequent lawsuits) had resulted in defensive practices. This has an adverse effect on closing cases timely as there had been additional oversight protocols, including the need for supervisor consult\\/review needed to close a case put in place, to ensure consistency in work practices. \\r\\nFinally, the agency culture supports working to serve families what they need, regardless of timelines. This trade-off between family-centered work and meeting administrative deadlines (45 day assessment closing deadlines) creates conflicts for workers when trying to balance quality vs. quantity.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"2\",\"Free_Text__349\":\"LP 1: As a result of the implementation of the Governor\'s Task Force recommendations, there was increased media coverage and a subsequent public perception that the child protection system failed. This perception led to staff movement within the agency and also increased turnover. This turnover and staff movement increased caseload levels, further impacting the worker needing to prioritize other cases in which safety and risk concerns were more imminent\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"2\",\"Free_Text__353\":\"LP 2: Both paper and SSIS tasks were stated to be barriers as SSIS requires many clicks to complete an assessment, including redundancies, such as ICWA documentation and limitations within the system such as FA and FI workgroups not being allowed to exist together (within one workgroup).\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"LP 1: Due to the nature of the child\'s injury, multiple law enforcement agencies were involved resulting in additional coordination time being needed to move through the investigation. Law enforcement\'s homicide unit was also involved and the agency was asked to not interview the child.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"LP 1: When the new report came in, the worker had seen the child just 3 days prior. The child was identified as safe at the time and additionally, the child was not with the alleged perpetrator and thus in no imminent harm. Also, the child\'s location was a significant distance from the staff\'s office, further supporting the decision to not go back out to the child\'s home to make timelines\\r\\n\\r\\nLP 2: Both paper and SSIS tasks were stated to be barriers as SSIS requires many clicks to complete an assessment, including redundancies, such as ICWA documentation and limitations within the system such as FA and FI workgroups not being allowed to exist together (within one workgroup).\",\"Multiple_Choice__360\":\"2\",\"Free_Text__361\":\"LP 1: When the new report came in, the worker had seen the child just 3 days prior. The child was identified as safe at the time and additionally, the child was not with the alleged perpetrator and thus in no imminent harm. Also, the child\'s location was a significant distance from the staff\'s office, further supporting the decision to not go back out to the child\'s home to make timelines\\r\\n\\r\\nLP 1: As a consequence of heightened media coverage, there was additional oversight by DHS on high profile cases and thus, more oversight by the local agency administration (managers, supervisors, County Attorney\'s, etc.). This additional oversight then resulted in more consult time needed as there were more people involved in high profile cases. The additional time needed for this further exacerbated the worker\'s ability to complete case duties. As a result, staff needed to prioritize their time to best meet the needs of the families they were working with, and since the worker had seen the child just 3 days earlier, and identified the child as safe, the worker prioritized other more pressing caseload demands rather than going out again to make timelines.\\r\\n\\r\\nLP 2: Agency staff primarily identified that the amount of work to close assessment cases was a contributing factor in this assessment not closing on time. Furthermore, the worker was prioritizing the FI work in order to meet the more pressing issues that arose within the FI workgroup. In addition recent high profiles cases had also increased the amount of work needed to close out cases. The increased media coverage due to high profile cases (including subsequent lawsuits) had resulted in defensive practices. This has an adverse effect on closing cases timely as there had been additional oversight protocols, including the need for supervisor consult\\/review needed to close a case put in place, to ensure consistency in work practices. Finally, the agency culture supports working to serve families what they need, regardless of timelines. This trade-off between family-centered work and meeting administrative deadlines (45 day assessment closing deadlines) creates conflicts for workers when trying to balance quality vs. quantity.\\r\\n\\r\\nLP 2: Also, the Federal PIP (Program Improvement Plan) requirements and State CFSR reviews resulted in the local agency having additional requirements needing to be completed to close out cases, including those contained within the PIP that resulted from the state CFSR\'s agency review.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"2\",\"Free_Text__367\":\"LP 2: Finally, the agency culture supports working to serve families what they need, regardless of timelines. This trade-off between family-centered work and meeting administrative deadlines (45 day assessment closing deadlines) creates conflicts for workers when trying to balance quality vs. quantity.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:51:11',NULL,'Lamel Stewart'),(312,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"08\\/06\\/2019\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Mower\",\"Short_Answer__303\":\"Landen\",\"Short_Answer__304\":\"Johnson\",\"Date__305\":\"03\\/15\\/2018\",\"Date__307\":\"07\\/13\\/2019\",\"Multiple_Choice__308\":\"1 Year\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 16:54:29',NULL,'Landen Johnson'),(313,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tracy Nielsen\",\"Date__293\":\"06\\/26\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"4\",\"Multiple_Choice__301\":\"Sherburne\",\"Short_Answer__303\":\"Landon\",\"Short_Answer__304\":\"Parker\",\"Date__305\":\"11\\/16\\/2016\",\"Date__306\":\"04\\/15\\/2019\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 17:37:29',NULL,'Landon Parker'),(314,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"10\\/12\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Latoria\",\"Short_Answer__304\":\"Thomas\",\"Date__305\":\"06\\/03\\/2010\",\"Date__306\":\"10\\/04\\/2016\",\"Multiple_Choice__308\":\"5 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 17:38:15',NULL,'Latoria Thomas'),(315,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"10\\/12\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Latorianna\",\"Short_Answer__304\":\"Thomas\",\"Date__305\":\"10\\/07\\/2013\",\"Date__306\":\"10\\/04\\/2015\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 17:38:53',NULL,'Latorianna Thomas'),(316,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"10\\/12\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Latorious\",\"Short_Answer__304\":\"Thomas\",\"Date__305\":\"05\\/27\\/2009\",\"Date__306\":\"10\\/04\\/2016\",\"Multiple_Choice__308\":\"6 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 18:02:33',NULL,'Latorious Thomas'),(317,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Fintan Moore\",\"Date__293\":\"03\\/09\\/2016\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Le\'vonte\",\"Short_Answer__304\":\"Jones\",\"Date__305\":\"02\\/06\\/2014\",\"Date__306\":\"07\\/08\\/2016\",\"Multiple_Choice__308\":\"2 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s boyfriend\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 18:05:20',NULL,'Le\'vonte Jones'),(318,22,92,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Kristine Frick\",\"Short_Answer__292\":\"Fintan Moore\",\"Date__293\":\"02\\/15\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Leilani\",\"Short_Answer__304\":\"Lee\",\"Date__305\":\"08\\/03\\/2016\",\"Date__306\":\"11\\/16\\/2016\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Face to face occurred after 5 day timeline\",\"Free_Text__318\":\"Information obtained during the Debrief regarding Learning Point:\\r\\n\\u00e2\\u20ac\\u00a2\\tMarch 2016 was a very challenging time for the agency\\r\\no\\tThere was a major influx in the amount of CP intakes being made and their system was being inundated with a backlog of CP intakes and screened in CP intakes waiting assignment for family assessment (FA) and family investigation (FI)\\r\\no\\tThe increased volume of reports being made was not manageable was influenced by:\\r\\n\\u00ef\\u201a\\u00a7\\tThe governor\'s task force recommendations and the multiple changes to the screening guidelines. \\r\\n\\u00ef\\u201a\\u00a7\\tThe agency was accepting more CP intakes for screen ins\\r\\n\\u00ef\\u201a\\u00a7\\tReporters who normally did not report were now reporting\\r\\n\\u00ef\\u201a\\u00a7\\tThe adverse media coverage increased defensive practice and fear based, CYA methods of practice\\r\\n\\u00ef\\u201a\\u00a7\\tWorkers were quitting all the time; turnover was extremely high due to the workload was not manageable\\r\\no\\tThere was one program manager to advise supervisors, whereas now there are three\\r\\n\\u00ef\\u201a\\u00a7\\tConsults with Program Manager gave minimal guidance for how to triage the backlog of FA\\/FI\'s pending assignment\\r\\n\\u00ef\\u201a\\u00a7\\tPriority response was given to CP reports that involved children under the age of 2 and to reports of allegations of physical abuse and sexual abuse.\\r\\n\\u00ef\\u201a\\u00a7\\tNo other guidance on how to triage CP reports in backlog \\r\\n\\u00e2\\u20ac\\u00a2\\tProgram manager was overwhelmed; there was no way for one manager to review all the cases needing to be triaged, therefore supervisors had some discretion on method used to triage.\\r\\no\\tRoutinely, it is common in the spring for the agency to experience increased reporting from mandated reporters i.e. school social workers.\\r\\n\\u00ef\\u201a\\u00a7\\tIt is a common pattern for the agency to experience one mandated reporter make multiple reports for many children they are concerned about at the end of the school year because they will no longer have the ability to check in with the children when school is let out for the summer.\\r\\n\\u00ef\\u201a\\u00a7\\tThe time of year being March 2016, in combination with the factors mentioned above, contributed to backlogs and delays in assignment to cases, thus impacting ability to meet the face to face timeline  \\r\\n\\u00e2\\u20ac\\u00a2\\tOccurring at this time was the largest backlog of FA\\/.FI\'s pending assignment for FA\\/FI response in the supervisors unit was 90 pending cases. It was the highest backlog of all the units, with many pending being ed. neglect types of cases.\\r\\no\\tThere were not enough staff to assign the new cases\\r\\n\\u00ef\\u201a\\u00a7\\tWorkers can handle 3-4 new case assignments a week, 4 being challenging, but in March 2016 workers were taking on 4-5 a week, and that was not manageable\\r\\n\\u00ef\\u201a\\u00a7\\tThere were 10 workers in this unit, it was not uncommon to get 14-15 new screened in reports in the FA\\/FI backlog a day.\\r\\n\\u00e2\\u20ac\\u00a2\\tWith 10 workers taking 5 reports a week, could get 50 cases assigned a week, but the volume surpassed the agency\'s ability to stay caught up due to staff turnover and not enough staff available to take new cases. \\r\\no\\tThis FA\\/FI unit was a specialty unit, meaning regardless of the rotation for CP intakes being assigned to FA\\/FI units, the supervisor\'s unit took all reports for a delegated city further contributing to this unit the highest number of cases.  \\r\\n\\u00ef\\u201a\\u00a7\\tThe city delegated to the supervisor\'s unit has a population that receives a large amount of new CP intakes and screened in reports. \\r\\n\\u00e2\\u20ac\\u00a2\\tThe CP Intake was assigned to the supervisor\'s unit on 3\\/25. \\r\\n\\u00e2\\u20ac\\u00a2\\tThe CP intake sat pending under the Supervisors name from 3\\/25 \\u00e2\\u20ac\\u201c 4\\/7. Was pending a little over 2 weeks; this was not as bad as it could have been.\\r\\no\\tEducational neglect intakes were not considered high risk during this time and they could sit in pending for as long as six weeks waiting for assignment at times. \\r\\n\\u00e2\\u20ac\\u00a2\\tIf another FA\\/FI unit did not have as many cases pending assignment, those units would assist and take CP reports pending from this supervisor\'s unit as a result \\r\\no\\tIn this case, the Supervisor assigned this ed neglect to a colleague supervisor in another FA\\/FI unit, when an available staff to take the ed neglect case became available\\r\\n\\u00ef\\u201a\\u00a7\\tThe agency was trying to dig out of all the ed neglects pending, there were 100\'s of them. \\r\\n\\u00ef\\u201a\\u00a7\\tA staff was brought back out of retirement to help specifically with the backlogged ed. neglect case assignments pending.\\r\\n\\u00ef\\u201a\\u00a7\\tThe other supervisor\'s unit was not a specialty unit.\",\"Free_Text__319\":\"SCIR - Narrative\\r\\nLP: Face to face occurred after 5 day timeline. \\r\\nThe face to face occurring after the 5 day timeline was impacted by the face to face timeline passing before the case could be assigned to a frontline worker. In March of 2016, more report were coming into the local agency, which placed pressure on the system, due to the amount of reports being made. Tending to this production pressure, the local agency brought on a group of professionals, to assist in entering and screening intakes. An increased volume of screened in CP intakes occurred when practices became defensive at the local level as a result of increased media exposure of a high profile child death. At the state level continual changes were being made to the intake, screening and response path guidelines stemming out of the 93 governor\'s task force recommendations, which also required the local agency to screen in more CP intakes. Further contributing to the volume of reports being made and screened in, was the time of year (March). At this time annually, a pattern of increased reporting occurs from mandated reporters in the school system just prior to the end of the school year. Commonly reporters will make multiple reports since they will no longer have the ability to check in with the children when school is let out for the summer. Systemically, the overall increased volume of CP intakes screened in at this time created backlogs in FA\\/FI units, contributing to delays in case assignment. Additionally, this FA\\/FI unit was also a specialty unit, meaning in addition to being on the general rotation for CP intakes being assigned to all FA\\/FI units, this FA\\/FI unit also took all reports for a delegated city which receives a large amount of new screened in CP reports. This specialty FA\\/FI unit had the highest backlog of all the FA\\/FI units, approximately 90 FA\\/FI\'s pending case assignment, many which were for educational neglect. \\r\\nA demand \\u00e2\\u20ac\\u201c resource mismatch existed which limited the amount of time one employed FA\\/FI program manager could provide to all supervisors needing consult time for cases needing to be triaged for case assignment. As a result, direction was given from the program manager to supervisors to prioritize assignment for CP allegations that involved children under the age of 2, and allegations physical abuse and sexual abuse for all aged children. Supervisors were allowed to use professional discretion when triaging and prioritizing safety\\/risk of all other cases pending assignment. Strategically, educational neglect cases were placed at lower priority for case assignment, and an accepted procedural drift away from meeting face to face timelines for educational neglect types of cases occurred. Further impacting the delay in face to face, was the limited resource of human capital to do the work. There were not enough FA\\/FI frontline staff employed to assign backlogged FA\\/FI cases to. With 10 workers in a FA\\/FI unit, each taking 5 reports a week, supervisors could get 50 cases assigned a week, but the volume continued to flow into the FA\\/FI unit backlog. This volume surpassed the unit\'s ability to stay caught up especially considering staff turnover was also high. Supervisors made the strategic trade off to keep unassigned cases in his\\/her name in the backlog when face to face timeline had passed, as a method of protecting and retaining frontline staff.  A cyclical pattern existed between high caseload sizes per worker and the high rate of staff turnover at this time. The agency attempted to combat the production pressure of the 100\'s of educational neglect cases pending case assignment in backlog by re-hiring a former staff who had retired, to specifically work unassigned educational neglect cases in the FA\\/FI unit backlog.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"-A demand \\u00e2\\u20ac\\u201c resource mismatch existed which limited the amount of time one employed FA\\/FI program manager could provide to all supervisors needing consult time for cases needing to be triaged for case assignment. As a result, direction was given from the program manager to supervisors to prioritize assignment for CP allegations that involved children under the age of 2, and allegations physical abuse and sexual abuse for all aged children. Supervisors were allowed to use professional discretion when triaging and prioritizing safety\\/risk of all other cases pending assignment. \\r\\n-Further impacting the delay in face to face, was the limited resource of human capital to do the work There were not enough FA\\/FI frontline staff employed to assign backlogged FA\\/FI cases to. With 10 workers in a FA\\/FI unit, each taking 5 reports a week, supervisors could get 50 cases assigned a week, but the volume continued to flow into the FA\\/FI unit backlog. This volume surpassed the unit\'s ability to stay caught up especially considering staff turnover was also high.\\r\\n- Supervisors made the strategic trade off to keep unassigned cases in his\\/her name in the backlog when face to face timeline had passed, as a method of protecting and retaining frontline staff.  A cyclical pattern existed between high caseload sizes per worker and the high rate of staff turnover at this time\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"3\",\"Free_Text__359\":\"Maltreatment determined SUID death. Autopsy results found Manner of death to be: Undetermined with type being labelled as: Asphyxia, and Cause of Death to be: Sudden unexplained death in infancy (SUID), with other significant condition to be: Co-Sleeping on adult mattress with one adult and two children on adult bed.\",\"Multiple_Choice__360\":\"3\",\"Free_Text__361\":\"-In March of 2016, more report were coming into the local agency, which placed pressure on the system, due to the amount of reports being made. Tending to this production pressure, the local agency brought on a group of professionals, to assist in entering and screening intakes. An increased volume of screened in CP intakes occurred when practices became defensive at the local level as a result of increased media exposure of a high profile child death. At the state level continual changes were being made to the intake, screening and response path guidelines stemming out of the 93 governor\'s task force recommendations, which also required the local agency to screen in more CP intakes. Further contributing to the volume of reports being made and screened in, was the time of year (March). At this time annually, a pattern of increased reporting occurs from mandated reporters in the school system just prior to the end of the school year. Commonly reporters will make multiple reports since they will no longer have the ability to check in with the children when school is let out for the summer. Systemically, the overall increased volume of CP intakes screened in at this time created backlogs in FA\\/FI units, contributing to delays in case assignment. Additionally, this FA\\/FI unit was also a specialty unit, meaning in addition to being on the general rotation for CP intakes being assigned to all FA\\/FI units, this FA\\/FI unit also took all reports for a delegated city which receives a large amount of new screened in CP reports. This specialty FA\\/FI unit had the highest backlog of all the FA\\/FI units, approximately 90 FA\\/FI\'s pending case assignment, many which were for educational neglect.\\r\\n- To combat the production pressure of the 100\'s of educational neglect cases pending case assignment in backlog by re-hiring a former staff who had retired, to specifically work unassigned educational neglect cases in the FA\\/FI unit backlog.\\r\\n-Frontline staff experienced daily production\\/efficiency pressures, goal conflicts, and competing priorities impacting their ability to do conduct work safely.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"3\",\"Free_Text__365\":\"One program manager did not have time to provide support to all the FA\\/FI supervisors needing consult time to triage each of their FA\\/FI unit backlogs.\",\"Multiple_Choice__366\":\"3\",\"Free_Text__367\":\"Strategically, educational neglect cases were placed at lower priority for case assignment, and an accepted procedural drift away from meeting face to face timelines for educational neglect types of cases occurred.\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,92,81,'2021-05-26 19:33:23','2021-05-26 18:06:29',NULL,'Leilani Lee'),(319,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"09\\/01\\/2020\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Leneesha\",\"Short_Answer__304\":\"Hester\",\"Date__305\":\"07\\/05\\/2020\",\"Date__306\":\"08\\/05\\/2020\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\'s partner\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 18:07:17',NULL,'Leneesha Hester'),(320,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Triage Review\",\"Date__293\":\"04\\/03\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"9\",\"Multiple_Choice__301\":\"Ramsey\",\"Short_Answer__303\":\"Levi\",\"Short_Answer__304\":\"Gardet\",\"Date__305\":\"06\\/02\\/2015\",\"Date__306\":\"01\\/15\\/2019\",\"Multiple_Choice__308\":\"3 Years\",\"Multiple_Choice__309\":\"2\",\"Short_Answer__310\":\"Mother\",\"Short_Answer__311\":\"Mother\'s partner\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 18:08:00',NULL,'Levi Gardet'),(321,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Tom Sandberg\",\"Date__293\":\"03\\/14\\/2018\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Liliana\",\"Short_Answer__304\":\"Aldinger\",\"Date__305\":\"11\\/19\\/2017\",\"Date__307\":\"03\\/02\\/2018\",\"Multiple_Choice__308\":\"3 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Mother\",\"Multiple_Choice__316\":\"1\",\"Short_Answer__317\":\"Cross-report to LE did not occur for the 2\\/1\\/2017 and 2\\/2\\/2017 screened-out CP reports.\",\"Free_Text__318\":\"No debriefing occurred as the LP was outside of the CW system.\",\"Free_Text__319\":\"Cross reporting to LE not occurring was influenced by LE coordination, workload and technology. It was learned that due to the size of the local agency and having multiple LE jurisdictions within it, there is often times uncertainty on jurisdictions and coverage for geographical areas. This makes it inherently difficult to identify where a report is supposed to be sent. This, coupled with the Governor\'s Task Force creating heightened expectations that screen-outs be cross-reported, led to staffing levels and capacity being an issue for LE to follow up on those cross-reports. Due to this reduction in capacity, some police departments were not assigning screened-out cross reports for follow up. Furthermore, LE indicated that they did not want them in the first place as their perception about screened out reports is that if CP doesn\'t take action, that LE won\'t either. This resulted in a lower priority being placed on these reports in general. \\r\\n\\r\\nStaffing levels at the local agency also impacted cross-reporting practices. Due to turnover and staffing levels, intake workers are often times working multiple intakes at a time. Each intake takes over 300 clicks to complete within SSIS and is very time consuming for intake staff. Prioritization for some intakes (more egregious) create the situation where staff are working different reports at the same time, thus increasing the risk of not being able to fulfill the cross-report mandate. Additionally, the agency prides itself on less than a 5 minute wait time for reporters as they want the community and mandated reports to continue making reports and not be discouraged when not being able to connect with an intake worker in a timely manner.\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"3\",\"Free_Text__349\":\"Staffing levels at the local agency also impacted cross-reporting practices. Due to turnover and staffing levels, intake workers are often times working multiple intakes at a time.\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"It was learned that due to the size of the local agency and having multiple LE jurisdictions within it, there is often times uncertainty on jurisdictions and coverage for geographical areas. This makes it inherently difficult to identify where a report is supposed to be sent.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"2\",\"Free_Text__359\":\"Each intake takes over 300 clicks to complete within SSIS and is very time consuming for intake staff.\",\"Multiple_Choice__360\":\"3\",\"Free_Text__361\":\"This, coupled with the Governor\'s Task Force creating heightened expectations that screen-outs be cross-reported, led to staffing levels and capacity being an issue for LE to follow up on those cross-reports. Due to this reduction in capacity, some police departments were not assigning screened-out cross reports for follow up (Pressure for additional reports was from our system)\\r\\n\\r\\nPrioritization for some intakes (more egregious) create the situation where staff are working different reports at the same time, thus increasing the risk of not being able to fulfill the cross-report mandate. Additionally, the agency prides itself on less than a 5 minute wait time for reporters as they want the community and mandated reports to continue making reports and not be discouraged when not being able to connect with an intake worker in a timely manner.\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 18:08:33',NULL,'Liliana Aldinger'),(322,22,90,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Ryan Hartneck\",\"Short_Answer__292\":\"Triage Team\",\"Date__293\":\"08\\/15\\/2019\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"5\",\"Multiple_Choice__301\":\"Des Moines Valley\",\"Short_Answer__303\":\"Loralei\",\"Short_Answer__304\":\"Thompson\",\"Date__305\":\"05\\/03\\/2019\",\"Date__306\":\"05\\/29\\/2019\",\"Multiple_Choice__308\":\"<1 Month\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,90,81,'2021-05-26 19:33:23','2021-05-26 18:09:15',NULL,'Loralei Thompson'),(323,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Jennifer Carlson\",\"Date__293\":\"02\\/17\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"8\",\"Multiple_Choice__301\":\"Hennepin\",\"Short_Answer__303\":\"Luis\",\"Short_Answer__304\":\"Ronquillo\",\"Date__305\":\"07\\/16\\/2003\",\"Date__306\":\"09\\/30\\/2016\",\"Multiple_Choice__308\":\"13 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 18:10:12',NULL,'Luis Ronquillo'),(324,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Tracy Nielson\",\"Date__293\":\"03\\/24\\/2017\",\"Multiple_Choice__294\":\"Fatality\",\"Yes_or_No__295\":\"No\",\"Multiple_Choice__300\":\"6\",\"Multiple_Choice__301\":\"Rice\",\"Short_Answer__303\":\"Lynnaya\",\"Short_Answer__304\":\"Stoddard-Espinoza\",\"Date__305\":\"10\\/08\\/2008\",\"Date__306\":\"12\\/11\\/2016\",\"Multiple_Choice__308\":\"8 Years\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Father\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"2\",\"Free_Text__355\":\"While the local agency and law enforcement had been communicating about the critical incident, formal law enforcement policies and procedures influenced law enforcements ability to provide a formal CP report to the local agency within a timely manner as to not compromise the open law enforcement investigation.  While this delay in a making a formal report did not impact the trajectory of care in this case, it did influence the local agencies ability to complete a child protection intake within a timely manner of being made aware of the critical incident.\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,81,'2021-05-26 19:33:23','2021-05-26 18:14:17',NULL,'Lynnaya Stoddard-Espinoza'),(325,22,91,NULL,13,NULL,NULL,'{\"Multiple_Choice__291\":\"Brittany Lochner\",\"Short_Answer__292\":\"Colette Roesler\",\"Date__293\":\"12\\/05\\/2016\",\"Multiple_Choice__294\":\"Near Fatality\",\"Yes_or_No__295\":\"No\",\"Yes_or_No__298\":\"Yes\",\"Multiple_Choice__300\":\"7\",\"Multiple_Choice__301\":\"Washington\",\"Short_Answer__303\":\"Mackenzie\",\"Short_Answer__304\":\"Wynne\",\"Date__305\":\"05\\/24\\/2016\",\"Date__307\":\"11\\/14\\/2016\",\"Multiple_Choice__308\":\"5 Months\",\"Multiple_Choice__309\":\"1\",\"Short_Answer__310\":\"Unknown Offender\",\"Multiple_Choice__346\":\"0\",\"Multiple_Choice__348\":\"0\",\"Multiple_Choice__350\":\"0\",\"Multiple_Choice__352\":\"0\",\"Multiple_Choice__354\":\"0\",\"Multiple_Choice__356\":\"0\",\"Multiple_Choice__368\":\"0\",\"Multiple_Choice__358\":\"0\",\"Multiple_Choice__360\":\"0\",\"Multiple_Choice__362\":\"0\",\"Multiple_Choice__364\":\"0\",\"Multiple_Choice__366\":\"0\",\"Yes_or_No__370\":\"Yes\"}',NULL,0,1,91,71,'2021-05-26 19:33:23','2021-06-01 19:04:26',NULL,'Mackenzie Wynne'),