OPI Power Hour 3-28-2018

By Adem Lewis / in , , /

good morning happy Wednesday morning thank you for deciding to spend some time with us here at the OPI power our I think we have a pretty interesting agenda we’re going to do we have lots of people coming in and joining us so I’m going to give it another minute or so before we get started remember that if you have questions which I would welcome throughout your participating in this to please type them into the question area and if I could is everyone hearing me if somebody could give me a hands up regarding hearing me that would be terrific great thank you for giving me some hands ups terrific thank you thank you thank you okay well let’s get started today our agenda is going to be really focused upon a review of an information memorandum that initially came out in December and then it was revised here in March to be more clear so we’re gonna spend some time with that because I want to make sure that the message that I gave you that they changed the programming changed that I’m clear and changing that for you and that you have that understanding we’re also going to spend some time regarding treatments and making sure that we’re adding treatments into our assessment and the reasons for that as well as natural supports in our OPI service plans so we have a pretty sturdy if you will conversation that we’re going to be having this morning again I welcome you and I would love to see your questions type them into the question area and I’ll get to them as we go through this information so IM 17-90 is included in the handouts that I thank you all I had some difficulty getting handouts going into the program today only a couple of them made it in but you can always look these up online in the apd case management tools area and over in the apd transmittals area this is an information memorandum so what has changed in this information memorandum is the sections that are in red and the key here is that assessments do not need to be done early we say that again because I said it so many times back in September and October regarding the dates related to our home care worker payment system there was some changes within the mainframe that allowed us to extend the end date of your existing OPI service plans to the next pay period so for example if you had consumer who’s eligibility would be ending on October actually I’m going to use a March date for you on March 31st it will have been extended automatically out to April 14th you’re not seeing it in Oregon access Oregon access looks exactly like you left it but if you go into the on-go system you will see the extension so we have two ways of covering this and I want you to check with your own triple-a or connect with me individually because the key is do you need to create a line item for those gap days as a benefit period beyond or do you need to just go ahead and get it started so the next one perhaps you’re going to start on April 15th perhaps you’ve already gotten it done and it’s going to go ahead and start on April 1st so the need to do these assessments as early as we previously had them arranged has dissipated the home care worker calendar has been updated again I want to show that to you so here you’re seeing the calendar which we had gotten earlier you noticed in the previous copies we had like every other week was skipped well now we can see that in the updated version every week has a presence there and as you read this across so I’m just going to specifically look here at the pay period we have ending on Saturday so on the 31st is when the pay period ends they need homecare workers need to submit their voucher no later than the fourth for timely payment and timely payment is going to occur on the 16th that’s when they actually get the checks cut the state deadline for that so this is the time that your office has to get that information input into the OATH screens for Oregon and project independence vouchers is on the 13th so those dates have not changed what’s different is that we’re saying to you that to have your your plan completed so the voucher would have been created appropriately for the next time period so this is for a CAPs a service benefit that ended on the 31st you needed to have had it done by 3/23 now that allows for 6 days 6 business days so that the vouchers can be printed and the on-go can be updated your clerk would need that whoever inputs this information into the payment systems so that the vouchers can go out timely and there isn’t a break in services so the other thing you will have noticed and you may have already is the language and the date that’s showing up directly above your benefits square so here’s the example right here above the benefit line you’re seeing that when you go in and you create a line you’re going to see a date in fill and that is going to be the pay period that this plan would be ending so it’s Auto filling the end date instead of based upon our assessment it’s going to be based upon when that pay period would end and that will be the suggested or infilled end date for you
again our goal here is that when we look at the benefit periods and we string that together it’s contiguous for our consumers and we can clearly show that we have an assessment and a benefit and that the providers who would fill take care of that are going to also have that information directly available to them so again here’s that calendar if you have the old calendar it might be helpful to print off a new one and update that share that with your co-workers so that they have it also so the payroll calendar is the other clarity point for showing what’s going in here as we spoke of earlier the six days example is that it needs to be updated by 11/2 – in my example here six business days prior to 11/10 so that those vouchers and other printed information can go out timely from APD here in Salem where they all get mailed out from any questions regarding this update to the IM hoping it’s good news for you regarding those early assessments perhaps not needing them to be moved into admin status to push forward I’m not seeing any questions come in so we’re going to move on into treatments the key here is I really need you to understand and to grasp why and how we add these treatments to the caps and why they’re important so here is an example of some treatments that have been added to a case they happened within the caps as you know they show up as you are going through the four ADL’s and you hit next it will take you directly into the treatments section and you’re able to then add the appropriate treatments I’m getting a message that some folks don’t have audio are could I get another hands up for information regarding that are some of you okay that individuals said they have it now good okay treatments in the land of OPI are somewhat different than in that of Medicaid so for those of you who do both types of assessments this information may sound slightly different but we’re really focused on OPI and what is required for that the treatment is an activity about the treatment I really worked at trying not to say that but it just kept coming out that way so I thought go with it here it is the treatment means a treatment that is essentially the act of having that treatment happen maybe it’s getting into the treatment such as a brace such as other sorts of putting it on kind of things taking care of that as well as the getting out of that or to have that treatment facility or treatment methodology occur the treatments that were interested in making sure assuring being confident are getting put into our service assessments are those that are being supported by the home care worker that’s really key home care worker treatments that’s because it could affect wages treatments do not ever affect hours they can support hours we can reference that if we have extra hours required perhaps some of your programs have exceptions to your standard so you’re really looking at what will you want the homecare worker to assist the consumer with if the consumer does it on their own if others such as their family members or other natural supports paid other paid providers not through OPI are doing that treatment we aren’t going to add that treatment we can put that into the appropriate subject area that we have within the caps so here’s an example a feeding tube a feeding tube which is the exact one I’m choosing here is that of maintenance care and RN or a doctor will place it they will insert it into the appropriate area it is to go to they also are required to be the ones who would change that feeding tube a home care worker might be assisting with the feeding or liquid that goes into that feeding tube to help nourish the consumer as well as they might be looking at the skin area around that tube entrance for example if it’s a Jay tube or a tube that is going into the abdomen area it may be have a a cut on the abdomen that is non healing that has to be kept clean as well as taking care of the actual tube and apparatus for the feeding all of those things could be the pieces that could be done by the homecare worker we can only add treatments when our Caps is in a pending status in other words only move it to complete we’re not going to be able to add a new one we are able to go in and put in information regarding that particular thing and we’ll look at that in a little bit as well as we’re going to see how these treatments could affect the homecare workers wage so could treatments affect a person’s service priority level or their service eligibility level that infamous number that we work for and create when we’re doing an assessment no it does not what it does is it just authenticates the need for the individual to have this kind of skilled assistance the definitions are treatments are found there over in the staff tools site and here is that website it’s also included in today’s handouts I think it’s important for us to be very aware that as with a lot of things in our system as we work through our APD definitions and information that we have to use we’re going to notice that some of these terms that if you don’t know this definition may not be consistent with what you might have as common knowledge my example I’m going to point out is that of aerosol therapy under medication so if an individual uses a handheld nebulizer or an inhaler pretty common in today’s world with folks with respiratory issues that will not be included in this kind of definition this has to do aerosol therapy with a complex treatment that is delivered through the respiratory tract and or through a tracheostomy using a humidification device and it requires it has to include humidification and medication and they would need monitoring throughout that treatment so in my mind I go back to hospital rooms folks in an impatient or at a physician’s office where they’re getting a specialized treatment someone is standing right there with them monitoring heart rates respiratory rates lung capacity all of those key factors that those professionals have to monitor so when we look at this list we need to be pretty aware of what these definitions are I would personally encourage you to save off the treatment definition list on your desktop so you can reference that when you’re putting in your caps another one that’s good to think about is sliding scale insulin down here at the very bottom we acknowledge sliding scale insulin meaning that an individual takes a set dose if their blood sugars are over this or over that or under this however this is a next step and that is that it requires frequent keyword frequent physician assessments for dose adjustments so the question to the consumer their caregiver regarding this would have to be with how often when you’re testing your blood sugar are you having to call the doctor to get your insulin amount adjusted and that’s a critical point and we don’t define frequent and I always appreciate times when we aren’t being real black-and-white with words such as that however I think that we have to apply the most pragmatic so frequent to me would not be every other month frequent to me may not even be once a month frequent could be weekly or more often and is the physician adjusting the amount of insulin at that time if that individual has that occurring then to get the enhanced rate to see this elevated up to that next level we also would need to choose as it shows here in the definition medications regarding skilled assessment judgment and monitoring
treatments so here’s a little more on how do we do this and how do we get it started so when you open up that particular field within the caps and again remember I’m inviting you to go ahead and type in any questions you may have treatments you open up the field and we’re gonna focus first upon dates you need to put in a start date now you could use the calendar which is here by this or you could type it in then you would go through and it will also autofill your valid until date that you would have from your front page of your assessment it already has a knowledge of what that might be so it will do that then we look at the type so when you think about the type that’s going to relate to these large categories that are in I’m getting that particular handout again here for you these larger categories there’s some regarding behavior bowel and bladder eating medication mobility quite a bit there with mobility as well as some clarity offered knows oxygen skin and nails and lastly tracheostomy so you’re going to choose the type and then you’re going to choose the description of that based off from your knowledge of those treatment definitions it’s a preset list that when you use these pull downs it will automatically go into that and then the frequency frequency is might say seem like why would that matter but some of the triggers for the enhanced rate for a home care worker to get that extra money per hour on this particular individuals care needs are triggered by the frequency of the need so for example in this situation is for routine and regularly scheduled meds and we show that it’s at least four times a day that this individual takes routine and regularly scheduled meds if you enter it wrong and it won’t let you erase it you know you could use the erase and the go back buttons up at the top of your assessment it won’t let you do that the way to get rid of it is use the invalid or invalidate button again just looking at how you would do this when you’re ready to add a new row another treatment you would use the button down here for add a row because the one that would normally be up here at the top is not enabled and you can’t use it so you’re going to be using this one and it will just allow you to keep adding these in you can use your comments area to help put in the details that might be helpful for you as well as any others who might have to review over this case and to know what kind of care needs this individual has so we’ll look at a question came in regarding changing the end date when a treatment changes you can and we will show you how in a few moments go in and change that date and put in a new end date if a new treatment is required you could make note of that but I have to say I’m not certain I do not believe that you can add one when one is completed
so here is when you click on the button to an validate an erroneous list something that got put in there accidentally you will get the pop up question saying are you sure you want this to be marked invalid the other reason you might want to end a treatment sooner is when it’s no longer being done by the homecare worker not just that the physician has changed the order or the treatment but it’s no longer being done by them by the homecare worker now once you get those fields completed and you know that it’s accurate the next most critical piece is going to be to notice that here it’s going to say underneath the frequency that the synchronization is still impending and the way that you synchronize it is row by row each one of these and you would click the synchronization of the mainframe row by row if you don’t do that you will see two things often it is the stark realization because when you’re done with this and you go to the next screen which brings you to the full benefit results and you say yes I want to go ahead and complete this assessment or go on to the service plan it will only give you this as your pop up the key here when it does this and it shows you that you only have the state plan personal care is that read your message in this particular situation you can read the message and see that there’s been a treatment that has not been synced to the mainframe another way you can catch that is when you look at the tree on the left hand side of the Caps see how all the fields that you have completed have those green checkmarks notice that treatments does not we’ve gotten clarity that we can go ahead and add a treatment during the assessment timeframe not just end it but you can add a treatment when you are in a completed assessment and we’ll be looking at how you would go in and and work on that particular screen thank you the other time that this can become pretty complicated with treatments is when you use the caps copy and create which right now the with the changes that we had in October not many of us are able to use those yet but there could be some of us who would like to and will begin to but when you use copy and create the other thing that it will give you so the top picture that we show here is that you want to create a new assessment and you want to copy and create from a prior then it will ask you which one of the priors and you highlight the particular one that you want done the next key is it will pop up the list of treatments for that individual and you go row by row or you select all so that they get moved into your new assessment
a warning message is going to pop up on this page that very front page of your caps that will alert you that you’re going to need to update these treatment dates specifically if you have any consumers who get the enhanced rate again we’ll be talking about that enhanced rate in a few slides it is not uncommon when you have treatments showing and you’re doing a new assessment whether it’s through copy and create or just a new one that you could get a message about treatment dates overlapping with another treatment date and this is where you’re going to have to go into the prior assessment and you’re going to need to edit the end dates for that so they don’t overlap with the date that you are now saying that this treatment is starting the other way to approach this would be that your start date would not be until after the end date of your prior assessment and you will get this message down here underneath the sync button in the status reason and it will give you the specific treatment and what’s overlapping so when you need to go in and edit a prior caps you would choose that particular caps from the list and you would right click then you get this pop up regarding editing and what you want to edit so once you highlight that you can go directly into treatments
when you go into your treatments it will look like this on the left you’re going to highlight the row that you need to update and you’re going to change whatever needs to be completed for that very thing
when you change it it is changing that particular row from pass which means it’s been saved in the mainframe it’s passed into the mainframe it will change it over to pending because every record row-by-row will need to be updated so as you have changed the end date you would go in and it would say pending you would click on sync mainframe and it would pull it up so for these treatments there has been a new mainframe screen that was created back in I want to say quite a while ago when the enhanced care rate started and that whole piece happened that goes to the mainframe so we’re just the front end in the caps of that and when you sync it it’s going back into that section so that they’re able to tell whether this particular consumer and that particular home care worker match for that enhanced rate
you’re also able to look at the full history of a treatment to be able to know whether or not a treatment has occurred in the past what’s gone on with it in the past so you’re able to pull this up and review over that you’ll see that it’s a screen within the treatment page once you have made all of the changes that you need to and you click the next button you will come to the full benefit results again OPI workers let me remind you these recommended hours that we see kind of obliterated over here on the left these only apply to medicade these hours do not apply to our OPI consumers your specific Triple A gives you guidelines as to maximum hours and you are negotiating discussing coming to an agreement with each consumer of what is their unmet need and where do they need hours if they have shown a need net particular category of course we are unable to provide for needs that do not show in our assessment this also confirms for us that all of the rows of treatments have been synced so let’s talk now about the why we’re doing this which has to do with the enhanced home care worker rate an enhanced home care worker first of all is intended to really recognize that we have some consumers who have higher needs that require a more skilled provider to assure their safety in their home in their community so consequently we have the task of identifying who those consumers are by working through those treatments screens we just looked at on the other hand the home care worker to get this enhanced rate of care to provide services to the consumer that might be a better fit for that consumers need level must go through a certification and training process that’s done by the Homecare Commission once they go through that and they are working for such a consumer they do get an increased hourly wage these home care workers are providing services to our consumers who require these medically driven services and they are those that we have identified as we’ve gone through our caps the rate of pay is greater as you know here April 1 so on Sunday we move to a new rate of pay and that new rate of pay for a regular homecare worker is going from fourteen fifty up to fourteen sixty-five for a regular home care worker for an enhanced home care worker working for a consumer who has these enhanced needs that individual their rate of pay will be fifteen sixty five an hour essentially a dollar more per hour the certification for the enhanced homecare worker is for a two-year period of time but it is dependent upon the homecare worker maintaining their CPR status and other certifications that the homecare Commission is monitoring and puts connects into their database the enhanced rate this $15.65 occurs for all the hours that that particular homecare worker works for that particular consumer so it may not have to do with eating or mobility if those are the areas that drive why this individual gets that higher rate it may also include housekeeping or meal prep or bathing because the care needs as we know often occur episodically throughout a period of time the designation of who is an enhanced worker is tied to their provider number and it’s able to be shown on the registry it will also show up on the hink screen that we could view to see wages for a homecare worker and you can see that it will show up as that higher rate so what are these treatments that an enhanced homecare worker could get that rate of pay that dollar more an hour there’s is if you will only a handful compared to the full list that we looked at earlier of all of the treatments so these might include or do include not might the bladder irrigation ileostomy care impaction removal new colostomy care or routine colostomy care your ostomy care catheter care feeding and eating specifically you can see here we’ve got the G tubes and the J tubes covered syringe feeding now’s nasogastric feedings as well as peripheral intravenous fluids which don’t occur very often anymore skin and nails as you can see here with these four areas these are very serious wounds they are open wounds they are stasis ulcers that are deep or infected or decubitus –is that are stage three or four and that means the more deep not just a decubitus is a bedsore it’s not just the surface is involved it goes down further into the skin and the tissue oxygen care as you can see we’re really looking only in individuals in oxygen who are ventilator dependent tracheostomy yes that does include an oral suctioning by a suction machine when they have a tracheostomy because of the risk and vulnerabilities with them the stoma care around the trach behavior when we have a documented behavioral plan that would be supported by your findings in the cognition areas now mobility there’s only two stump care for a new stump so someone who’s had an amputation and they need the homecare worker to assist them with the care of that stump or the use of a wyer left as we know that takes a certain level of skill and awareness lastly in the area of medication we have the aerosol therapy that we talked about earlier very specific dialysis when it’s peritoneal so this is the kind that can occur in the home and would involve setting up the fluids to go in and the fluids being removed IV injections or infusions insulin injections when there are a sliding scale as well as and remember with the insulin sliding scale that has to correspond with that skilled medication as we saw back on the definitions page for that particular category and then lastly the feeding tube medication administration so if an individual gets their meds the home care worker gives it to them through the feeding tube again I invite any questions that you may have regarding treatments and enhanced rate that would be this is a good time to bring forward those questions so a question that’s coming in is does the home care worker need to be designated by an RN for any of these treatments certainly they do unless that particular home care worker is a nurse or a doctor they do need to have teaching that is documented to meet the nurses Practice Act so that they aren’t doing medical care outside of their scope so you’d want to involve your contract nurse any further questions so we just want to confirm that yes you’re only adding the treatments to the caps that the home care worker is engaged in it’s not that this individual requires the care now if you’re also wearing a Medicaid hat you know that you need to add it for other cases I want to remind you that today’s conversation regarding this topic purely deals with Oregon project independence and home care workers not in home agencies they do not get a higher rate of pay because of this they would be managing that so this is services that we are asking the homecare worker to provide to the consumer another question is do we need to look at treatments we have in place on our caseload or do we review them as reassessments when they’re scheduled or coming up I would say the latter there because you really this is an opportunity for some training and to look at what do you we need to be remembering and we have not spent time in the OPI program during these calls regarding treatment so I’m just raising it up the flagpole if you will we also need to ensure that if we have a homecare worker doing one of these treatments that you see on your screen right now we need to end they have the training and have the endorsement from the homecare Commission for enhanced rate that they’re able to access that higher rate another question that came in is how common are these treatments for OPI clients well I can’t really say since it doesn’t drive service priority level I know that in my review over statewide cases I would guess that these individuals would have a full assist need in some of these areas that may be reflected in our service priority levels so these could be individuals who are four three two or one in the service priority level mix and with that said that’s a minority of our consumers the majority of our consumers are an SPL ten and greater another question just to help clarify if you can edit the treatment for previous caps can you add them in a mid-year if you will of the caps for a condition change without doing a new caps yes you can we got that confirmed while we’ve been here during this webinar that you can do that good questions thank you so much so another important topic that I want to go into are natural supports and showing the natural support in a capsule service plan natural supports in the OPI program are really defined as services and benefits not paid for by OPI my doesn’t that leave a great big wide door open on who are you talking about what kinds of things would that be certainly when we think natural supports I think all of us think about family roommates people who are immediately and readily available to assist our consumers but when we have a consumer such as this individual that I put up the caps for you can see that this individual has quite a few needs and this person came up as a service priority level 10 what we’ve done to follow the guidelines of our Triple A regarding how many hours per pay period and for this particular triple-a it’s no more than seven hours per pay period so my case is showing six and when we discussed with the consumer and their support system the individual who provides most of this person’s care is out of the home three hours a week and so in comes the home care worker the agency to assist them during those three hours with some very specific tasks at hand and this is the kind of thinking that you have to do case managers and service coordinators as you put together this service benefit what’s the unmet need when are they fitting in what tasks are they going to do what tasks are they not going to do so you’ve identified all of that out you’ve given reasoning here you can see that we have needs and in the areas that we used some of the hours in this example I have shown both natural support and OPI program this particular example that we’re looking at is for a two-week period of time you can see that that would be true because the begin date of it is here as March 18th so any plans that we have developed after October 1 are for the pay period of two weeks keep those questions coming so here I have the plan specified out for this particular consumer we know that they have chosen to hire an agency to come in for the service plan those six hours every other week or excuse me for a two-week period of time or three hours a week is they choose to have that plan implemented but then the others that support this individual there is spouse who lives in the home and is doing assistance as well as there’s a child who’s involved who’s also giving care and being involved so we do not assign hours to natural supports ever and when we have even in our most remote areas where we might have a family member work for an OPI consumer as a home care worker we want to be really clear about what is that line how do they know when this is paid OPI activity and when it’s natural support time and they may be showing up twice we may show OPI daughter as a natural support as well as the provider for the home care worker being OPI so a question we’re being asked is why are we being asked to add natural supports when the addition of this information doesn’t drive anything well actually what it is doing is it supports the holistic assessment we do and it supports your role as a case manager and as a Service Coordinator it shows all of the need when we statistically or we review over the OPI program and we see that this individual is existing in the community with 13 hours of care per month and their service priority level 10 where is then the logic takes you to a Medicaid case that is a service priority level 10 and they’re being supported in the community in their own home with a 45 hour a month or a 75 hour a month plan we need to be able to explain the rest of the story is there a greater risk for those on OPI than there is on Medicaid who else is standing beside them are they using some of their own natural resources so this is really to help us provide that clarification on how is this individual’s care needs being met the goal of the OPI program to help enhance this person’s ability to use their natural support or resources to help them function within the community without having to be placed outside of the home you can narrate this information that would be great it’s also really good to include it in your service plan because it’s a quick look whereas narration easily gets somewhat lost during the year of contacts and and you have to look for it you have to hunt for it it’s a good way to elaborate on the rest of the story because we really don’t have that capacity that ability with the way the software currently works so to put it both in either the synopsis or the case narration as well as to list who are the natural supports here is ideal let’s say for example this individual also gets home health you can add as a natural support Providence home health you put them in as a contact you could put Ruth is the primary RN and their phone number they’re not being paid with OPI dollars and maybe they’re coming in weekly to do wound care that would be a good way of being able to track that kind of information another question is in a program that has a max of 15 hours a month how would you authorize for a two-week period what if there are five weeks in the month good question and we go back to that conversion that occurred in October and the tool that we put forward and we aren’t giving hours again to the natural support only to the paid services and you’re doing it according to your own agency guidelines and using that tool and looking at that information and the question is if we add folks as a natural support how do they get pulled into that of course these natural supports are coming off from our contact list and that is there on the person tab or you will also also find it when you’re going through the caps and you work off from the page that shows the individuals needs and whether they’re met and whether they’re met by someone who’s paid unpaid or both
question is if they use a private pay provider do we list this as a natural support you yes because they’re private paid they’re not using OPI dollars for that privately paid worker and it could be the same homecare worker maybe they’re hiring them that home care worker chooses to work not as exclusively as a home care worker paid through the department but also as private and they work ten hours a week for them and then three hours a week for the OPI program and again what you’re looking at is what was the unmet need and you’re really focusing in on what is the unmet need couple further questions about is this a requirement that needs to be added well it is very clear that we are called out by rule that we are doing a complete assessment of this individual and when we put such limited hours into these consumers homes we’re going to need to justify that so is it a requirement it’s pretty easy for me to draw to the line of saying yes I would love to hear from you on why it shouldn’t be and where else could that be found so that we are able to give a more accurate representation when our program is under regular analysis for funding and for purpose and intent of program this is part of our quality assurance our monitoring tool we just put out the OPI monitoring tool earlier this month it’s going to be coming due here in July as the triple A’s do self monitoring of the OPI program and seeing if natural supports are in the service plan is something that is on the monitoring for this particular time and certainly we are limited because of our budget but it was always intended that OPI would only provide a modicum of services it was never intended to be replicating the services available to the Medicaid program because of the funding bases were really assisting consumers to do as much as they can to do well in their community great questions good thoughts and again I strongly would encourage you to communicate with me if you don’t see this also as something that could be called a complete assessment would need to show what natural supports it would need to support your assessment so that if this person only has three hours a week six hours of pay period 14 hours a month how these needs are being met we need to be able to include that in our comments and then if there’s a statement about is this just busywork oh my gosh no I think your work is some of the most critical and we have to be so sensitive to only asking you to participate in activities that strongly support the goals and outcomes of OPI and this certainly fits within that scope in that nature thank you for bringing that out well keep on asking the questions I really would welcome your ideas for future webinars as you recall we are now doing webinars every other month and then we do a phone call every other month that is an open line phone call at the same time I’m going through our call system here so you can talk with one another we can discuss some of these pieces and it’s not just limited to what we’re seeing here in the webinar itself and through the questions another question that came up is how does a holistic assessment reflect treatments not provided by a home care worker being paid at the enhanced rate great question the key here is going to be that that task is going to be included in your comments regarding that particular activity of daily living so for example if a person has a dressing change on an open sore and it gets changed when they bathe or when they dress you could include that information within those sections
so again I thank you for your time and attendance today if you did not get the handouts from today please email me I did see that we had more folks sign up after I sent them out so let me know or if you’ve gotten them from a co-worker super but I will get them to you and I look forward to talking with you in the future and hearing from you have a great day thank you

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