{"Short_Answer__76":"A954660000","Date__77":"10\/15\/2019","Multiple_Choice__78":"David Vukelich","Multiple_Choice__79":"Kelly Sather","Short_Answer__80":"Stepping Stones for Living","Short_Answer__81":"Laura Flynn","Short_Answer__82":"laura.flynn@sslduluth.com","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"St. Louis County","Date__86":"08\/24\/2019","Free_Text__87":"Tracy was outside the patio smoking. A few minutes later, the staff didn' t see Tracy outside anymore AND he hadn 't seen him come inside the house. Staff searched the house and then went outside to look down the street, but could not locate Tracy.\r\n\r\nStaff called the on-call supervisor, who told staff to call 911 to report a missing person. After doing so, the police officer called the house to talk with the staff and then the officer came to the house to gather more information. Staff was instructed to update the officer if Tracy returned home. Close to 1 pm, Tracy came back to the house and the staff asked him where he went. Tracy told staff that he took a cab went to the mall. Tracy was carrying pop, chips, and cookies that he had bought at the mall. He then sat down in the dining room and ate his food.","Multiple_Choice__96":"1","Short_Answer__91":"Staff did not observe the individual leave the home","True_or_False__94":"Yes","Date__97":"12\/09\/2019","Free_Text__98":"The day of the incident the staff person(SP) was supervising the individual who eloped as well as 3 other residents.   SP doesn\u2019t work at this home regularly.  The individual was outside smoking and told staff that he was going to walk to a convenience store located nearby the home.  SP advised the individual to take a \u201cwalkie talkie\u201d with him.   SP was cleaning the bathroom and never directly observed the individual leave the residence or confirm whether he took the walkie talkie with him.  The SP stated that there is a plan in place that supports this individual going to the convenience store unsupervised, with a walkie talkie for a period of 30 minutes.  Approximately 30 minutes later he noticed the individual had not returned to the home.  SP noted that the individual had not taken the walkie talkie with him.  SP stated there is protocol in place when the individual doesn\u2019t return after 30 minutes.  Following protocol, the SP called the agency\u2019s crisis staff.  The convenience store was contacted and they informed staff that the individual had not been to the store.  SP was advised to call 911 and did.  Shortly after the 911 call was placed, the individual returned to the home via taxi cab.  The individual disclosed that he took a cab to get McDonald\u2019s and went to the mall.  The individual had recently received money from a renter\u2019s rebate.  The individual manages their own spending money and the day of the incident he had $400(est.)in cash in his possession.  The agency has assisted the individual to go to other places besides the local convenience store.  On the day of the incident SP stated that the individual did not express a desire to go anywhere else.","Free_Text__100":"Staff was preoccupied, cleaning the bathroom during the time the individual left the home.  From the bathroom the staff did not have a vantage point to see the patio area where the individual was smoking prior to leaving the home.  The staff cleaning the bathroom was influenced by the provider assigning staff multiple duties such as cleaning, cooking, etc. Staff cleans the home as the home is required to be safe and sanitary which is also part of the licensing requirements through Minnesota Statutes, 245D.  The staffing ratio at the time of the incident also influenced the staff performing multiple duties.  There was a 1:4 ratio with no other staff on duty, so staff was supporting the four individuals as well as completing other support related tasks such as cleaning. \r\n\r\nOther contributing factors to staff cleaning in an area where they were unable to observe the individual was that staff had no concerns that the individual would leave without confirming with staff and taking the walkie talkie. The individual frequently smoked outside without leaving, in particular, the individual had not previously left the house without telling this staff person. The individual mentioned they might go to the convenience store and staff asked him to take a walkie talkie with, which also influenced staff\u2019s comfortability in cleaning the bathroom as the staff assumed he would take the walkie talkie if he left. The Staff's perception that the individual would follow alone time protocol was supported  by the individual\u2019s plan which allowed him to go for a 30 minute walk without staff supervision.   This unsupervised time is driven from the CSSP which allows for unsupervised time and individual\u2019s team developing specific parameters around unsupervised time.  The individual is his own guardian  which directly impacted the development of the CSSP and specific parameters around unsupervised time.   Per the individual\u2019s 6790, they were not allocated one-on-one supervision which has a reciprocal relationship with  the person\u2019s CSSP.  The 6790 is a tool created by DHS to implement the Disability Waiver Rate Setting statutes, created by the Minnesota Legislature, which provides a calculation for the person\u2019s service rates based on  the staff ratios required of the provider. The ratios and rates in a 6790 are negotiated between the provider and the case manager based on the needs for supervision a person has in their CSSP and the provider\u2019s assessment of the staff a person needs as well as the staff they have available. \r\n\r\nThe individual being outside prior to elopement was also influenced by a provider rule of no smoking in the home.  This rule was created to comply with the Minnesota Clean Air Act, which legislatively prohibits smoking in many public places. The rule is reinforced by DHS not allowing smoking in a licensed facility.  Society in general is aware of concerns for smoking in homes.  These concerns influenced DHS provider rules along and the Minnesota Clean Indoor Act.","Multiple_Choice__101":"3","Free_Text__102":"Staff was preoccupied, cleaning the bathroom during the time the individual left the home. From the bathroom the staff did not have a vantage point to see the patio area where the individual was smoking prior to leaving the home.  The staff cleaning the bathroom was influenced by the provider assigning staff multiple duties such as cleaning, cooking, etc. Staff cleans the home as the home is required to be safe and sanitary which is also part of the licensing requirements through Minnesota Statutes, 245D.  The staffing ratio at the time of the incident also influenced the staff performing multiple duties.  There was a 1:4 ratio with no other staff on duty, so staff was supporting the four individuals as well as completing other support related tasks such as cleaning. \r\n\r\nOther contributing factors to staff cleaning in an area where they were unable to observe the individual was that staff had no concerns that the individual would leave without confirming with staff and taking the walkie talkie. The individual frequently smoked outside without leaving, in particular, the individual had not previously left the house without telling this staff person. The individual mentioned they might go to the convenience store and staff asked him to take a walkie talkie with, which also influenced staff's comfortability in cleaning the bathroom as the staff assumed he would take the walkie talkie if he left. The Staff's perception that the individual would follow alone time protocol was supported  by the individual\u2019s plan which allowed him to go for a 30 minute walk without staff supervision.","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"1","Multiple_Choice__109":"0","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"1","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"1","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}