{"id":186,"form_id":"23","user_id":"81","question_id":null,"organization_id":"10","tab_id":null,"question_type":null,"text_answer":"{\"Short_Answer__76\":\"Care Manager\",\"Date__77\":\"12\\\/16\\\/2019\",\"Multiple_Choice__78\":\"Charles Young\",\"Multiple_Choice__79\":\"Kristie Pittman\",\"Short_Answer__80\":\"Harry Meyering\",\"Short_Answer__81\":\"Emily Britz \\\/ Tana Helleksen\",\"Short_Answer__82\":\"ebritz \\\/ thelleksen \\\/@harrymeyeringcenter.org\",\"Multiple_Choice__84\":\"245D Service Termination\\\/Suspension\",\"Multiple_Choice__85\":\"Blue Earth County\",\"Multiple_Choice__96\":\"2\",\"Short_Answer__91\":\"Person's services were terminated due to challenging behavior\",\"True_or_False__94\":\"Yes\",\"Free_Text__100\":\"Influencing why the ICF\\\/DD provider terminated this person\\u2019s services due to challenging behavior was that the person was posing a safety risk to others in the home. The other 3 individuals in the home were considered to be more vulnerable to abuse due to their lower functioning levels, and so the person posed a greater risk to them. The provider had to balance their responsibility to protect the health and safety of three people in the home with their responsibility to meet the needs of the person whose services they terminated. The guardians of the other 3 individuals had an expectation that the provider would keep them safe, and due to their higher vulnerability the guardians expressed their concern often in this instance. Another impact to the provider\\u2019s responsibility for people\\u2019s health and safety include county case managers assigning this function to providers via the CSSP. Unique to ICF\\\/DDs is that they are licensed by both the Department of Human Services and the Minnesota Department of Health. Both Departments require providers to protect the health and safety of the people they serve. Minnesota Statutes 245D outlines the requirements for providers enforced by DHS while MDH relies on other statutory requirements in Minnesota statutes 144 and Rule. A unique requirement enforced by MDH is that ICF\\\/DDs are expected to protect the people they serve from \\u201cimmediate jeopardy\\u201d. The provider in this instance noted that many times in the past they had been asked after a critical incident how they were going to protect the people they served from \\u201cimmediate jeopardy\\u201d in the future, so this mandate shaped the perception of the provider\\u2019s managers and supervisors whenever a health and safety concern arose and placed pressure on them to prioritize their response in a way that would satisfy MDH reviewers. The provider in this instance noted that terminating the person\\u2019s services was part of their response as to how they would respond to MDH\\u2019s questioning of how they were protecting the health and safety of the other people in the home. Between the requirements of DHS and MDH as well as the expectations of the guardians and case managers, the provider felt a strong need to act in this situation and felt that termination was the only way they could keep the majority of the people in the home safe. \\r\\nThe provider noted that the team had explored the possibility of implementing rights restrictions with the individual, but the team determined they wouldn\\u2019t be possible due to the requirements of 245D surrounding rights restrictions, or wouldn\\u2019t be sufficient to meet the safety needs of the person and others in the home. Due to the ineffectiveness of a rights restriction, the provider felt they had few options to address the person\\u2019s challenging behavior. \\r\\nAnother influence as to why the provider terminated a person\\u2019s services due to challenging behavior was that the person\\u2019s challenging behavior did not dissipate as expected after the person moved to the home. While it was known prior to intake that the person sometimes exhibited challenging behavior, there was an assumption by the team that this environment would likely help decrease the triggers that impacted the challenging behavior in the past. \\r\\nA number of factors were identified that  person\\u2019s challenging behavior not dissipating. For one, the provider noted that the staff at the site were trained more on meeting the medical needs of the other people in the home than de-escalating challenging behavior. While Minnesota Statutes 245D and the Positive Supports Rule (9544) required the provider to ensure their staff had training and were competent on positive support strategies, de-escalation techniques and the use of restrictive interventions, because the other people in the home didn\\u2019t exhibit challenging behavior, the focus of their training was centered more on medical needs than \\u2018behavioral needs\\u2019. The provider also noted that the staff felt a fear to administer pro re nata (PRN) medication to the person during mental health episodes due to the stigma of providing medication at these times and the training and reporting requirements of the Positive Supports Rule. The Positive Supports Rule (MN Rule 9544) requires providers to report the use of PRN medications when administered in a behavioral situation, and there was a belief among staff that the use of PRNs in this manner were not ok because they required reporting. \\r\\nThe provider \\u2013 and the person\\u2019s team - expected the person\\u2019s challenging behavior to dissipate after intake not only because they thought the environment would suit the person, but they assumed that a behavior support plan would positively effect change and decrease the person\\u2019s interfering behavior and that other external services would be able to assist with challenging episodes. Unfortunately, upon arrival the provider found there was a lack of external behavior services in their area and that they had a lack of information about what mental health services were available. Additionally, the person\\u2019s case manager \\u2013 who would typically be expected to also help find needed services \\u2013 was very busy and unable to devote much time to the person\\u2019s case. A number of influences as to why case managers would be busy were identified \\u2013 between high case load and recent federal and state initiatives changing services. MnCHOICES, HCBS rule and person-centered planning initiatives were all noted as positive changes, but changes that took a lot of time away from case managers to learn and meet the new requirements. This program was located in southern Minnesota, and the team noted that this region in particular has a scarcity of mental health resources. The provider and the team did find a neuropsych practitioner that was willing to work with the person, but unfortunately they were too far away and the drive was too long. This made it hard to make regular meetings and implement the neuropsych\\u2019s recommendations. Additionally, the provider was able to bring the person to a nearby hospital during challenging episodes, but noted that any interventions offered by the hospital unfortunately were ineffective.\\r\\nAlong with the lack of mental health resources, the provider also noted there was a lack of behavioral resources available to the person. Some practitioners had recommended that the person be admitted to an inpatient facility where they could try a \\u201cmed holiday\\u201d \\u2013 taking the person off all their meds and slowly re-introducing medication to determine their effectiveness. The provider could only find 1 program in the state that offered \\u201cmed holidays\\u201d, and that program had only 9 beds and waiting list of 25 people. The mapping team noted that the Jensen Settlement, which limited community base intensive services and the interventions they could use, influenced the lack of behavioral services like this one. \\r\\nWithout interventions that met the needs of the person, coupled with the lack of training of the staff, the provider noted their staff were stressed at the site. They often times engaged in power struggles with the individual and spent time trying to keep the other 3 residents safe. The provider did note that one option they wanted to explore before terminating the person\\u2019s services was to find out if they could obtain 1 on 1 staffing for the individual, but didn\\u2019t know who to ask or where to start. ICF\\\/DD rates have many regulations and oftentimes hard to navigate they noted. The provider noted that the ability to obtain reimbursement beyond the facility\\u2019s establish rate was a mystifying process.\",\"Yes_or_No__128\":\"Yes\",\"Free_Text__132\":\"Influencing why this person was placed in what was seen as an atypical placement was that the person had never stayed at an ICF\\\/DD before and the other people in the home were seen as having more medical needs than behavioral challenges. Despite these differences, the team, including the case manager, guardian and the provider thought this could be a good fit for the person because they could have more attention from staff and the person wouldn\\u2019t see the other roommates as a \\u2018threat\\u2019. \\r\\nAnother factor into this placement was that the provider had an open ICFs\\\/DD bed. The fact it was an ICF\\\/DD bed was one of the reasons why the bed was open. The providers in the room noted that there isn\\u2019t much interest in ICF\\\/DD beds any more. Regionally, statewide and nationally, ICF or other institutional placements are seen as undesirable and passed over for foster care or other community-based settings. A number of factors have influenced this opinion about ICFs\\\/DDs, including; public sentiment shifting away from institutions and large settings; the HCBS settings rule which has required systems to move towards community settings; the Minnesota Olmstead Plan which reflects the Supreme Court\\u2019s 1999 Olmstead ruling determining people should be served in the \\u201cmost integrated setting\\u201d, and; the Jensen Settlement Agreement which resulted in both Minnesota\\u2019s Olmstead Plan and the closure of some institutional services.\\r\\nAnother factor as to why this person was placed in an atypical placement was that the provider was willing to take a risk by accepting someone who didn\\u2019t fit the typical profile for this home. They were willing to take a risk because they did have an open ICF\\\/DD bed that needed to be filled and hadn\\u2019t had much interest from other people in. The provider was also willing to take a risk because they determined the person could do well at the site.  This determination impacted the placement and was impacted by a number of factors. While the other people in the home didn\\u2019t have similar needs as this person, the team thought this might work well in this case. The other five people in the home had higher Activities of Daily Living (ADL) needs than this person so it was thought the person wouldn\\u2019t add much to the staff\\u2019s workload in this area. The five people also exhibited challenging behavior that was more easily redirected and managed by staff, so it was thought the house wouldn\\u2019t be overwhelming for staff to manage challenging behavior in the home as a whole. Additionally, it seemed to the provider that the person\\u2019s challenging behavior appeared manageable. This was due to a number of influences such as the case manager reporting there weren\\u2019t major recent behavioral concerns and the paperwork received from the person\\u2019s previous provider before intake. Beyond the concerns around the person\\u2019s challenging behavior, the paperwork from the previous provider supported the new provider\\u2019s assessment that the person could do well at this site. The person\\u2019s psychiatrist also weighed in and supported this particular placement, contributing to this assessment.\\r\\nAlong with the provider being willing to take a risk by accepting the person\\u2019s placement in this atypical setting was that both the case manager and the person\\u2019s guardian were willing to take a risk by placing the person in a home that didn\\u2019t fit the \\u2018typical\\u2019 profile. The person had failed at multiple community-based settings before so they both reported being interested in trying something different. Their options were likely limited too because this region has a lack of residential placement beds, which is also the trend statewide. This lack of residential beds is seen as influenced by a statewide moratorium on foster care beds as well as a moratorium on ICF\\\/DD beds. The providers in the room also noted that the current statewide workforce shortage prohibits them from opening new programs as well as influences the closure of other residential sites. Without staff, programs cannot open or even stay open as providers can\\u2019t meet the supervision needs of the people living there.\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"Unique to ICF\\\/DDs is that they are licensed by both the Department of Human Services and the Minnesota Department of Health. Both Departments require providers to protect the health and safety of the people they serve. Minnesota Statutes 245D outlines the requirements for providers enforced by DHS while MDH relies on other statutory requirements in Minnesota statutes 144 and Rule. A unique requirement enforced by MDH is that ICF\\\/DDs are expected to protect the people they serve from \\u201cimmediate jeopardy\\u201d. The provider in this instance noted that many times in the past they had been asked after a critical incident how they were going to protect the people they served from \\u201cimmediate jeopardy\\u201d in the future, so this mandate shaped the perception of the provider\\u2019s managers and supervisors whenever a health and safety concern arose and placed pressure on them to prioritize their response in a way that would satisfy MDH reviewers. The provider in this instance noted that terminating the person\\u2019s services was part of their response as to how they would respond to MDH\\u2019s questioning of how they were protecting the health and safety of the other people in the home. Between the requirements of DHS and MDH as well as the expectations of the guardians and case managers, the provider felt a strong need to act in this situation and felt that termination was the only way they could keep the majority of the people in the home safe.\",\"Multiple_Choice__109\":\"2\",\"Free_Text__110\":\"The provider \\u2013 and the person\\u2019s team - expected the person\\u2019s challenging behavior to dissipate after intake not only because they thought the environment would suit the person, but they assumed that a behavior support plan would positively effect change and decrease the person\\u2019s interfering behavior and that other external services would be able to assist with challenging episodes. Unfortunately, upon arrival the provider found there was a lack of external behavior services in their area and that they had a lack of information about what mental health services were available. Additionally, the person\\u2019s case manager \\u2013 who would typically be expected to also help find needed services \\u2013 was very busy and unable to devote much time to the person\\u2019s case. A number of influences as to why case managers would be busy were identified \\u2013 between high case load and recent federal and state initiatives changing services.\",\"Multiple_Choice__115\":\"3\",\"Free_Text__116\":\"Influencing why the ICF\\\/DD provider terminated this person\\u2019s services due to challenging behavior was that the person was posing a safety risk to others in the home. The other 3 individuals in the home were considered to be more vulnerable to abuse due to their lower functioning levels, and so the person posed a greater risk to them. The provider had to balance their responsibility to protect the health and safety of three people in the home with their responsibility to meet the needs of the person whose services they terminated.\",\"Multiple_Choice__119\":\"3\",\"Free_Text__120\":\"The provider \\u2013 and the person\\u2019s team - expected the person\\u2019s challenging behavior to dissipate after intake not only because they thought the environment would suit the person, but they assumed that a behavior support plan would positively effect change and decrease the person\\u2019s interfering behavior and that other external services would be able to assist with challenging episodes. Unfortunately, upon arrival the provider found there was a lack of external behavior services in their area and that they had a lack of information about what mental health services were available. \\r\\nAlong with the lack of mental health resources, the provider also noted there was a lack of behavioral resources available to the person. Some practitioners had recommended that the person be admitted to an inpatient facility where they could try a \\u201cmed holiday\\u201d \\u2013 taking the person off all their meds and slowly re-introducing medication to determine their effectiveness. The provider could only find 1 program in the state that offered \\u201cmed holidays\\u201d, and that program had only 9 beds and waiting list of 25 people. The mapping team noted that the Jensen Settlement, which limited community base intensive services and the interventions they could use, influenced the lack of behavioral services like this one. \\r\\n\\r\\nAnother factor as to why this person was placed in an atypical placement was that the provider was willing to take a risk by accepting someone who didn\\u2019t fit the typical profile for this home. They were willing to take a risk because they did have an open ICF\\\/DD bed that needed to be filled and hadn\\u2019t had much interest from other people in\\r\\n\\r\\nAlong with the provider being willing to take a risk by accepting the person\\u2019s placement in this atypical setting was that both the case manager and the person\\u2019s guardian were willing to take a risk by placing the person in a home that didn\\u2019t fit the \\u2018typical\\u2019 profile. The person had failed at multiple community-based settings before so they both reported being interested in trying something different. Their options were likely limited too because this region has a lack of residential placement beds, which is also the trend statewide. This lack of residential beds is seen as influenced by a statewide moratorium on foster care beds as well as a moratorium on ICF\\\/DD beds. The providers in the room also noted that the current statewide workforce shortage prohibits them from opening new programs as well as influences the closure of other residential sites. Without staff, programs cannot open or even stay open as providers can\\u2019t meet the supervision needs of the people living there.\",\"Multiple_Choice__125\":\"2\",\"Free_Text__126\":\"Without interventions that met the needs of the person, coupled with the lack of training of the staff, the provider noted their staff were stressed at the site. They often times engaged in power struggles with the individual and spent time trying to keep the other 3 residents safe\",\"Yes_or_No__432\":\"Yes\"}","mcq_answer":null,"other_answer":"0","status":"1","created_by":"81","updated_by":81,"created_at":"5\/25\/2021 1:14:26 am","updated_at":"6\/11\/2021 1:55:24 pm","deleted_at":null,"report_name":"CY_Harry Meyering-BEC-2019-11"}