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Polish Your Writing Skills: How to WOW Your Clients Session 3: Dana Jolly and Angie Duke

Haynes

Instructors provided by www.patiyer.com and www.learnlegalnursing. com

Copyright 2011 No duplication permitted via written or electronic means

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Polish Your Writing Skills Webinar - Session 3 of 4

Pat:

Slide 1 Welcome back to Session 3 of our Polish Your Writing Skills Webinar. This final

session will last an hour and it will focus on long term care records which are very

different than hospital records in many respects. With me are Angie and Dana

who will be presenting this session. I wanted to bring up a couple points before

they start. Some of the people who have signed up for the webinar have

approached us about wanting to have the critique of a work product. Many of you

who have signed up for the webinar have already requested the critique, but a few

people have said, “oh now, I changed my mind. I would like to have it done.”

There is an option on patiyer.com to sign up for the critique which is an additional

fee of $60. It will be a critique of either the work product that you produce after

Session 3 and before Session 4 or any other work product that you have produced

up to 5 pages. One of the three of us will give you feedback on your work

product, an overall assessment of how it is put together, and any suggestions for

improving the materials from the way you have put them together.

A couple of dates and things that are coming up: May 16th

is a webinar on

Facebook Fan Pages and how you can build your legal nurse consulting practice

with Facebook Fan Pages taught by Michelle Scism. She is a not a legal nurse

consultant but a woman who has basically built her business from zero to 320

miles an hour over the course of one year through social media. She is a real

expert on social media issues and opportunities. Next, on May 25th

, is a webinar

in the evening also, on branding starting at 8 PM Eastern, on how you can use

branding concepts to promote your business. Now, with that I am going to turn

this over to Angie and Dana so that they can proceed.

Dana: We want to welcome back everyone and we hope you are finding this format a

good way to learn so at the end of the today‟s session, you will be getting some

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evaluation tools. We appreciate your feedback on the format with the built in

breaks. We are interested to know your thoughts so we are going to get started.

Angie:

Slide 2 There we are! I can tell you when I am working at my desk during the day, I don‟t

look like that, and I am really glad you guys can‟t see me. Just briefly I will tell

you a little about Dana and myself. We both have independent consulting

practices and together we have over 20 years of LNC experience. We decided to

combine our background in 2007 and we formed Legal Nurse Consulting Institute

which offers education to registered nurses that are clinically experienced and

interested in legal nurse consulting. I do have an extensive background in long

term care starting off as a staff nurse working my way up to a director of nursing.

I have also worked as an expert on long term care as well. I just wanted to

mention for those of you who aren‟t familiar with nursing homes, nursing homes

are often referred to as long term care facilities and the patients in these facilities

are often called residents or sometimes, you might see them referred to as a

customer.

Dana:

Slide 3 Pat, I think we have a polling question.

Pat: Give me a minute and I will select the poll for you.

Dana: All right.

Pat: Again please click on the appropriate item on the screen that would match your

experience in looking at long term care cases. People are voting. Angie, looks

like we are getting quite a few responses in and we are almost done. I appreciate

everybody voting on these polls because that gives us a real good sense of who is

in the group!

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Dana: Right!

Pat: So, what I am saying in the way of numbers for Angie and Dana who do not have

the results on their screen, and I will show the results in a minute, is that 35% of

our attendees have looked at cases as a consultant, 15% say “yes” as an expert and

58% say “no, they have not reviewed cases involving long term care.”

Dana: That is great!

Angie: That is really good considering we are talking about long term care cases today

and for those of you who have no experience; this is going to be a great starting

place for you.

Dana: Exactly! Which is probably why they signed up?

Angie:

Slide 4 Exactly! I‟d like to give a little introduction about what we are going to be

talking about today. This is a case about Ethan Allen. He is a 27-year-old man. He

was diagnosed with multiple sclerosis when he was about 20 years old and prior

to getting diagnosed with MS, he spent 2 years in the navy, and completed 2 years

of college. Then he was diagnosed with MS and needed his mom and sister to

take care of him at home. He then became sick with a UTI, went to the hospital

and from there he was admitted to the nursing home because his family just felt

that his level of care had gotten to the point that they could not continue to care

for him at home. When he was admitted to the nursing home, his mother and his

sister remained very active in his care there.

Dana:

Slide 5 And so when he came to Hopper Nursing Home, he had the following deficits

which are listed on your side. And as you look at the deficits limited assistance

with ADL, fall risk, behavioral issues, some confusion, occasional bladder

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incontinence, it paints the picture of the progressive neuromuscular disease from

which he suffers. We are going to talk a little bit more about each of these deficits

focusing on some of them more than others as we go through this.

Angie:

Slide 6 Mr. Allen‟s mother was very upset, of course; her son died. I know you all have

gone through the records during the break to identify the missing records, so you

are probably a little familiar with the facts of the case at this point. But Mr. Allen

choked on a hot dog on August 4, 2006 and he died. So his mother is very upset

and she said that if the staff at Hopper Nursing Home had not been negligent in

his care, her son would still be alive today. Now, the attorney turns to you, the

legal nurse consultant, and asks for your help in reviewing this case to determine

if the staff at the nursing home was indeed negligent and if they were breaching

the standards of care.

Dana:

Slide 7 This is not demonstrative evidence that was used on his case but it certainly does

paint a picture. Certainly a picture is worth about 1,000 words!

Angie: Indeed!

Dana:

Slide 8 This is just a brief timeline of critical events and it is a great tool to provide a

client attorney about what happened. On August 4, 2006 at 5:10 PM, Ethan is in

the dining room enjoying the culinary delights from the kitchen, which happened

to be hot dogs that day. A GNA (Geriatric Nursing Assistant), who is just a

nursing assistant (sometimes you will see different terminologies used in long

term care and this is an example of that), reported to the nurse that Ethan was

choking on food. There is no difference between GNA and CNA. The CNA sees

he is choking. She goes to the LPN, who is very typically found in a nursing

home, and says, “You know Ethan is choking.”

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The Heimlich maneuver was immediately attempted which was unsuccessful. The

physician was in the building, which is not a usual occurrence in long term care,

but he had happened to be there that day and he advised staff to take Ethan back

to his room and call 911, which was done. By the time they got him back to his

room from the dining room, Ethan was in a cardiopulmonary arrest and they

started CPR. Eight minutes later, EMS had arrived and they transported him to a

hospital and at 6:10 PM, where he was pronounced dead.

Angie:

Slide 9 As Pat mentioned earlier, there are tons of very specific records from nursing

homes. There are skills lists; there are assessment tools; there are so many

documents that you won‟t see in other records from hospitals or from doctor‟s

offices. And today we are just going talk about a few select documents. We can‟t

go through each and every one of them, but we are going to discuss the

documents that we thought were helpful in review of this long term care case.

Dana:

Slide 10 The first one we are going to talk about is the MDS and I know Pat mentioned

that briefly in her presentation. Let me just give you a little background about this.

In 1987, the federal government mandated that all Medicare certified long term

care facilities or nursing homes provide a detailed assessment of patients that

would then be linked to their individual care plan. And this process is known as

the resident assessment instrument, which is called the RAI. So, the three

documents that make up that resident assessment instrument are the MDS, the

RAP which Angie is going to talk about in just a second, and the care plan.

So the MDS is the first of the 3 documents. Now, the main purpose of the MDS is

to provide that detailed assessment information upon which the care plan can be

based. It is also used for reimbursement, but because it is federally mandated, it is

applicable to facilities throughout the US. It does not vary between states. So, if

you are looking at a nursing home case outside of your state, the MDS is going to

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look the same. It is also meant to be a communication tool, to track changes and

evaluate the care plan. And, as you can see, it identifies physical and mental

functioning. It provides specific information on highly litigated areas of pressure

ulcers and falls.

Now, I will just say this little disclaimer. The MDS that we are using in this

particular case example is the 2.0 version. It is before October 2010. The MDS

3.0 rolled out and we will be discussing some of the main differences between the

2.0 version and the 3.0 version as we review some of these documents. But what

you need to be aware of is the date that rolled out - October 2010. So if you have

a long term care case you are reviewing prior to October 2010 you need to be

looking at the MDS 2.0.

Angie:

Slide 11 Dana mentioned the 3.0 MDS came out in October and basically it is a bit more in

depth than the 2.0. If you answer a question to show that there is a deficit, it goes

into more in depth questions. So it collects a little more data than what you see in

the 2.0. One of the important things about the MDS is, like Dana said, it paints an

overall picture. It is a very comprehensive assessment towards the patient but it is

very important to compare this document to the other documentation within the

file. I often find the MDS might say one thing but ADL documentation, which is

performed by the nursing assistant, says another. Nursing says one thing and

therapy says another. We are going to talk a little bit about each of these and why

it is important to compare.

Like I mentioned, the ADL (Activities of Daily Living) documentation in the

nursing home is completed by the nursing assistants. And often you will find

comments about how much assistance was needed with care, how much they ate,

how much assistance they needed, whether or not they were incontinent. So it is a

really good place to gather a lot of information and determine whether or not they

were consistent throughout the organization.

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It is also important to compare the MDS to what is documented: the therapy

notes, physical therapy, occupational therapy, and speech therapy notes. RNP

stands for Restorative Nursing Program, which is a program within the long term

care environment. When a patient is discharged from physical therapy, he will

then be taken under the wing of the restorative nursing program so that they can

work to maintain their current level of functioning. They do daily ambulation and

range of motion. The nursing assistants that work in the RNP program should

document the level of care provided to them and their response to treatment. This

is another area that is important to compare.

Now in this case, we know that Ethan choked and we know that he had

progressive muscular disease; so, we are specifically going to look at any

documentation that helps us prove negligence in this event. We will be looking at

his ability to feed himself and whether it was consistently documented among the

disciplines. Also, what was his swallowing ability and his meal intake? How

much supervision did he require? Was there a significant change in his

condition? Therapy notes, specifically speech therapy, are going to be very

important - if there are any in this case - to determine if he has been evaluated for

speech, swallowing abilities, and what were the recommendations? If you have a

case with swallowing issue and you don‟t have a speech therapy note, it is always

good to take a look at the dietary or nutrition notes to see what was there.

Dana:

Slide 12 We are still on MDS and you want to compare what Angie just said with the

nutrition notes. So, based on the allegation that the Hopper Staff failed to

appropriately monitor that resulted in Ethan choking to death, what are you

looking for when you go to these records? You need to know if he was able to

safely feed himself. Did he require assistance? Did he require a special diet

related to his ability to chew or swallow? Did the staff assess these issues? If so,

were those assessments accurate? Go back and compare the MDS sections related

to the ADL and his physical ability to the nutrition notes. And as Angie was

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talking about earlier, you are always looking for consistency and inconsistencies.

We know that if one thing is documented in multiple places, the higher the

instance of inconsistencies. If it is not consistent, then you want to investigate

that a little further and include the details in the report you are preparing for the

attorney.

Angie:

Slide 13 And, of course, you have to compare the MDS documentation to the nursing notes

and nursing summaries. In long term care you will find nursing monthly

summaries and you will also have myriad of notes. They don‟t have to document

on a daily basis but certainly if there is a change in condition or anything of

concern, you find notes for that.

The minimum requirement in a nursing facility is monthly documentation and the

requirements are based upon whether or not that patient is skilled or not skilled.

But definitely look through the nursing notes and the monthly summaries and

make sure that the information in there is consistent with what you are finding on

the MDS. And specifically, like Dana said, in this case you are looking at

anything involving his intake, his swallowing ability, supervision required during

meal time, any problem behaviors that he had, and anything demonstrated that

could have been problematic or caused the problem. What about pain? Was that a

factor? These are things to consider in this matter particularly.

Dana:

Slide 14 So, this is actually what an MDS looks like and we want to learn a little bit more

abut Ethan‟s functional abilities. I realize this maybe a bit difficult for you to see

on the screen but I want to point out a couple of things so you can either switch to

a full screen view to see the document more clearly or you can adjust the zoom on

your machine.

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On the left hand side, you are going to see the date of the assessment reference

which is 4/18/06. Can you see my mouse circling that? This is important because

the date the MDS is done reflects the patient‟s abilities over the prior 7 days. So

4/18/06 really reflects 4/11/06 to 4/18/06. This is important when you are

comparing the MDS to the other documents we just went through. As you review

the nurses‟ notes and review something that you think should have been included

in the MDS like a fall, for instance, and you see that it is not in the MDS, what

you want to do is go back and see what your assessment date is. Did it fall within

that range?

Then on the top right is where you find some psych indicators such as anxiety and

depression. Then you should move down towards the middle of the page to see

some behavioral symptoms - this is on the right hand side - like wandering,

abusive behavior, etc. We‟ll get to that highlighted section shortly.

Angie:

Slide 15 Okay. Here we have just a part of the MDS that we just blew up. It talks about

memory. This is directly from Mr. Allen‟s MDS so what we can glean from this is

he did have long and short term memory problems. Looking down at the area B3,

we specifically want to know over the last 7 days, did he remember the current

season? Did he remember the location of his room? Did he remember staff names

or faces; did he remember he was in a nursing home? And you will see none of

those are checked so he had no recall of any those 4 areas. This tells me, his status

was moderately impaired. The next area under there is cognitive skills for daily

decision making, which shows he was moderately impaired. He had poor decision

making ability and he required cues and supervision to make these decisions. The

MDS is such a great document as you can see it has very, very specific

information that you can get on the patient. It is a great place to start doing the

review, and you get a good review of the patient‟s ability.

Dana:

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Slide 16 Here is the highlighted section I promised we were going to get to. This is the

ADL section and it obviously describes a person‟s performance of his ADLs. It is

assessed over all shifts during the prior 7 days we talked about. There are codes

for rating the level of assistance and then there are codes to rate the level of

support required to complete the task. You will see that on the bottom right of

your screen that it says self-support and support. When you review Ethan‟s

records, take a moment to study this section of the MDS because it is going to

have important information for you about his ability to feed himself and the codes

are the ones we have highlighted for you.

Angie:

Slide 17 Now again, this is an example of Mr. Allen‟s MDS so what you are seeing here is

his current status as of April 2006. Remember, his date of death is in August and

this is a few months prior. What we can see here at the top left is the assessment

of his ADLs status. As far as walking in the room, walking in the corridor and

walking on the unit, it shows he required only supervision but he did require some

limited assistance with dressing. But, for the category of eating, there was 2 zeros

there so this shows that he is totally independent, doesn‟t even need set up with

his tray. The toilet use, personal hygiene, bathing - it only shows he needed

supervision. There is a highlighted area at the bottom left describing scoring for

continence. It shows a zero, which means completely continent, 1 means usually

continent, 2 is occasionally and then 3 is frequently or totally incontinent. The

scoring here for Mr. Allen shows he was totally continent for bowel but, he was

occasionally continent of his bladder.

Another important area I use constantly when reviewing these cases on the MDS,

is the pain section. You will find out that there is a little yellow indicator on the

right hand side down underneath current problems, and an area for pain

symptoms. Now this was not a problematic area for Mr. Allen but, a lot of older

patients in long term care facilities have pain problem. Whether it is arthritis or

compression fractures, you always look at the pain issues involved there and grab

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some really important information. If you see notes in the section talking about

moaning or yelling out or behavioral issue, it could be related to pain. If so, is the

nursing staff recognizing that? Is the patient on or off the medication? Pain is not

one of the issues of this case so it is not relevant to this case but, I had to throw it

in there! But do note that the pain section also talks about the highest level of pain

that the patient had for the prior 7 days, so you are only looking back for one

week‟s time.

Now just beneath that area there is a section that says accidents. This is where

you are going to find documentation of falls. There are 3 different sections with

no documentation if the patient had a fall in the past 30 days. Did he have a fall

within the past 2-6 months, and if so, did he have a fracture anytime in the past 6

months?

Dana:

Slide 18 Nutritional information is at the top left of this page and is something very

important to this particular case but, it is also important, in my opinion, to most

long term cases. In the prior slide that we just showed you, if you look on the

right hand side below the yellow marker, you will see at the very bottom: height,

weight, and weight change. If you are looking for something that is nutritionally

related, such as a pressure ulcer case, this is going to be a great place to start

looking at his overall weight. Was it increasing? Was it stable? It kind of gives

you good view of the overall nutritional status.

Now back to the slide. Nutritional approaches are at the top left, and as you can

see, it is talking about 1) are they getting IV, 2) are they on a feeding tube, 3) are

they on a planned weight change program? Again, this is related to Mr. Allen and

he is none of those. Obviously, he wouldn‟t be because he was deemed

completely independent with his feeding. Below that are your ulcers, the

difference between MDS 2.0 and 3.0. You are going to see in the 3.0, that this

area has been expanded quite a bit. But on MDS 2.0, which is what we are dealing

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with, you can see the stages all listed and the definition is listed. That is

important because we all know that a lot times, staging of pressure ulcer is

somewhat subjective, but here is what their definitions are spelled out for them.

And, as you can see, he didn‟t have any problems with skin, as you would expect.

Then the types of ulcers - is it a pressure ulcer, is it a stasis ulcer, skin problems,

skin treatments, foot problems? All of that is listed there for you. It is a great

starting point if you are looking at a pressure ulcer case.

Over on the top right side are special treatments, procedures and programs. Now

this is an interesting section because it goes back prior 14 days. So the sections

that we have discussed so far were the prior 7 days. This one goes back 14 and

then there is a couple of other sections that also go back 14 days. I am telling you

this so that you are aware that when you are looking at MDS you need to be

aware of the timeframe that this information was gathered. At the bottom line you

will have information about the therapies, the strains, and physician visits. I am

not going to spend time with you on the specifics on this document. This is part

of your case review and things that you will be doing and I don‟t want to take

away all of your fun. For now, I just want to point out where the information can

be found.

Let‟s move on from the MDS to the second document on the resident assessment

instrument, the RAP.

Pat: Before you do, there is question from our audience asking, “Is the MDS used

regardless of payer source?”

Angie: Yes it is! Great question!

Pat: Yeah, that is good!

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Dana: So in other words, you should see this for every single long term care case. MDS

should be a part of the record as long as he was there long enough to have the

MDS completed. These are completed at certain times intervals; admissions is

one of these times, but they have a certain amount of days. Is it 2 weeks, Angie,

or 14 days to complete the initial MDS?

Angie: I believe it is 14 days and I tell you I don‟t want to quote if it has changed or not

because there has been some changes and I couldn‟t say 100% if it is. They made

it a 7 day or 14 day and then a 21 day, but I know that there have been some

changes in regards to the timing requirements.

Pat: I think we have just given the answer to the second question, so I think we should

just move on!

Dana: Oh good! Sounds good to me!

Angie:

Slide 20 Right on to the RAP! Again, here we are talking about prior to October 2010 there

was a document called the RAP - Resident Assessment Protocol. Now after 2010,

this document also changed and now it is called a CAA – a Care Assessment

Area. Essentially they perform the same task as the RAP. You can kind of think

of it as a RAP sheet. It documents all the resident‟s problems. All of the

questions and answers from the MDS that indicate there is a deficit within a

patient go over to trigger a RAP. And the RAP is then a foundation for the

patient‟s individualized plan of care. Now as we just saw in Mr. Allen‟s MDS, he

had a significant cognition issue, so we would expect to see that trigger a RAP

and the staff would want to proceed to formulate a care plan for that resident.

Now in some cases, there is a reason not to proceed. For example, if you have a

patient that triggers below ideal body weight, but the reason for that is an above

the knee amputation, then we can document the reason for the low body weight,

and state - “do not proceed to care plan.” So we are going to proceed to the care

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plan when there is a problem but we need to have a plan of care for that issue

there.

Dana:

Slide 21 This is Ethan Allen‟s RAP (or RAP sheet is how I like to call it after Angie told

me that, I thought that was funny). You want to look to see cognitive is definitely

on that list, potential for injury due to falls, self-care deficit, urinary issues,

urinary incontinence, and psychotropic drug use. These are all based on the MDS

but not all of his issues are listed on his RAP.

Angie:

Slide 22 Now this is an example of a RAP and Resident Assessment Protocol summary but

this one is not for Mr. Allen. This is just an example so you can see what it looks

like. In his case they didn‟t produce the RAP so we didn‟t know what to show

you. But this is just an example. This patient‟s ADL functional ability triggered.

This patient was incontinent. There were some mood issues, obvious previous

falls, nutritional issues and dehydration possibilities and all of those were

triggered. On this document, the staff has to document where they found the

evidence to support the issues. For example, there was a deficit in the ADL

function and in this case they said “See social worker notes.” You would think it

would be under the ADL sheet or nursing notes but they say social work. Next,

the check in the far right head corner that they are going to proceed with the plan

of care and then you will expect then to see a care plan for each of these issues

that have an X besides them.

Pat: Any questions?

Angie: Yes, you have a question for them?

Pat: Okay you may have to fill in a couple of words at the end of that question there.

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Angie: Is a comprehensive assessment of each resident‟s functional abilities, required in a

Medicare Medicaid facility? I think that‟s what the questions states?

Pat: We have eliminated a character, chopped it off prematurely, so we have people

voting and I think we also have a question or two from people up to this point. So

I will give those to you after we are done with our poll. I have a question for you,

Angie and Dana: Who collects the data for an MDS? where is all that coming

from for all those items?

Angie: Typically the facility will have an MDS coordinator. She reviews the chart. She

should meet with the patient, assess the patient and review documentation from

all the disciplines to complete the assessment.

Dana: And that position is usually a full time position and paid just to do that particular

function, which is typically an RN.

Pat: It looks like everyone has voted; I am going to close the results and share them.

50% of the people say true and 50% say false.

Angie: Wow! That was kind of a tricky question wasn‟t it? I think the key there are the

words “comprehensive assessment.” RAP is a trigger from the care plan; all the

deficits that were identified trigger the potential problem so that you know to

proceed with the care plan. But, the MDS is actually the assessment, so the

answer would be false.

Dana:

Slide 24 All right! That is good we got people paying attention. We are going to move

from the RAP. We are now into the third portion of the resident assessment

instrument we talked about. The MDS is the first portion, the RAP is the second,

and the care plan is the third. We should all know what care plans are. We are

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familiar with them; we suffered through these in nursing school and use them in

our clinical practice regardless of what area your clinical practice lies.

So after reviewing the MDS and getting the RAPs triggered, I find it helpful to

just kind of take a minute when I am doing my own case now, to figure out what I

expect to see on this care plan before I actually look at. It is a little game I play to

compare what I came up with and what the staff came up with. Again, just like in

other areas, the care plan is a dynamic tool and it is used by staff to guide patient

care. When there is a change in condition, you should also see a change in that

care plan based on that changing condition.

And an example will be, if a patient falls, the plan of care needs to be updated to

include the new fall preventions. The staff would certainly be doing something

new to prevent further falls so you want to look to the care plan to see was that

risk identified, was that updated, and were the interventions updated. Now, you

are going to go back and look at the nursing and the CNA documents to see were

those interventions actually implemented? Where is the evidence of that?

So when you are reviewing the patient‟s plan of care you want to look and see if it

appropriate. Is it complete? Where was the evidence that it was followed? You

know, having a beautiful care plan is a great thing , but if they don‟t implement

the interventions that are listed there, that is weakness. And is the care plan

updated as needed? Now, one of the things I want to say about care plans is in

long term care most of the long term care facilities have yet to make the transition

over to electronic medical records. You actually can see the date the care plans

are updated electronically. My experience has been you can see the day and time

that those changes were implemented. I recently had a fall case where some of

the injury-preventing interventions like floor mats were discontinued the day

before the patient fell. That is going to be pretty compelling evidence as this case

moves forward. But most of the care plans that you are going to see, and most of

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the documents that you are going to see, are still hand written except for the

MDS. That is usually computerized.

Pat: And, you know, I promised I would share a couple of questions with you right

after we did the poll and I realize I didn‟t do that. So let me give you a couple that

came in. A person asked, “Can the work product from the critique of the

documents in this program be used as a writing sample for marketing in

purposes?”

Angie: Sure!

Dana: Yes, and I think that is one of the great things about doing these kinds of

workshops. If you are looking to develop some work samples and you are

actually not doing legal nurse consultant work, this is a great way to do that.

Pat: Next question. “Who does the MDS because when you see an MDS, there are

many signatures with lots of different dates?”

Angie: That is a great question! Like we mentioned there is an RN that is in the role of

the MDS coordinator and she is the one who does all the nursing questions. The

RN meets with residents, assesses the residents, and reviews the record. But,

there are other members of the interdisciplinary team, which is essentially the care

plan team. They are involved in planning the resident‟s care. So you are going to

have Dietary assessing the dietary needs and completing the dietary questions.

The Social Services Department documents the cognitive status and later,

behavioral problems. You are going to have the Activities Department involved,

and someone from therapy involved. When they have the care plan meeting, all

these disciplines are together. You will give the RAP and the care plan that was

developed from that, to discuss the patient‟s care. The resident and his family is

invited to attend the care plan session, so that everyone can take part of the care

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planning. That is a great time to discuss any problems that come up, add to the

care plan, and incorporate any new interventions.

Dana: To answer the question, when you look at the front sheet, it has several signatures

but as you move through the MDS documents, you will find there is a single page

with one signature on it. That is usually who I identify as the MDS coordinator.

There are also the ones that usually will fill out the RAPS that are triggered by the

MDS and they sign those as well.

Pat: There is another question. “In reviewing long term cases I have found the MDS

was completed on a schedule such as 5 days, 14, 30 days and 60 days, but there is

not always a RAP completed in conjunction with the MDS. Is it a requirement to

complete the RAP with every MDS?”

Angie: You know, that is a good question and since there are so many done as part of

admission and sequence, I don‟t believe that they have to have a RAP with each

and every one of these updates. But, like I said, things changed back in October

and I am not completely up to date on what all these changes encapsulate. I

wouldn‟t want to say and give anybody a wrong answer.

Dana: I know in going through records, I see RAPs much less frequently than MDSs. It

seems like it is more on a yearly basis or if there is significant change in the

resident condition that might change the RAP, but there isn‟t a 1:1 ratio of every

MDS to RAP.

Angie: And just to clarify, the MDS is done upon admission and there is a series of

MDSs that they go through. The full assessment is required yearly, but quarterly

is what we call a “mini-MDS.” It is like a quarterly MDS, a smaller version. It

doesn‟t ask as many questions and they don‟t have to have a RAP every time that

is completed. It‟s quarterly assessment of the resident‟s needs to see if there are

any changes in their condition that warrant changes to the plan of care.

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Pat: That is it for questions right now, but please keep adding them in and we‟ll

answer them before we terminate today.

Angie:

Slide 25 We are talking again about the plan of care and looking at this case about Ethan

Allen. When you are reviewing his care plan, is the level of feeding with

assistance addressed? What about his swallowing ability? Has Dietary added any

input to the care plan? Have they added any guidelines? Have the dietary orders

changed and if the orders changed at some point, was that updated and reflected

on the plan of care? Are there any issues with his weight and if so, is that

documented? And like Dana said, most importantly, any interventions that aren‟t

indicated as needed on the care plan, is there evidence that they were followed up

on in the nursing notes?

As we‟ve talked about several times, this man has a progressive neuromuscular

disease so he is going to be changing, and so will his needs. Was that care plan

updated as needed to meet his level of care need?

Dana: And I will just say you don‟t need to go through the MDS and RAP process to

update the care plan. The care plan is just like in acute care, home care and any

other care that we are delivering as nurses. If there is a change in a patient‟s

condition, we would expect the care plan to address that.

Angie: In long term care facilities the MDS coordinator is not the only person who can

touch that care plan. The care plan might be initially written by the MDS

coordinator and the care plan coordinator, but it is just meant to stay on the

nursing unit. It should be accessible to the CNAs and the nursing staff at all times

and the staff is encouraged to update it anytime there is a change that affects the

care that should be delivered to that resident.

Dana:

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Slide 26 Ethan‟s care plan, as you can see, is very typical. It is a pre-printed sheet that is

filled out that meets the criteria of being individualized. You will see the

diagnosis up at the top. It says care plan, alteration in nutrition and then it has

problem number 1. Well, we get excited when we see the number 1 problem is

alteration in nutrition, when we know that this guy choked to death. But, I will

caution you, that doesn‟t necessarily mean that the staff felt it was his primary

problem or a way of prioritizing. It may be just the way it was numbered off the

RAP. So, usually that number does not have a lot of relevance.

If you come down you see it looks like this was written 10/06/05. I am not sure

exactly what that date is. It looks a little illegible to me, but they have checked

off dehydration, constipation, and non-compliance. I wonder what that means,

non-compliance? Then you can see there is other relevant information on this

document that we have conveniently highlighted for you, but I just want to give

you an overall sense this is what the care plan looks like. This is what you are

assessing - is this appropriate? Is there something on here that should be added? Is

there something here that is inappropriate, that shouldn‟t be on there? You can see

here he is taking a regular diet and that would go along with the MDS that we

looked at, where it said that he was an independent feeder.

Angie:

Slide 27 I like therapy notes. When therapy is involved with the resident in a long term

care facility, they see them on a regular basis and document on a regular basis, so

we have documentation. This gives us something to look at because as I

mentioned, he is a non-skilled patient, and there is not necessarily going to be a

lot of nursing documentation to read or go through. And therapy notes are usually

very specific for all kinds of great information, especially on that initial

assessment and usually on discharge as well. This is a great place to find out what

was his level of functioning, what are his current functional deficits? Pain? This is

a great place to find out if the patient has pain. And as I mentioned before, you

will find a lot of patients with long term care have pain problems, and yet it is

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never addressed by nursing. There is no pain medication ordered yet, but you will

see that every time they went to therapy, they asked them to write down their

pain. They got a level of 6 out of 10 for their pain, which got worse during

therapy. Often there‟s no document saying they informed nursing of the pain

level or that the nurses contacted a doctor for an order based on that pain level.

See if that was followed through upon.

The section for Cognitive status is a great place to check. You will find out what

therapy department thinks here. You are going to see the nursing documents but

what is therapy showing? Because therapy is writing specifically to document if

this patient is retaining his education. Does he remember to lock his wheelchair

every time he gets up, every time he sits down or goes to get up off the

wheelchair? That is assessed every single time, so you are looking at some

consistent documentation. Whereas in the nursing department, you have different

nurses, different shifts and often you find a lot fluctuating documentation.

Therapy is generally pretty consistent because you have the same therapist, so

assessments are going to be more consistent.

They also document any limitations the patient has or issues with safety

awareness, and of course they always have a treatment plan. I definitely will go

through his therapy notes and note what they are assessing. Look at the

functional level of the patient and compare it to the other documentation within

the file. In fact, I just reviewed a case of a patient yesterday and it was a patient

who apparently became suddenly ill with respiratory issues. After going to the

hospital he was admitted, and of course, I wouldn‟t be looking at it unless there

was a bad outcome. The patient ended up dying and there is nothing in the nursing

notes. For days it looks like everything is fine because there is no documentation

at all. But the patient was in therapy and looking at those notes, there are all kinds

of problems going on: shortness of breath, lethargy and weakness, and refusing

therapy because he doesn‟t feel well. So again, it‟s a great source of information.

Dana:

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Slide 28 Nutrition notes are also very fun to read as a legal nurse consultant. Nutrition is

usually going to play a role in almost every long term case that you look at.

Pressure ulcers are certainly related to nutritional status. What is their protein

intake? Are they getting the proper nutrition to help heal the wounds? Were they

getting the proper nutrition to prevent that pressure ulcer? Dehydration and falls -

was it related to some type of nutrition or dehydration in any way? Weights are

usually ordered weekly for the first month or so and then they go to monthly so

long as there are no issues like weight loss, pressure ulcers, that kind of thing. If

the patient is losing weight, are they following up on that? Are they reporting

significant weight loss to the physician and the responsible person? That is

something that you see a lot in long term care facilities. The personal

representative a responsible person, and it is usually the next of kin or power of

attorney.

Are proper referral notes made to the dietician? And if there was a referral made

to the dietician, did the dietician make recommendations? They always do and

where is the evidence that those recommendations were followed? For example,

in a pressure ulcer case, the dietician knows that this person has inadequate

proteins stores and recommends ProMod which is a protein supplement. She

wants that to be given twice a day. You need to go and say, “Okay here is the

recommendation, let me go to the I&O sheet, and let me go to CNA

documentation. Let me see that there is evidence that the supplement was given to

the patient consistently”, and you also want to see if they took the supplement.

Did they eat or drink the supplement that was given to them?

I know in pressure ulcer cases I have found a treasure trove on the plaintiff side of

inadequate supplementation. The dietician made the recommendation and it was

not carried out by the nursing staff 75% of the time. You also ask to see if the

appropriate labs were ordered. Are these patients being monitored appropriately

based on the nutrition issues that they may be having? Was the care plan

updated? So there is lots of information from nutrition and it is usually a pretty

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good source of information for legal nurse consultants to look at for most cases

that involve long term care.

Angie:

Slide 29 The treatment and medication administration records can often reveal a failure to

follow physician orders. Dana was just talking about checking to make sure that

nutrition recommendations were carried through. Sometimes, oftentimes, in

facilities you will find that there is an issue of communication. The doctor or a

consulting registered dietician may take the case, look at the patient and make

recommendations. Then the nursing staff needs to take those recommendations

and contact the physician, get the order and have the order implemented. And

often I find a problem with that. So in reviewing this documentation, MARs and

the TARs, you can sometimes pick up on that.

Also you want to make sure that you have reviewed that to ensure medications

and treatments are carried over from month to month. There are processes in long

term care where the MAR is in the treatment records, and are reviewed at the end

of the month, to make sure they are accurate and include all of the current

medications, any new orders that came out since the treatment sheet and the MAR

was printed. And the evening before the day shift goes off, like if it is evening

shift on May 31st, they are going to go through once again and make sure no

orders have come through during the time they were last checked until the current

time. Sometimes they have none, but sometimes accidents happen and orders are

dropped. So do look for those because that is what you will find sometimes if you

are looking and saying, they ordered a supplement and all of a sudden they are not

getting it. What happened here? Because mistakes do happen.

If dietary recommendations require labs or certain supplements, do look and make

sure that they will carry it through. Failure to communicate recommendations or

communicate any issues in a long term care facility can end up being kind of a

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theme of a case for an attorney, if you found that to be consistent throughout the

care that is delivered throughout the disciplines.

Dana:

Slide 30 And the same can be said for the ADL flow sheets. These are typically completed

by the nursing assistant level. Are they complete? Are they thorough? Are they

following up on any abnormal findings? If they find they have abnormal vital

signs or something like that, are they reporting them to the LPN? Does the ADL

status listed on those sheets match the other documentation? I will just caution

you, we are talking about a lot of different documents here. What you need to

focus on is what is relevant to the case that you are reviewing. I think if you see

an inconsistency in an ADL flow sheet, you have to ask, is that relevant to the

case that you are reviewing? If not, you might just not want to point that out.

Was it an inaccurate assessment or did they fail to properly assess? If it is relevant

to your case, of course, you want to delve deeper into that, but I know that one

mistake newer LNCs make is to include irrelevant facts in their reports. And it is

because you see that there was something not filled out correctly, or something

that was not followed up on, that you want to point that out – inconsistencies and

inadequacies. Angie was just talking about the themes or failure to properly

communicate, but if these issues are not particularly relevant to your case, you

don‟t want to spend a lot of time on them. Just pointing it out is enough. That is

just my opinion; I don‟t know if Angie or Pat agrees with me or not, I am sure

they would speak up if they didn‟t.

Angie:

Slide 31 Exactly and like we said earlier, you need to make your client happy with your

report and the information provided within it. Also, billing and spending a lot

time on information that is not relevant, is not going to make the client happy if

he/she thinks you have spent entirely too much time reviewing the case.

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Social services notes are the Jerry Springer‟s section of the medical record! I love

to read social services notes. They contain the background information and social

history of the client, but also any psychosocial issues, dysfunctional family

information, family concerns and family complaints. There is so much more great

information in there. So don‟t skip over it thinking, “Oh this isn‟t important”,

because it is. That is where you are going to find quotes, family members saying,

“They are just tying to kill my mother here!” And, “I want to move her to another

facility!” You will be amazed what is documented in there. So always review

them.

Social services notes also talk about behavioral issues and cognitive status.

Whether or not you are working for the plaintiff or the defense, there is great

information in here. If you have any issue you want to cover about the plaintiffs

that could be bad for the plaintiff attorney or could be good if it is bad information

for the defense, you need to let them know that. Share the good, the bad and the

ugly! Things that you might find in this section of the record include drug use,

being in jail, noncompliance or criminal history.

I know there was one case I reviewed and the gentleman was able to get around in

a motorized wheelchair and they would document that. He would leave the

facility, wheel his little motorized wheelchair down the street to a convenience

store and buy his drugs. You know, use these drugs and come back to the facility.

So there were tons of issues with non-compliance documented there. If someone

had totally skipped that section of the chart, they would have missed that because

it wasn‟t documented in the daily nursing notes or anywhere else. And, of course,

after the plaintiff attorney hears that, he is likely to not take that case, because that

is quite an issue there.

Pat: And, Angie, I can think of a case where a son was coming in and visiting his

mother, threatening her, hitting her, and eating her food. She was losing weight

and it was case where the son then turned around and said that he wanted to sue

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the nursing home for neglect. The plaintiff attorney asked me to review the case.

It was documented in the social services notes!

Angie: Absolutely! You know I had a very similar case once, Pat.

Pat: Yeah, it is important to be kind to your children!

Dana: I would just say that surprise is the enemy of the trial attorney. When you uncover

anything that is going to reflect poorly on his client, he needs to know that. I think

we are skipping the polling question, correct?

Pat: That is right, in the interest of time.

Dana:

Slide 33 So the primary role of the LNC is to evaluate and to render an informed opinion

on the delivery of health care and the resulting outcome. So this is really what you

are going to be doing when you evaluate and analyze the case we gave. We want

you to render your informed opinion on the health care that was delivered to

Ethan and the resulting outcome of that health care.

Angie: We put this in there because sometimes you just might get stuck in performing the

review and you should always go back to the basics. What are you being asked to

do? Summarize and analyze these medical records. The attorney relies very

heavily on us to interpret those big medical records and convert them into a small

report, in layman‟s terms, that they can understand. So as I said earlier, define

these medial terms and anything that you find significant that is a medical issue.

You need to explain to the attorney why it is important. What does this mean?

Dana:

Slide 34 So focusing on the review for Ethan Allen, this is what you should be working on

between this week and next week‟s session. You want to focus on the claim,

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which is the allegation that the Hopper nursing staff failed to appropriately

monitor Ethan, which led to him eating a hot dog on which he choked to death. So

you want to look for evidence to support or refute that allegation as you review

these records. And again, you don‟t want your attorney to be surprised further

down the road about what is in that record. If you find evidence that supports the

claim, great. If you find evidence that does not support the claim, you also want to

include that.

As you find that evidence, the attorney will want to look at it too. He is going to

want to be able to put his hands on that document and believe me, he doesn‟t want

to flip through a 1,000 pages to find it. So you need to put a reference in your

report. These happen to be page numbered for you. So you want to refer to that

page number. We had an attorney come to speak at our Central Virginia chapter

of the AALNC last month. He does multi–district litigation and he talked about

being on a flight going out to depose a witness. Of course, he was not prepared

prior to that flight, so he was looking at the nurse‟s report on his way out there

and to his horror, there was no reference to the documents that she was talking

about. She would say the nurses‟ note from August 4, 2006 said such and such,

but he couldn‟t find it in the record because she didn‟t put the Bates number on it.

So it is really important to be able to do that.

Angie: To add to that story, also to the attorney‟s horror, the nurse didn‟t put her contact

information on the report. So, he needed to find the information and get his hands

on this record, but he didn‟t have a way to call her. He is on a flight and he

doesn‟t have a phone number. Maybe he has it back in his office, but she didn‟t

put it on her report. So remember, put your contact information in the report to the

attorney as well as referencing those page numbers if they are present on the

records.

Dana: Most of the people I work with are last minute kind of people, so it is not an

unusual scenario for them to be reading your report on the plane to the deposition.

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And, if they have a question, you want them to be able to get in touch with you.

You want your clients to be dependent on you. So what will you recommend to

the attorney? And your recommendation should be based on the purpose of your

report. Are you screening this for the plaintiff? Are you providing an analysis for

the defense of a claim that has already been filed? The other thing I would say is

that your reports are dynamic documents. They are going to change when you get

additional discovery. More records received in response to a request may shed

some light on a pre-existing condition, so you should be able to go back to the

report and amend it. Keep the door open for more work by always ending your

report with the offer to review additional medical records or assist in finding

experts for doing medial billing analysis. Your goal is to provide an excellent

report and to get more work.

Angie:

Slide 35 Begin with the end in mind. You have heard that a couple of times today. Always

be thinking about the purpose. You know it is great to spend a few minutes with a

client on the phone when they call you up and say, “Mrs. Allen came into my

office. She was very upset and she says the staff at Hopper Nursing Home killed

her son.” Get as much information as you can and find out exactly what this client

wants from you. What type of report do they want? Always ask them if they

prefer a narrative report or maybe a table chronology? Sometimes they say, “I

don‟t know, give me the best thing or whatever you recommend”, and then that is

fine. But sometimes they have very specific opinions and they will share those

with you. In this case we are going to be asking you to draft a narrative

chronology. So that is what you are going to be working on in the next week.

Going back to looking at the end in mind, who asked for the report? Is it a

plaintiff or defense attorney? Is it a risk management facility or an insurance

company? And what are they going to do with your report? How will it be used?

And as I mentioned before, do not forget to define these medical terms and

explain the significance of any findings. It is also good to have a systematic

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review, or a certain method that you use. Scan and compare those important but

relevant documents. And we know in this case that is going to be his care plan,

the dietary needs, anything that references his ability to feed himself and his

dietary intake. Look over this physician order and any consults that were done.

New legal nurse consultants can get caught up in the review of unrelated issues.

If you start looking at some documents and you realize that it really has no

bearing on the case whatsoever, you know not to include it in the review. You do

need to go through those just like I said earlier, because if you decided that social

services notes were relevant to assessing his swallowing ability and you skipped

over them, you might have missed the fact, just as an example, that maybe he had

an extensive drug history. Or he had gone somewhere that day and he used drugs

while he was out of the facility. That is the type of information you are getting

from social services. So I am not saying you skip over them, I am just saying if it

is not relevant, don‟t spend a lot of time and dwell on it in the report, because the

attorney is going to say, “Why do I need to know this? It is not important.”

You will see that there is a Bates number on the bottom, right hand corner and

they are out of sequence. That is because we didn‟t give you all of the 500 pages

in this case. You would not have liked printing out 500 pages. So we gave you

the relevant documents to this case and Bate stamped those records in the upper

right hand corner. That is the document number that you will reference in your

report.

Dana:

Slide 36 This is just an example to help you get started. We have written an introductory

paragraph and you start at the second paragraph. This is in the form of a narrative

summary; usually it is presented a little different between different legal nurse

consultants. My reports looks different than Angie and Pat‟s. This is just one

example. We want you to write the medical summary in chronological order and

remember that this is a focused review, so there is no need to summarize each and

every note, just the relevant facts we talked about this afternoon. In the

32

highlighted section you will see the Bates number reference to the documents and

where this information came from.

Angie: You will also notice in a couple of paragraphs, there is a problem that Pat talked

about earlier, when she was talking about documenting and consistency in the

formatting. Now this is a poorly justified report, because the first paragraph is

indented and the second one is not. So those are the small things that we are

talking about. Be consistent throughout your report.

Slide 37 Keep an inventory of the missing medical records as you go through the file. I

know you have already gone through them and you should have identified a lot of

missing records during the break and some of those will be provided to you

between Session 3 and 4. In any case review, always keeps a record of missing

documents because when you go through discovery and more records are

produced, you always want to go back to that list, update it, document what has

come in, and what you have reviewed. So you always have an up-to-date list of

what records you have reviewed and what is still missing.

When you are thinking about missing records, still consider any outpatient

records, doctors office visits, physical therapy, occupational therapy or speech

therapy that might have been performed on an out patient basis. And also EMS

reports and any diagnostic testing performed. Often in long term care care, you

will have the mobile X-ray come in, and that should be a part of the medical

record. But if you see it ordered and you don‟t have it, you will need to request

that. And, of course, at times there are outpatient physicians and visits and

consults as well. So consider those when you are writing your report.

Dana:

Slide 38 Okay, now for the homework. We want you to perform that focused chronology

of the facts, identifying critical documents from the records that you are using.

We have talked about that. The focused review is particularly important in long

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term care because these people could have been in the facility for years, which is

several boxes for records. In this case the focus is narrow, just a few weeks. But if

the case focuses on a long period of time like a pressure ulcer case, you want to

focus on the claim and the documents critical to that claim.

We want you to list out the missing medical records that you have identified,

analyze facts, and draft your informed opinions based on those facts, while

identifying any breaches of care. We want you to make recommendations based

on your analysis and facts. What should the attorney do from this point forward,

based on what you see in these records?

Pat: We have some additional questions that have come in during the second part of

your presentation. “Can an RN employed as an MDS coordinator be used as an

expert witness for a long term care case?”

Dana: Yes!

Angie: As we talked about earlier, it does vary from state to state. In Virginia, I can say

yes, they have been used and I know that there are other states that have used RNs

employed as an MDS coordinator. Some attorneys will specifically say, “I want

only want a nurse that is on the floor that is giving the hands on care”, but one

way you can get around that is the MDS coordinator might not be giving out the

meds and the treatments, but she does assess as she meets with the patients to

perform that very full comprehensive assessment.

Dana: And I will just add, she is also aware of the state of the care related to the long

term care facility, so they qualify easily in Virginia. But again, state laws are

different, as Angie said.

Pat: “The homework states „narrative chronology‟ is required. Is a table chronology

acceptable for review?”

34

Dana: The assignment says narrative chronology.

Angie: And that is what your attorney client has asked for.

Dana: So if you want to submit a table chronology, feel free to do that. You have paid

for the review. But I think following the narrative chronology is probably a little

more challenging and will force you to practice some of the writing skills we are

offering in this course. I think I can speak for the panel group here, we strongly

recommend that you try out the narrative chronology.

Pat: Okay. There is a statement, “MDS and RAPs in Illinois are to be done with

admission change of condition and yearly”, so we have clarification from one of

our attendees is about the frequency of the RAPS.

Angie: Yes and they are done and we didn‟t mention that, with any significant change in

condition. They are very specific. For example, if you have within a month‟s time

5% weight loss or weight gain or if you lose or gain 10% within the 3 month

period or if there is a change in your functional ability in 2 or more sections, or

for example, if you go from being independent to needing assistance for bathing

and dressing. That would trigger in MDS so that there are a lot of specifics as to

when they are required but that is absolutely correct!

Pat: There is a question from a viewer about the mechanics of being able to watch this

presentation again. When you signed up for the course, we provided it to you in

three formats. The first is the live program in which you are participating in today.

The second is the replay, which are the recorded programs. Think of watching a

television show that has been recorded and at some point later you click a replay

link and then you can see the program again. It will contain audio and the slides,

just as we have presented it. And thirdly, we are also having the programs

transcribed. One person was having problems with the sound fading in and out,

but the transcripts will fill in any blanks that might have occurred in the audio

35

quality and usually sound issues related to the Internet carrier that is providing

you with service. It might be on our end, but it also might be on your end. So we

will have transcripts available for you.

We will send you an announcement through email when the replay links or

transcripts are up and when the slides for Session 4 are available. And as Angie

mentioned, there are some missing records that will be supplied to you. Likely,

the slides and the missing records are going to be posted on Monday and the other

items will follow as soon as the processing of the replay, the transcription and the

creation of the transcripts, is completed.

So we have time for any additional questions and I appreciate everybody staying

to participate in a long day. One more question. “Did the new version of MDS

lead to changes in the RAP report requirements or plans of care? Do all current

patients have to have new MDSs done to update to version 3.0?”

Angie: No, I don‟t believe that they do. No, I am going to give the disclaimer that I am

not completely versed on the new MDS 3.0 in the CAA that came into effect in

October. But what would happen is that if the residents are due for an MDS, let us

say back in October and they are due for MDS in February, they should just get

3.0 at that point. Because from a facility standpoint, if you had to go back and get

everyone up-to-date with the new MDS assessment within a short period of time,

that would be lot of work.

Dana: And I would just caution people, I know that we have talked a lot about MDS and

RAPs, but really what you want to look at it from a legal standpoint in my

opinion. Was the care plan appropriate and were the interventions listed on the

care plan carried out? So whether or not an MDS was filled out, is that going to

impact the care plan and did that have an impact on the patient‟s outcome?

36

Pat: The evaluation form to be sent following this session or after the 4th

session, each

of the sessions that you have seen today, should have been followed by a screen

that flushes out with some questions asking you for feedback and rating the

instructors. There will be a final form that is downloadable for the website to

evaluate the course; it would also appear at the end of Session 4. You will receive

12 contact hours as a result of participating in this course and there is a form

already up that gives you instructions on where to send your check for $15 to get

those 12 contact hours. They are offered by a provider in California and they are

valid in every state. They are particularly useful if you are in a state that requires

contact hours for re-certification or re-licensure.

So with that Angie, Dana, and I are going to close off the program. We

appreciate everybody staying and hope that you have learned a lot and hope that

we haven‟t made your heads spin! You have a week to catch up on the homework

and then join us one week from today at 8 o‟clock. We will do a final hour of

presentation related to this long term care case with Dana and Angie as the

moderators. If you have any questions that we haven‟t answered, any problems

accessing the private password protected members site, if you want to have your

resume or CV added to that site and you haven‟t given it to us up to this point,

please feel free to contact Jill at Med League, who is my senior administrative

assistant. She is the person who has been sending you emails up to this point.

Contact her via email at jillmedleague@gmail.com. She and I will help you with

anything that you need.

And with that, thank you all and go home or if you are home, relax!

Dana: Thanks everybody - talk to you next week

Angie: Have a great one.