Section M: Skin Conditions (Pressure Ulcer/Injury)

Section M: Skin Conditions (Pressure Ulcer/Injury)


»» Good afternoon everyone. We’re going to try to stay on time. Hello. My name is Ann Spenard. This afternoon we’re going to be talking about
Section M, Skin Conditions and pressure ulcers and injuries. So the same framework that we’ve had all morning. We have the acronym list. And so they’re all here for which we’re going
to be using in this presentation. And let me just pause for a moment for those
of you who are watching live streaming. Please remember to go to your landing page
from which you are watching the live streaming and the first link, it will download a ZIP
file. We are in, we are Session 6. There’s two things that say Session 6. One is a coding scenario worksheet. And for those of you in the room I think it
is on the — you open up your folder on the right-hand side. If you can pull those out in anticipation
of the presentation. We don’t need them right away. We can just pull them out and have them off
to the side. For those of you who are watching live streaming,
if you want to print them out, we’ll be using it about halfway through the presentation. And it’s an easy way to follow along and actually
practice some of your coding. Everyone have theirs? Yes. So in our overview today we’re going to define
skin conditions. We’re going to talk about the intent of Section
M. We’re going to talk about new items or changes in the Long-Term Care Hospital Continuity
Assessment Record and Evaluation or CARE Data Set. And we’re going to compare v3.00 to v4.00. And we’re going to discuss the coding instructions
needed to inform for the items. And we’re going to spend a fair amount of
time doing some practice scenarios. Because we find that those are, especially
with skin, I think are the most valuable. By the time that we finish this program hopefully
we’ll be able to state the intent of the changes to Section M. They’re not major, which is
good. We’re going to describe the new pressure ulcer/injury Quality Measure. And we’re going to be able to hopefully be
able to have you articulate the purpose for the new wording and any implications for the
coding, and to apply coding instruction to accurately code the practice scenarios, but
more importantly to be able to actually complete the data set accurately. So the intent of this section is to document
the presence, or appearance, or change in the status of pressure ulcers/injuries based
on a complete and ongoing assessment of patient’s skin, guided by clinical standards. And this will hopefully promote effective
pressure ulcer/injury prevention and skin management programs for all patients. And so we need to kind of start the day and
say what is a pressure ulcer/injury? Well the first thing you’ll notice, that word
“ulcer/injury.” If you were at previous trainings we didn’t
have the word “injury” in there. That’s one of the changes we’ll be going through. It is a localized injury of the skin and/or
underlying tissue, usually over a bony prominence and as a result of pressure or pressure in
combination with sheer and/or friction. So that’s a key concept. It’s been interesting as I’ve taught this
section in a variety of the different post-acute settings. Even my counterparts working in acute care,
the ability for staff to understand and be able to stage what is a pressure ulcer and
what is something else, moisture associated dermatitis, is it a diabetic ulcer, is it
a stasis ulcer, is it an arterial ulcer? So it’s really important, because it’s amazing
how many people are saying we have all these pressure ulcers when it’s moisture
associated dermatitis in fact, or some sort of a yeast infection that’s not pressure related. The key indicator when you go back to your
facilities one is to say, let’s not code it in this section unless pressure is related. Which means you need to be able to relieve
the pressure, right, as part of your plan to be able to progress this to a healing state,
if possible. And I would challenge you, if you heard me
speak the last time, especially to this group, like all the other post-acute settings, I
said the same thing. How confident are you today in your staff’s
ability to be able to identify and stage a pressure ulcer? It’s worth the effort. It’s worth the time. It’s worth the effort to investigate that
and to ensure that what you have in fact is pressure related for this particular section. But it’s going to help you in your treatment. I tell the story. I was once in a facility and they were struggling
with some of their skin issues. And the facility staff said, we have this
gentlemen, elderly gentlemen who we just can’t seem to heal this ulcer towards his coccyx
area. Could you look at it? So I went down with the staff. And I met this gentlemen walking down the
hallway. And we walked. I introduced myself. We walked into his room and I said, the other
nurse was with me, I said, I heard you have this ulcer and I was wondering if we could
take a look at it and see if we can come up with a different treatment plan. He said I’ve had that darn thing, he said,
for like six-weeks now. And I realized, he’s up, he’s about. He’s alert and oriented. He’s a normal body weight. And he eats well and he drinks well. What do you think is wrong with that picture? Probably should haven’t a pressure ulcer,
right. I said, is he sitting around? What is he doing? They said nope, nope, he didn’t doing any
of those things. So we took a look at the ulcer. He in fact had a yeast infection going on. And it was a very classic yeast infection. So they treated it and it went away. But they had been treating it as a pressure
ulcer and coding it as a pressure ulcer. But I said to the staff, what were you removing
pressure from? What were you doing that was related to
pressure? They said well, it looked like a pressure
ulcer. I said, but it was missing the one main component. They looked at me, they said what? I said pressure. So, you know, we kind of laugh on that. But when we think about this and how important
and how really significant pressure ulcers are, we want to make sure that we’re accurately
coding, right. So this is what we’re looking at, Changes
in Skin Integrity Post-Acute Care: Pressure Ulcer/Injuries So the changes in this particular item, we
have M0300, what we use to calculate the new Quality Measure, Change in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury So that’s the item. And the data collection will begin on July
1, 2018. So you have what, six months almost seven
months to make sure that you have this correct in your organizations. And I encourage you to do that. For this measure a ulcer is considered new
or worsening at discharge if the Discharge Assessment shows a Stage 2-4 or unstageable
pressure ulcer that was not present on admission at that stage, so whatever stage it was on
admission. Meaning that if the ulcer has progressed in
its stage, or is now unstageable, we’re going to be coding that in this particular measure. So it’s always important to understand our
numerators and our denominators. So our numerator is stays in the denominator
in which the Discharge Assessment indicated one or more new or worsened Stage 2-4 pressure
ulcers, or unstageable pressure ulcers compared to admission. So it’s discharge compared to admission of
what they had. The denominator for this, patient stays with
both an admission and a planned or unplanned discharge. So we can’t have this measure, right, if we
don’t have a Discharge Assessment to compare to the Admission Assessment. And there will be a few exclusions. We’re going to go through those exclusions. And the exclusions are, the patient stay is
excluded if data on new or worsened Stage 2-4 in unstageable pressure ulcers including
deep tissue injuries are missing on the planned or unplanned Discharge Assessment. So if for some reason you don’t capture the
information on your Discharge Assessment, we can’t use it. It makes sense, right. And a patient stay is excluded if the patient
died during the stay. So that’s an absolute exclusion. So the time frame, so how is this going to
be reported? Well the measure time frame window will be
calculated quarterly using a rolling 12 months of data. For public reporting, the quality measure
score report for each quarter is calculated using 12 months of data. So as a new quarter comes in, the oldest quarter
drops off. So it’s always a rolling 12 months. It just moves through. All LTCH stays during the 12 months except
for those that meet the exclusion criteria are included in the denominator and are eligible
for inclusion in the numerator. So, anyone who had an Admission Assessment
and a Discharge Assessment, excluding ones that died in your facility will be — and
met the other criteria, will be included in that quarter’s data and as that moves in,
again that will be the new quarter data and the oldest quarter will fall off. So it will change over time. For patients for multiple stays during a 12-month
time window, each stay is eligible for inclusion in the measure. So you may have one patient, okay, who may
be included multiple times in a particular quarter based on this criteria. So items from the Admission Assessment used
to risk-adjust this quality measure so risk adjustments are important. Functional Mobility Admission Performance,
so looking at GG0170C, mobility. And which we’ll be looking at specifically the lying
to sitting on the side of the bed. So that item is used. Bowel Continence is used. So that is H0400. So that’s a risk adjuster also. Peripheral vascular disease, peripheral arterial
disease or diabetes are included. So those are I0900 and I2900 which is diabetes. So that makes sense right. That can impact pressure related issues. Then Low Body Mass Index, and that is calculated
based on looking at the Height and Weight. All right, so that is K0200A, and K0200B. Those are all your risk adjusters. So why do I even bother telling you about
them? Because you want to make sure — first off
you should make sure every item in this set is accurate. But when we’re trying to look at this from
a quality perspective, if we’re looking at our numerators and our denominators, those
that are falling in, are we first coding them correctly as having a pressure ulcer or not? And then two, are we also making sure that
all these risk adjusters are accurately coded? So again, ensuring that we have an actual
height on a person. We estimate it? Have we actually measured the person? Do we have a recent weight on the person? So all of these things matter. Did we capture bowel continence and whatnot. So let’s look just quickly on some of the
changes between v3.00 and v4.00 of the data set. So CMS is aware of the array of terms used
to describe alteration in the skin integrity due to pressure. And they’ve evolved over the years from pressure
ulcers to pressure injuries, to pressure sores, to decubitus, to beds score. These are all words to describe a pressure-related
injury to skin. That being said, it’s acceptable to code a
pressure related skin condition in Section M if different terminology is recorded in
the clinical record. So just because someone calls it a decubitus
ulcer or bed sore, as long as it meets all the other criteria and in fact is a pressure
related ulcer, you can go ahead and still code this. It does haven’t to say pressure injury or
pressure ulcer. So we kind of, now we’ve said that CMS is now aware
of all these different terms, but now we’re going to define some of them. Throughout from LTCH CARE Data Set and QRP
Manual for this training, CMS adheres to the following guidelines. So a Stage 1 pressure injury and deep tissue
injuries are termed pressure injuries because they are closed wounds. So this is how CMS is saying it. So when we’re talking about a deep tissue
injury where the skin is intact, or like a Stage 1, we’re going to call those pressure
injuries. When we start to get into the Stage 2s, 3s,
and 4s, the pressure ulcers, or unstageable ulcers due to slough or eschar, they’re going
to term these as “pressure ulcers” because they’re usually open wounds. We have an injury where the skin is still
closed then we have an ulcer where the skin is an open wound. Unstageable ulcer/injuries due to non-removable
dressing or devices are termed “pressure ulcers/injuries” because they may not be open — they may be
open or they may be closed. But we don’t know because we haven’t been
able to take the device off or dressing off, or whatever it is to assess them. Does everyone understand? So these are just important terms to know. They’re minor. But you want to make sure that whoever is
completing the data set understands the different verbiage and what it means in these manuals. So this is just a picture of the item set. And I’m sure all of you can read this. This is a real test for how your eyesight
is. It’s teeny, tiny. We were hoping to be able to do a blowout. But basically the words in yellow, that’s
the most important word is where the change is. And what it just says is, it says, “reporting
based on the highest stage of existing ulcers/injuries.” So you’ll see that throughout the item set
that word “injury” has been added to the items. So it did not change significantly. So the term “device” was added to the item
M0300D1 through M0300E, and then M0300E2 in the Admission, Planned Discharge, and Unplanned Discharge Assessment effective July 1, 2018. So basically, what it says here is the number
of unstageable pressure ulcers/injuries due to non-removable dressing/devices. And it’s just taking into consideration, I
think a lot of this came from actual, I think feedback that the industry has given CMS to
say, not everything’s a dressing. It could be a type of splint. It could be a cast. It could be something else that’s not what
we would consider a dressing, like a primary surgical dressing. So it was just saying it could be a device
and/or a dressing. They removed the term “suspected deep tissue
injury” in evolution, and replaced the term with “deep tissue injury” to items M0300G
and M0300G1 in the Admission, Planned Discharge, and Unplanned Discharge Assessments effective July 1, 2018. So instead of that suspected deep tissue injury
we went to “deep tissue injury” will be the terminology. And again it’s highlighted in yellow on the
screen. And this is a screenshot. One of probably the biggest changes in this
particular section is M0800A-M0800F Worsening in Pressure Ulcer/Injury Status Since Admission. These items have been removed from the Planned
Discharge and the Unplanned Discharge Assessment. So they’re gone from the assessments. So now what we’re going to go through is looking
at the various skin conditions, and coding guidance and coding scenarios. And hopefully we’ve gone through — we’re
going to go through quite a few of them. Some of them are based on direct questions
that were asked, some areas of confusion in previous trainings. So hopefully this will just clarify it. What I would encourage you to do is, you don’t
have the answers in your sheets, I do. But we will post on the site, the CMS website,
the slides with the answers in here. And what you can do is use these for some
training scenarios with your staff. These are, you know, ready-made training materials
that you can use with your own staff to ensure that, one at least they would know how to
apply the coding methodology. It wouldn’t ensure that they understood how
to code an ulcer by looking at it and looking and assessing the patient. But at least will help with the coding side
of things. So what we’re looking at here in M0300 is
current number of unhealed pressure ulcers or injuries. So at admission, we’re looking at M0300A1-G1. It identifies the number of unhealed pressure
ulcers or injuries at each stage and establishes the patient’s baseline assessment. So this starts kind of the clock for you. So how quickly should we gather this information? It should be gathered as soon as you can get
it as close to admission. So I don’t know, people may have their own
facility or organizational policies or procedure that says a skin assessment must be done within…
fill in the blank hours of admission. Certainly you want to follow that. But we don’t really want to be doing you know,
skin assessments day 2. You know, a lot can happen even in the first
24 or the first 12-hours of someone being in your organization. So you want to try to get that done as soon
as possible. The Discharge Assessment Planned and Unplanned
looks at M0300A1-G1 and identifies the number of unhealed pressure ulcer injuries at each
stage. And then it says, of those that are there
at discharge, it asks the next question, M0300A2-G2. It says, okay at the time of discharge, it
identifies if the unhealed pressure ulcer injury in M0300A1-G1 were present on admission,
or if the pressure ulcer injuries were acquired or worsened during the stay. That’s what that question is asking. We’re going to give you lots of examples on
how to do that. So it’s a subset. So if I said I had a Stage 2 pressure ulcer
on admission on my coccyx, and then on discharge I still had that same Stage 2 pressure ulcer,
it’s a yes. I still have one. Right, yes, I still have a Stage 2 pressure
ulcer. And then it would say, how many of the above
Stage 2 pressure ulcers at discharge were there on admission? I would say well, I only had the one, and
it was there on admission. So I would say it was there upon admission. So steps for completing M0300A-G. Well we certainly want to determine the deepest
anatomical stage of the wounds. We want to identify unstageable pressure ulcers
or injuries. For the Discharge Assessments, we want to
determine the number of ulcer injuries that were present upon admission. This is just a screenshot. I’m sure you all can read that in the back
of the room. I’m sure you at home, I’m not sure how clear
this will be because I’m sure it’s very small. But this is just a screenshot of the item
set. So M0300A1-G1 the coding instructions are,
complete only if A0250 equals an Admission Assessment, a Planned Discharge or an Unplanned
Discharge. Those are the only times that we’re doing
these questions. And we want to enter the number of pressure
ulcers that were currently present. And enter 0 if no pressure ulcers are present. Here we have M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage at discharge. And then this actually, we couldn’t fit on
one screenshot. And this just is a continuation of what you
would see on your form. It would all be together. But we had to split it into two sections. So M0300B2-G2 we’re going to complete only
again if this is a planned discharge or an unplanned discharge, right. Because this is done only, these items are
only done at discharge. We want to enter the number of pressure ulcers
or injuries that were present on admission. And you could go back to looking at M4 under
steps for completing M0300A-G. And then Step 3 is to determine present upon
admission. And then enter 0 if no pressure ulcer injuries
were noted at the time of admission. Again, don’t worry about this. We’re going to go through lots of examples. I think this will be very clear for you at
the end. So the present upon admission items are coded
at discharge. So we want to know what was there upon admission. And it addresses whether the pressure ulcer
or injury observed at discharge were, one, present on admission. And if they weren’t — so if I have an ulcer,
was it there? And was it there at the same stage at admission? If not, it’s saying it was acquired or worsened
during the stay. That’s really what it means if it wasn’t there
upon admission. That’s what this area is looking at. Hence we can get rid of that other whole set
of questions that we have. The pressure ulcer injury reported at discharge
and coded as not Present on Admission on the Discharge Assessment would be interpreted
as a new or worsened ulcer. That’s what it’s telling us. The pressure ulcer or injury reported at discharge
and coded as Present on Admission on the Discharge Assessment would not be considered
a new or worsened pressure ulcer. So if it was there and there at the same stage,
it wouldn’t be indicated as present on admission. So we’re going to just start going through
some coding scenarios. These first couple of ones we’re just going
to do together. And then, we’re actually — I’ll go through
a scenario and give you some time, a minute or two, to complete what you would say would
be the coding on that. And then we’re going to come back together
as a group and we’ll code them. So here’s our first scenario. A patient is admitted to the LTCH with a Stage
2 pressure ulcer on the right hip. At the time of discharge there is no change
in the Stage 2 on the right hip. Additionally, there is a new Stage 2 pressure
ulcer on the right heel. So they came in with a right hip. By discharge that right hip ulcer is still
a Stage 2. But, oh by the way, they have a new Stage
2 pressure ulcer on the right heel. So in this scenario, we’ve already completed
the coding, but let’s talk it through. So here we have the first question, M0300B1
the number of Stage 2 pressure ulcers. And there’s two columns there is right. There’s admission and discharge. And in the Admission Assessment we’re coding
as 1. And we said 1 because, what? They had one Stage 2 pressure ulcer on their
hip. And then the Discharge Assessment, how many
Stage 2 pressure ulcers did they have? They had two, right. They had one on the hip and one on the heel. Then the next question says, M0300B2 the number
of these Stage 2 pressure ulcers that were present upon admission. So now, right, 1. And what it’s saying here is, in the discharge
we had 2. But of those 2, one was there, present upon
admission. But one is new. And that’s where that coding a 1 comes in,
under new. Make sense? Okay. And here’s just the rationale. Again you’re going to have, the nice thing
is you’ll have all of this information that you can use for training when you go back
to your organizations. So upon admission the patient had a Stage
2 pressure ulcer on the right hip. And we coded that. And then upon discharge the Stage 2 pressure
ulcer on the right hip was the same. And so we coded the M0300B1 as having the
2. And we have M0300B2 coded as 1 because they
had the two ulcers, one on the hip was there on admission and of course the heel which
was developed. So let’s just pause for a second and talk
about pressure ulcer and program interruption. There was a lot of questions in the past around
this. If a patient is transferred from your long-term
care hospital and returns within 3 days, including the day of transfer, the transfer is considered
a program interruption, which you all know, and is not considered a new admission. Right. So if they go out, and they come back within
that 3 days, including the day of transfer. Therefore, any new pressure ulcer or injury
formation and/or an increase in the numerical staging that occurs during the program interruption
should not be coded as present upon admission. So what does that mean for you? It would would show up as new or worsening,
right, even though it’s a program interruption. I know that’s probably a very bitter pill
to swallow. It is the coding on that. The only time that this would be considered
new would be if it wasn’t a program interruption, right. They were gone four or five days, then what
is it considered? A new admission, right. Then you would go through the whole process
again. (comment from the audience) So we’ll — can
you hold that question for the end? We’ll talk about that. Okay. All right. So let’s go through another coding scenario. A patient is admitted to your LTCH with a
Stage 2 pressure ulcer on the left hip. The patient is transported to the acute care
hospital and returns to the LTCH within 2 days. Upon return to the LTCH, the lift hip pressure
ulcer is a full thickness ulcer assessed to be a Stage 3. The patient is discharged to home with a Stage
3 pressure ulcer. So think about how we would code that one. So we’re starting with the Stage 2 pressure
ulcers, M0300B1 there. The number of Stage 2 pressure ulcers on admission
was 1. Right. And then the Discharge Assessment, the number
of Stage 2 pressure ulcers present at discharge went to 0, right. Because that Stage 2 progressed to a Stage
3. At discharge they didn’t have any Stage 2
pressure ulcers. Everyone agree with that? I’m seeing some not sure — okay. Now we’re looking at — so then M0300B2, the
number of these Stage 2 pressure ulcers that were present upon admission is a skip. It’s a skip because we don’t have any showing
on the Discharge Assessment. So if it’s a 0, the next item underneath it
will be a skip. Because it’s saying, of the ones that are
present at discharge at that particular stage, how many were present upon admission? So since I don’t have any Stage 2s right now
on discharge, I’m going to skip that next question. If you had this in a program in your computer
it would automatically skip you out of this. The number of Stage 3 pressure ulcers coded
at admission, patient didn’t have any, right. They had a Stage 2. Now, at discharge, we know that they have
one. That Stage 2 now progressed to a Stage 3. So they have one Stage 3 pressure ulcer upon
discharge. The next question M0300C2 says the number
of these Stage 3 pressure ulcers that were present upon admission. And that answer is 0. Why? Because the only thing we had on admission
for this particular patient was one Stage 2 pressure ulcer. So on the back end what this is telling you,
if you were looking at this assessment but, what it’s going to tell when they do the analysis
is, this patient had a new or worsened pressure ulcer. Even though it happened during a interruption
of stay. Because they did not have an actual Discharge
Assessment done and a new admission being done. So we kind of talked through this already,
the rationale here. So they had that Stage 2 on the left hip. And that’s the reason we coded that one at
admission. They went to the acute-care hospital. They came back. It was a Stage 3. So since no new Admission Assessment is required,
the change in the pressure ulcer status is captured on the Discharge Assessment as new
or worsened. And so this is what we ended up coding, this
particular patient. So let’s talk a little bit about unstageable
pressure ulcers or injuries. So when you’re going to code unstageable pressure
ulcers or injuries, visual inspection of the wound bed is necessary for accurate staging. That’s really important, right. You need to be able to look or to see enough
of the wound bed to understand, are you seeing the deepest part of that wound bed, especially
if it’s covered with slough or eschar. If they have eschar or slough tissue present
such that the anatomical depth of the soft tissue damage can not be visually inspected
or palpated in the wound bed, it should be classified as unstageable. So let’s give you a couple of scenarios. If I’m looking at a wound and I’ve got, let’s
say half to three quarters of it covered with eschar or slough, but I see bone or tendon,
can I stage that ulcer? Yes, I can. Maybe a Stage 4. It’s very clear what that is. Once you see that, you know it’s a Stage 4. It doesn’t matter if I clear out the rest
of it. I can already see it’s down to that deepest
stage. But if you can’t see enough of the wound bed
to understand that you’re looking at the deepest part of it, and the majority of that wound
is covered with slough or eschar or it’s all covered, then you have to code that as unstageable. If the wound bed is only partially covered
by eschar or slough and the extent of the soft tissue damage can be visualized, which
I just talked about, so that means you can numerically, confidently numerically stage
it. Then please don’t code it as unstageable,
but go ahead and stage that wound. I think, I didn’t really talk a lot about
it here. I think the biggest opportunity for clinicians
who are not specifically trained in wound care, so your average kind of R.N. out there
who’s looking at wounds, besides understanding what’s pressure and what’s not pressure, once
they realize that it is pressure is being able to identify and differentiate between
a Stage 2 and Stage 3. So if there’s any kind of slough in the wound
and someone wants to code it as a Stage 2, so sometimes you’ll see someone stage something
as a Stage 2 and then describe the slough on it. A Stage 2 can’t have slough. So that’s another opportunity when you’re
working with your staff and you have the opportunity to give them a variety of different scenarios,
that’s always one I like to throw in there. Because you want to make sure that they understand
that if it has slough, it’s automatically, minimally at that point it’s a Stage 3. All right. Let’s do another coding scenario. So a patient is admitted to the LTCH with
eschar tissue identified on both the right and the left heels, as well as a Stage 2 pressure
ulcer on the coccyx. So they have 3 ulcers. The patient’s pressure ulcers are reassessed
before discharge. And the Stage 2 on the coccyx pressure ulcer
has healed. The left heel eschar became fluctuant, showed
signs of infection, and had to be debrided at the bedside and then was subsequently numerically
staged as a Stage 4 pressure ulcer. And the right heel eschar remains stable and
dry, i.e. it remains unstageable. Now we’re going to look at how we would code
this particular scenario. So here we have the number of Stage 2 pressure
ulcers. We code it as a 1 on admission and 0 at discharge. And then we would do a skip for the next one
because it asks us, of the above — so of the number of Stage 2 pressure ulcers at discharge,
how many were present upon admission? Since I had 0, I skipped that. M0300C1 the number of Stage 3 pressure ulcers
we coded that as a 0 on admission. And we had 0 at discharge. So we skipped that and the next question,
M0300C2. Then we get down to Stage 4. So we have M0300D1, number of Stage 4 pressure
ulcers present upon admission. We didn’t have any Stage 4s present on admission. But at discharge we do, right. That heel that was debrided, we ended up having
a Stage 4. The number of these Stage 4 pressure ulcers
that were present upon admission, and the code here is 1. It wasn’t present upon admission. Then we go on to the series of questions here. M0300E1, the number of unstageable pressure
ulcer injuries due to non-removable dressing. Well we didn’t have any that were unstageable
dressings or devices. So we would code 0 at admission and 0 at discharge. Then we would skip the next question of M0300E2. Then we have M0300F1 the number of unstageable
pressure ulcers due to slough or eschar. We would code that as 2 of those because those
were both the heels that we had. They were both unstageable when the person
was admitted. And then upon discharge, one heel still had
intact eschar on it. So we had 1 unstageable on one of the heels. And then the number of these unstageable pressure
ulcers due to slough or eschar that were present upon admission. So that one heel that didn’t progress that
didn’t need debridement was there on admission and was there as discharge. And it was stable. So we code that one as a 1. So the rationale here, we went through this. We had the coccyx was present upon admission
and then healed. So it wasn’t there on discharge. And then we talked about the left heel being
debrided. And now become a Stage 4. And the right heel having the eschar that
remained intact. So in fact, we had one of those on discharge
and it was present upon admission. So non-removable dressing or devices. Known pressure ulcers or injuries covered
by a non–removable dressing/device should be coded as unstageable. So there’s a word in here that’s important,
it’s “known”. So we would code this only if we had communication
or documentation as they were coming in that said, geez they have this cast or whatever. We had this pressure ulcer we had to cover
it. It’s got a dressing that we can’t remove or
whatever it is. But we know that we have something under there. And so it’s known to you. So for an example, includes a primary surgical
dressing that can not be removed per physician orders or orthopedic device or cast. But they’re telling you there was this pressure
ulcer underneath it, or injury. “Known” refers to when documentation is available
that says the pressure ulcer or injury exists under the non-removable dressing or device. And so, that has come up frequently as a question. So it’s the idea that you have to know about
it, not that you didn’t know about it and then you take the dressing off or the cast
off and then all of a sudden they have these injuries, but they came into you and you didn’t
know about them. All right. So what I’d like you to do, we’re going to
start to go into some of the coding scenarios where we’re going to have you start to practice. And for those of you who are on live streaming,
if you want to pull your coding scenario documents out. If you didn’t get a chance to print it or
whatever, you want to just use scrap paper, you do that in your office or wherever you’re
watching this. So we’re going to talk about Coding Scenario
4. That’s the first one that we’re going to do. I have it up here on this screen. We’re going to talk about it. But if you look at your coding sheets, the
scenarios for each one of our coding scenarios is right on top also, so that you can reference
it right at your tables. So Coding Scenario 4. A patient is admitted with documentation in
the medical record of a sacral pressure ulcer/injury. This ulcer/injury is covered with a non-removable
dressing, and therefore the pressure ulcer/injury is unstageable. On day 5 of the stay, the dressing is removed
by the physician and the assessment reveals a Stage 3 pressure ulcer. On day 10 of the stay, the pressure ulcer
is covered with eschar and is assessed as unstageable. The eschar-covered ulcer is unchanged at the
time of discharge. So I want you to just take a moment, if you
will, and answer the assessment on the first page where it says Coding Scenario 4. Again the coding scenario is right on top. I’ll give you just a moment, then we’ll review
the scenario. Okay, are we ready? Okay. So let’s go through this scenario. So M0300E1, the number of unstageable pressure
ulcers due to non-removable dressing or device. What do we have for the Admission Assessment? 1, does everyone agree on 1? Okay. Good. How about on the Discharge Assessment? 0. Correct. So if we have M0300E1 on discharge being a
0, how would we answer M0300E2 the number of these pressure ulcers or injuries due to
non-removable dressings that were present upon admission? We’re going to skip it, exactly. It’s a skip pattern. Because we didn’t have any at discharge. So the next question, M0300F1, the number of
unstageable pressure ulcers due to slough and/or eschar on admission? Do we have any of those? No, 0. Okay. Correct. Same question, but at discharge. Do we have any? We have 1. Correct. So now the question M0300F2, the number of
these unstageable pressure ulcers due to slough or eschar that were present upon admission? Okay. I have some people saying 1. Anyone else? Some people saying 0. So the answer is, 0. In fact, we didn’t have any of these ulcers
that were unstageable due to slough or eschar on admission. So where we had that 1, none of that 1 was
present upon admission. So you would code that as a 0. And we’ll just go through the rationale here. So the documentation that accompanied the
patient on admission identified a pressure ulcer that was located beneath the non-removable
dressing. This known ulcer — so this known ulcer/ injury
is coded as a 1 on the Admission Assessment as a unstageable pressure ulcer or injury
due to non-removable dressing or device. And then once we remove the dressing, the
physician staged the ulcer as a Stage 3 pressure ulcer. And at the time of discharge, that then progressed
to the point that it was covered with slough or eschar so it couldn’t be stage. That’s the reason that the unstageable pressure
ulcer, which is M0300F1 due to slough or eschar is coded as a 1. And M0300F2 is coded as 0 because the pressure
ulcer was not unstageable due to slough or eschar on admission. Okay. It was unstageable due to a non-removable
dressing or device, but not because of eschar. Just subtleties within the questions. So healed pressure ulcers or injury, the terminology
referring to healed versus unhealed ulcers or injuries refers to whether the ulcer or
injury is closed versus open. So a Stage 1 pressure ulcer and a deep tissue
injury are unstable pressure ulcers although covered with tissue eschar or slough would
not be considered healed. And of course we know, for those of you that
are clinicians, you know, that term “healed” is really complex terminology. Because once we have damaged the skin with
a pressure ulcer, you know that’s full thickness, that as it heals or closes, sometimes you
can end up with a primary epithelialization — that was a tough word for me to say — closed
on top. But in fact, the scar tissue and the other
tissue underneath it hasn’t filled in. And we know that once we have that, the tensile
strength of that tissue is about 80%. So it’s always kind of at-risk any way. So it’s never going to be as strong as the
skin that we were born with, okay. So we know that someone could be at risk with
them. So let’s go to Coding Scenario 5 in your little
coding sheet here. And we’ll go through a different scenario. So here we have, a patient is admitted to
the long-term care hospital with a bruised butterfly-shaped area on the sacrum and a
blood-filled blister on the right heel. The sacral area, based on assessment of the
surrounding tissue, is determined to be a deep tissue injury. The heel blister is also assessed, and based
on the assessment of the surrounding tissue, it is determined that the heel blister is
also a deep tissue injury. Four days after admission, the right heel
blister is drained and conservatively debrided at the bedside. After the debridement, the right heel is staged
as a Stage 3 pressure ulcer. On discharge the right heel remains at a Stage
3. And the sacral area continues to be assessed
as a deep tissue injury at discharge. So you’ve got the scenario on the top of your
sheets. I’ll give you a minute or so to go ahead. There’s more question to answer here. But go ahead and complete it. Now there’s two pages of answers, right. So there’s the first page with the scenario
on it. Flip it over and then you have to continue
to answer all of these questions in this assessment. For those doing live streaming, I ask you
to do the same thing. Okay. Let’s go through the coding together on this
with this patient. So you can keep the scenario in front of you. So with this particular patient, M0300B1 the
number of Stage 2 pressure ulcers on admission? Any Stage 2s? No. So we put a 0 there, right. Okay. How about Stage 2s at discharge? Okay, they didn’t have any, 0. Correct. Okay. How about M0300B2, the number of the Stage
2 pressure ulcers that were present upon admission? Skip. Very good. You guys got this down pat. How about M0300C1, the number of Stage 3 pressure
ulcers on admission? Okay. They didn’t have any, 0. How about the number of Stage 3 pressure ulcers
at discharge? Right. They had 1. The number of these Stage 3 pressure ulcers
that were present upon admission? We’re going to go through the rationale. Okay. Number of Stage 4 pressure ulcers? Right. The number on the Discharge Assessment? 0, right. And the number of these that were present
upon admission? Skip. Right. How about the number of unstageable pressure
ulcers due to non-removable dressing? 0, right. How about at the Discharge Assessment? Do we have any of them for non-removable dressing? No. How about the number of the unstageable pressure
ulcers due to non-removable dressing that were present upon admission? We’re going to skip that, right because they
had 0 ahead of it. How about number of unstageable pressure ulcers
due to slough or eschar on admission? 0. How about at discharge? 0. Okay, so then we’ll skip the next question,
right, because we didn’t have any. The number of unstageable pressure injuries
— the number of unstageable pressure injuries with deep tissue injury? 2. Then how about at discharge? 1. Right we had 1 left. So then we ask the question, number of these
unstageable pressure ulcers with deep tissue injuries — for the Discharge Assessment that
were present upon admission? 1. Right. We had 1. Okay. So let’s go through the rationale on how we
coded these particular questions. I’m just going to flip forward in my notes. All right. So after thorough clinical and skin examination
as well as an assessment of the lesions and surrounding tissue, the sacral and the heel
areas were determined to be consistent with what is constituting a deep tissue injury. You assessed it. You said this is what we’re dealing with,
a deep tissue injury. The Admission Assessment M0300G1 is coded
as 2 because there were 2 deep tissue injuries, both present upon admission. We agree about that, right? Once the heel deep tissue injury is drained, debrided
and numerically staged, so M0300C1 and M0300C2 are coded as 1 on the Discharge Assessment. M0300C1 is coded as 1 on the Discharge Assessment
because the heel deep tissue injury was debrided and was able to be numerically staged because
this was the first time that you were able to assess and stage, numerically stage it,
it is considered to be present upon admission. So they came in — so I see some confusion. So they came into — you knew you had a deep
tissue injury. You just didn’t know what it was when it really
declared itself, right, when you got a sense either it had dried up. Let’s say the blood dried up and you ended
up with eschar. Sometimes that cap will come off and you get
to look underneath and see what it is. Sometimes it just, you know, may get infected,
gets debrided here for whatever reason, they chose to drain it. But now for the first time we get to look
at the bed of that wound. And we know under that blood-filled blister
once that was all cleaned out, the physician is telling us it’s a Stage 3. So nothing happened to make that worse. There was something there. We just didn’t know what it was. So the first time that we can numerically
stage it, we then say that that was present upon admission. Because that injury has already happened. Does that make sense to everyone? Upon admission. So we identified it was there, we just didn’t
know what it was. M0300G1 is coded as 1 at the Discharge Assessment
because the sacral deep tissue injury can not be numerically staged. M0300G2 is coded as 1 at the Discharge Assessment
because of the two deep tissue injuries that were present on admission. Only one remains as a deep tissue injury,
right. Because the other one ended up being a Stage
3, right. Because we are able to say we now know that
it’s a Stage 3. All right. That was Scenario 5. Let’s flip to our coding scenarios here. And let’s go to Coding Scenario 6. This should be a quick one for you to do. Not a lot of questions. So Coding Scenario 6. The patient’s skin assessment on admission
reveals no pressure ulcers or injuries. On Day 5, the patient record identifies a
Stage 2 pressure ulcer on the right elbow. On discharge, the patient’s skin assessment
reveals a healed Stage 2 pressure ulcer on the right elbow. So let’s go ahead and do Coding Scenario 6 on your papers. Everyone got that one done? That was quick. Yes? Okay. So now we’re looking at M0210, unhealed pressure
ulcers. Do we have any unhealed pressure ulcers at
admission? So we would code 0, right. Any unhealed pressure ulcer or injuries at
discharge? 0. Right. So here we have the rationale. The patient had no pressure ulcer injuries
on admission. Although the patient developed a Stage 2 pressure
ulcer on their elbow on Day 5, that pressure ulcer healed or closed as we are calling it,
at discharge. Therefore, M0210 would be coded as 0. And all of M0300 pressure ulcer injury items
would be skipped. Right. So if we were doing this on a computer this
would skip us out because we wouldn’t have any pressure ulcers to ask all those other
questions about. They actually did have a pressure ulcer while
they cared for them. But they got it after admission and healed
it before they were discharged. So it’s not accounted for in this assessment. Does that make sense? So medical devices related pressure ulcer. So when a pressure ulcer is caused due to
the use of a medical device, you need to assess the area to determine if the pressure is the
primary cause. Again, remember it’s not a pressure ulcer
unless I can remove pressure from the area of the wound to help heal it. And so you have to determine whether pressure
is the primary cause. These ulcers or injuries generally conform
to the pattern or shape of the device. And so ones that we’ve seen can be from braces. And we’re actually going to do an example
around that. It could be in a seating. I’ve seen people develop pressure ulcers from
how they’re seated in a wheelchair. And their leg rests against a part of the
wheelchair and they’re just not repositioned. And, you know, depending on someone’s circulation
and all those other things put them at higher risk. All of a sudden if you put them back in the
chair you can match that area of the chair to the wound that they have. And often you’ll see staff do that. You’ll say, obviously I need to remove the
pressure. So I need to figure out what was putting the
pressure on. If you’re a good kind of detective and you
look for these things you can find them. If pressure is determined to be the primary
cause, use the staging system to stage the ulcer or the injury, and code in Section M
of the LTCH CARE Data Set. If the ulcer/ injury is not due to pressure,
do not code in Section M. So this just goes back to everything I’ve already said. Make sure that you’re only coding pressure
ulcers here. Don’t take credit for everything else. Inevitably that’s what I see, stasis ulcers
coded here, again arterial ulcers, other things. Now that doesn’t mean that you can have peripheral
arterial disease or peripheral vascular disease and still have pressure and still end up with
a pressure injury. The other one that tends to get staff a little
bit are diabetic ulcers. So making sure that you understand whether
there’s pressure involved with that, depending on where the ulcer is. Is it a diabetic ulcer or are we looking at
a pressure ulcer? That doesn’t mean that diabetics don’t get
pressure ulcers. It’s just a matter that you have to use your
clinical judgment to make an assessment on that. If you’re not the person who has all those
skills, within your organization I’m sure there’s someone who’s considered the expert
in that. You may want to bring that person in. Some of the staff will get very comfortable
with the everyday type of things. Then they’ll look at something and go, hmmm. I’m not sure what I’m looking at. And so, that’s your opportunity to bring someone
in who has maybe greater expertise in a particular area and have them take a look at it and help
you to decide whether it a pressure-related injury or not. So we have another scenario, Coding Scenario
7. So if you pull out your forms we’re going
to do another coding scenario. So here we have one that’s device related. So a patient is admitted with a right ankle
foot orthosis, an AFO, to compensate for weakness in foot drop. On the initial skin assessment, the clinician
notes a Stage 2 pressure ulcer at the right calf. And this conforms with the shape of the AFO. The orth — I can’t say that word — an orthotist
is consulted and the AFO is adjusted. They brought someone in. Looked at the brace. They made adjustments to it. The ulcer heals before discharge and no other
pressure ulcer injuries are present. Let’s go ahead and answer the questions in
Scenario 7. Okay. Let’s go through this staging on, the coding
on this. So we’re starting out in a slightly different
spot here for this set of questions. So M0210. So this is part of our admission assessment. Is there an unhealed pressure ulcer or injury? Yes. We’re saying, yes, there’s something there. Okay. How about at discharge? Right. So we’re coding that as a 0, right. There’s nothing at discharge. M0300B1 number of Stage 2 pressure ulcers
on admission? 1. Right. How about number of Stage 2 pressure ulcers
at discharge? 0, right. Actually it should be a 0 not a skip. And then M0300B2 the number of these Stage
2 pressure ulcers that were present upon admission? No. So skip. So we’re saying that the number of Stage 2
pressure ulcers at discharge was 0, right. And it was 0 because what, it healed? Right. It healed. So at discharge I don’t have any — they came
in with a Stage 2, right. Actually I should probably go to the rationale
because it takes us through all of this. So the patient came in and we identified that
they had a Stage 2 in the calf by the AFO, right. So they determined it matched the shape and
size. It actually was a pressure ulcer caused by
the AFO. So they had that and they staged it as a Stage
2. They actually got someone in to make adjustments
to it. We certainly want to do that because we have
to relieve pressure to help heal or allow progression of a pressure ulcer. So here again, following the instructions for the purpose of coding, a determination was made that the lesion being assessed is
primarily related to pressure. It wasn’t any kind of vascular ulcer or anything
else. We said put the AFO on. Here it matches perfectly. It even has the shape and the size. So we call in someone. We have an adjustment made to it. So we knew that they had at least one Stage
2 pressure ulcer on admission. And then the Stage 2 pressure ulcer is healed
at the time of discharge. And there are no other pressure ulcers. So the number of pressure ulcers at discharge
are 0. And then we have when you look at the number
of these Stage 2 pressure ulcers that were present upon admission would be a skip. So if we don’t have any — remember that whole
coding pattern. If I don’t have any, if I’m saying I don’t
have any Stage 2 at discharge. I don’t have any Stage 3. We’re unable to say how many of those are
present. Because it’s asking at discharge, of the ones
that we have at discharge, how many of them were present upon admission? Everyone get that piece of it? Yeah. Okay. Because that’s an important piece. Because you know, I saw people saying wait
a minute. They did have a Stage 2 on admission. And that’s true. But at discharge they didn’t have any. That follow-up question is asking just about
the ones left at discharge. How many of those were present upon admission? And that’s what we’re skipping and saying
that there’s none. So let’s talk about other types of ulcers,
mucosal ulcers. So mucosal pressure ulcers are not staged
using the skin pressure ulcer or injury staging system. Because the anatomical tissue comparisons
can not be made. They’re different, different tissue type. Therefore mucosal ulcers, for example those
related to nasogastric tube, oxygen tubing, endotracheal tubes, urinary catheters, mucosal
ulcers in the oral cavity should not be coded as pressure ulcers on the LTCH CARE Data
Set. Does that make sense? That doesn’t mean that you can’t get a pressure
ulcer from oxygen behind the ear. Is that mucosal? No. No. That’s not what this is saying. It’s really looking at what would be, in the
nasal area if you were doing a pronged nasal cannula, or the nasogastric tubes and whatnot. So they can’t be staged. Does that mean that we ignore them clinically? No, of course. We’re still going to be ever-vigilant, very
aware. Try to prevent any kind of skin injuries where
we can. And then certainly treat and care for and
plan for any kind of injury that may occur. All right. So Coding Scenario 8. I told you we’re going to do a lot of coding. This is our last kind of practice scenario. So if you pull that up on your sheet. So in this scenario a patient with a gastrostomy
tube, or a G-tube, is admitted to your organization. The G-tube insertion site is covered with
a dressing. The admitting clinician removes a dressing
to complete an admission skin assessment and identifies a lesion present at the stoma. There are no other lesions identified at admission
and throughout the stay. So here’s the question. Just if you could quickly answer those questions
we’ll talk those through then. Okay. This is a easy one. Okay. So we’re looking at M0210, unhealed pressure
ulcers. Do we have any unhealed pressure ulcers at
admission? So we’re going to code that as a 0, correct. None. And then the same question. Do we have any unhealed pressure ulcers or
injuries at discharge? No, 0. Right. The lesion is present at the gastrostomy stoma,
the stoma mucosa is not staged using the pressure ulcer system, which we just talked about. But think about your own staff. Do you think they might code something like
this? I’ve seen it. I’ve seen it staged. I’ve seen it staged. So when we continue towards the end, I think
we’re going to end up having a little bit of time. We may want to take some opportunity when
I finish up my program today of this section, this is a section where I think there’s lots
of great opportunities to write some ideas down in your Action Plan. Oh, let me check on this. Let me check on that. Let me check with my educator, if you’re not
the educator. Let me go back and ensure that all of the
staff who may be staging anything really are competent in being able to understand what
they should stage, what they shouldn’t stage. And if they are going to stage something as
a pressure ulcer, let’s say they assess it and determine that it’s a pressure ulcer,
am I really confident that they can stage it at then the appropriate stage? So this lesion, so the mucosal pressure ulcers
are not staged using the skin pressure ulcer staging system because that tissue is different. We just talked about those. Those related to G-tubes and all the other
things that we talked about wouldn’t be covered in this particular area. So let’s take an opportunity to talk about
the Kennedy ulcers. Those caused some confusion the last time
we taught on this. So the Kennedy ulcer is a skin ulcer that
occurs at the end of life and are known as the Kennedy or terminal ulcer. Kennedy or terminal skin ulcers are not captured
in Section M of the Long-Term CARE Data Set. However, they should be assessed and staged
using pressure ulcer/injury staging system, documented in your clinical record, and addressed
in your care plan, and whatever else you’re going to do for that person. So we’re saying clinically don’t ignore them. We’re just saying don’t identify Kennedy ulcers
on the data set. Etiology is believed to be related to tissue
perfusion issues due to organ or skin failure, right. One of our biggest organs is our skin. So in part of the dying process, the perfusion,
everything is shunting away and just trying to get to the brain and the heart and the
kidneys, the liver, and trying to keep all of our vital organs. So we start to see the perfusion of the skin
decrease. And the evolution and appearance differ from
a typical pressure ulcer. So the reason for not capturing it here is,
it’s not going to follow the pathway of a normal pressure ulcer. And so, we want to make sure that again staff
can identify what they look like. Generally, a Kennedy ulcer can appear from
six-weeks to two to three days, or even within 24 hours of someone’s death. For many people, especially the very classic
Kennedy ulcer, happens around the coccyx area. It can be a pear, a butterfly shape. Once you’ve seen one in your life you’ll never
forget one and what it looks like. Just know it’s there. Please don’t ignore it. Please plan for it. Do everything else you need to do. Just don’t put it on the CARE set. Okay. So we’re just going to go through a couple
of quick other scenarios. But we’re not going to have you write anything. We’ll do these together. So a patient is admitted to your LTCH with
one large Stage 3 pressure ulcer on their coccyx. At the time of discharge there’s some epithelialization
in the center of the pressure ulcer. So let’s think about how we would code this
one. So the first question is the number of Stage
2 pressure ulcers present upon admission? 0, right. The number of Stage 2 pressure ulcers on discharge? 0, right. And then we would skip. Remember that skip pattern. Number of Stage 3 pressure ulcers present
upon admission? We had that 1, right, that we talked about. And then at discharge we still had the 1. It’s starting to heal though, which is great. But it’s still, you still have a Stage 3. Then it’s asking the number of these Stage
3 pressure ulcers that were present upon admission? 1. That same ulcer that was there was there at
admission, there at discharge, although it looks like it’s starting the healing process. Then it was present upon admission. Which is exactly what we have here in our
coding scenario. Let’s go through. So here’s another quick scenario. A pressure ulcer described as a Stage 2 on
the heel was noted and documented in the patient’s medical record upon admission. On discharge this wound is noted to be a full
thickness ulcer, thus is now a Stage 3 pressure ulcer in the same location. Not an uncommon thing that happens, especially
in heels. So if you’re coding this, think about your
coding. So here we have number of Stage 2 pressure
ulcers? What did they have on that heel? They had a Stage 2, right. A Stage 2 on the heel when they were admitted. So we’re going to code as 1. At discharge, did they have any Stage 2s? No. Okay. The number of Stage 3s on admission? 0, right. They didn’t have any on admission. They only had a Stage 2. That same heel now progressed and so now at
discharge they have 1, they have stage 3. They have one of those. And then we ask the question, of that Stage
3 that we have on our discharge, how many of those were on admission? 0, right. We didn’t have any on admission. If you start to look at the patterns on these,
it really is very telling. If I didn’t have any on admission and now
have I some on discharge, none of these were present upon admission. You almost know the answer is going to be
0. Now have you ever seen a patient with like
seven pressure ulcers? Yeah, I mean I have over the years. So sometimes this can get pretty complex. You may have someone with all kinds of things
going on. So you want to kind of write it all out and
know exactly your count on each one. What was there on admission and now what do
I have at discharge. So this is the rationale. We just went through that. Because we didn’t have the Stage 2, it progressed
to a Stage 3. We skipped it. This just goes on to the rest of the scenario. We put those instructions in there so that
again, we think that not only in just reviewing it here today, hopefully you’ll take this
information back, you’ll have the blank ones that are out there now. But then you’ll also have the answers. You can use that for teaching. So in summary, I’m going to be ahead of schedule,
but we’re going to talk through what we’re going to do there. To be inclusive of updated terminology supported
by NPUAP, the National Pressure Ulcer Association, the term “injuries” as been added to Section
M headings in the following items. We went through all of those. So we’ve added that word “injury” to be updated. We’ve also removed the term, CMS has removed
the term “suspected deep tissue injury” and replaced it with the term “deep tissue injury”
then to improve clarity, the term “device” was added to M0300A, M0300E, M0300E1, and M0300E2. Also we took away M0800A-M0800F. That’s gone. You see where that made sense. This is gone because you can gather the information
with the current questions. The way that they’re asked you’re going to
get that same information. So, we are ahead of schedule. So what I was thinking, Mark, is that we would
take a few minutes to, since we really want to stay on time with speakers is that true? We can take a few minutes for you at your
tables to think about your Action Plans from everything we’ve done from this morning to
this point, but especially if you can think about the Section M. Because I think that’s
the greatest opportunity for your nurses on your units and whatnot. But would you be able to, what education or
what validation do you want to do when you go back to your organization to make sure
that you’re ready when these assessment items change? And make sure that your staff is prepared
to answer them. So everyone has an Action Plan in their folders
for those of you on live streaming, take your Action Plan out. If you happen to have someone in your office
with you for live streaming, talk that through with them. If not, I guess you can talk to yourself. I do that sometimes. (Laughter) I write out my plan. But just take a an opportunity to start thinking
about not only Section M but some of the other sections that we did this morning. Think about Med Rec. and the other sections
and say what are those things that I need to do? If you want to talk at your table about what
strategies, either you used from the last trainings that you did, or ongoing, it’s always
nice, especially if you’re sitting with people from other LTCHs in other areas that they
can share a best practice and what worked for them. I feel like even though I’ve been doing this
for a long time, I have this ah-ha moment. It’s like, oh wow. I didn’t think we could do it that way. I think we join again at 3:30. Does anyone have a schedule? I’m sorry, break is at — break is at 3:15. Okay, so we’re going to take a break, you
have 7 minutes to work on your Action Plan. 1, 2,3, go! Then we’ll take a break at 3:15. Thank you very much.

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