Author: Reliant Communications

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Care Matters Spotlight: Sept. 2020

Mr. Bell lives with us at Terra Bella Health and Wellness Suites. He survived a major stroke that left him unable to swallow, requiring a feeding tube and unable to speak. Mr. Bell was referred to speech therapy with a main goal of wanting to eat his favorite foods again. Elsa, our speech language pathologist, began intensive dysphagia intervention tailored to Mr. Bell’s personal goals.  His therapy sessions included VitalStim, a device that provides neuromuscular electrical stimulation to improve his ability to safely eat again. 

Mr. Bell’s self-motivation and consistent progression in therapy helped him achieve his goals and aided in the removal of his feeding tube. He is now safely able to eat by mouth again and enjoys eating snacks, especially desserts. His gains in therapy have facilitated improvements in his overall quality of life.

Congrats to Mr. Bell on his success in speech therapy!

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The Impact of Isolation and New Guidance from CMS

As healthcare providers, it has been our priority to encourage and maintain as much “normalcy” as possible while following all guidelines issued to protect our residents from COVID-19 over the last 6 months. We have seen firsthand the impact these regulations have had on our residents, and have used creativity to modify the environment, teach our residents how to utilize technology to speak to their family members, and encourage continued mobility and activity. Even with exhaustive efforts to bridge family communication and daily support and love from staff, depression and loneliness among residents continues to rise.

Recently, the Centers for Medicare and Medicaid Services (CMS) has announced new guidance for long-term care facilities in relation to visitation stating, “we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting.” While allowing visitation will certainly improve resident morale, CMS has also opened the door to increased social interaction between residents throughout the day.

Deep within this guidance, CMS advises to resume communal activities and dining while adhering to infection prevention recommendations. For example, residents may eat in the same room with social distancing. Group activities may also be facilitated with social distancing among residents and use of appropriate hand hygiene and face covering. Facilities may also be able to offer a variety of activities while taking the necessary precautions. CMS further states that “facilities may not restrict visitation without a reasonable clinical or safety cause.”

The detailed memo largely outlines visitation for indoor, outdoor, and compassionate care situations. CMS advises that visitation should be person-centered, taking into consideration each resident’s physical, mental, and psychosocial well-being. Outdoor visitation is preferred and should be utilized whenever practicable as it poses a lower risk of transmission. Facilities should also accommodate and support indoor visitation as safety and risk assessment allow utilizing data from the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data website. Facilities should continue to reduce transmission risk while allowing visitation through the use of physical barriers (i.e. clear Plexiglas dividers or curtains).  Among these guidelines, CMS emphasizes the need to follow core principles of COVID-19 infection prevention and use of social distancing.

Although this is not a return to normal, the new guidelines from CMS provide hope for our residents and caregivers by allowing them to have time with their loved ones and other residents within their facility. As healthcare providers, we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care. By promoting safe interaction among residents and their families, friends, or neighbors, we are creating a more understanding and supportive environment for our residents.

The CMS guidance for visitation can be found here.

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

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Keep Information Safe with Good Password Practices

These days we all are overloaded with the number of accounts that require credentials and remembering all of them is nearly impossible. Using the same password for different accounts is tempting—like having one handy key that opens every lock you use-but reusing passwords is not the solution.

Compromised passwords are one of the leading causes of data breaches, and reusing passwords can increase the damage done by what would otherwise be a relatively small incident. Cybercriminals know that people reuse credentials and often test compromised passwords on commonly used sites in order to expand the number of accounts they can access.

For instance, if you use the same password for your work email as for Amazon or your gym membership, a breach at one of those companies puts your work emails at risk.  Reusing credentials is like giving away copies of the key that opens all your locks. Before reusing a password for different accounts, especially across work and personal ones, think of all the data that someone could get into if they got that credential.

 Here are some tips to help you avoid falling in this trap:

• Use completely different passwords for work and personal accounts.

• Avoid words that can be guessed easily by attackers, like “password,” “September2020,” Fall2020 or predictable keyboard combinations like “1234567,” “qwerty,” or “1q2w3e4r5t.”

• Add some complexity with capitalization or special characters if required. “Fido!sAnAwesomeDog” is a stronger password than your pet’s name.

• Just adding numbers or special characters at the end of a word doesn’t increase security much, because they’re easy for software to guess.

• Avoid words like your kids’ names that could be guessed easily by coworkers or revealed by a few minutes of online research.

• Answers to security questions often are found easily — your mother’s maiden name is public record—so pick another word for whenever that question comes up.

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Clinical Appeals Corner: Sept. 2020

Earlier this year, the U.S. Centers for Medicare and Medicaid Services (CMS) deleted certain Correct Coding Initiative (CCI) edits related to physical, occupational, and speech therapy during the public health emergency. Recently, CMS announced that effective October 1, it will reinstate previously deleted coding edits for code pairs that represent common and appropriate therapy practice (i.e. 97116 and 97530 or 92526 and 97129).

The reinstated edits will require the use of the 59-modifier when these code pairs are provided on the same date of service. For clinicians, data entry within Optima will remain the same. The 59-modifer will automatically be added by Optima when appropriate and viable on the Service Delivery Logs.

CLICK HERE for the list of edits from CMS.

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Care Compare and New SNF Healthcare-Associated Infection Measure

In an effort to streamline the 8 existing CMS healthcare compare tools, CMS has combined them all into one streamlined tool, Care Compare.  Beginning withthe October 2020 refresh, CMS will publicly display six new measures on the Care Compare website:

  1. Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  2. Drug Regimen Review Conducted with Follow-Up for Identified Issues
  3. Application of IRF Functional Outcome Measure: Change in Self-Care
  4. Application of IRF Functional Outcome Measure: Change in Mobility
  5. Application of IRF Functional Outcome Measure: Discharge Self-Care Score
  6. Application of IRF Functional Outcome Measure: Discharge Mobility Score

Additionally, CMS announced the SNF Healthcare-Associated Infection measure will be a part of the Measures Under Consideration list later this year.  CMS has posted Draft Measure Specifications: SNF Healthcare-Associated Infections Requiring Hospitalizations for the SNF QRP (SNF HAI measure) and is seeking input from the public. 

Comments can be emailed HERE. (add email address QM-Public-Comment@acumenllc.com)

CLICK HERE to review the full Draft Measure Specification documents.

CLICK HERE to view the Care Compare website.

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SNF Quality Reporting Program (QRP)

The SNF QRP Reporting User’s Manual Version 3.0.1 has been updated.  These updates will be effective October 1, 2020.

Specification updates

  • All four SNF Functional Outcome Measures
    • Exclusion criteria: The age exclusion criterion for these measures has been updated from 21 years to 18 years, such that any resident younger than 18 years of age will be excluded from measure calculations.
  • SNF Discharge to Community Measure:
    • Exclusion criteria: This measure has been updated to exclude residents who had a long-term nursing facility (NF) stay in the 180 days preceding their qualifying hospitalization and SNF stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization.

Data Refresh

Early in the public health emergency, CMS made reporting requirements “optional” or “excepted” based on quarter.  CMS indicated that data submission for Q4 2019 was optional and that any data submitted would be used for reporting purposes. Since data submission for Q4 2019 was strong, the data will be included in measure calculations for the Nursing Home Compare site refresh scheduled for October 2020.  Because data from Q1 and Q2 is not included in the category or group specified for reporting, the data will be held constant following the October 2020 refresh.

CLICK HERE to view the SNF QRP User’s Manual Version 3.0.1

CLICK HERE to view the Tip Sheet.

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MDS Updates: Sept. 2020

Beginning, October 1, 2020, MDS version 1.17.2 will be instituted. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment.

  • This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.
  • Sections GG, I, and J

The updated item sets will not have a revised RAI manual released. As of 9/18/2020, AANAC is reporting 31 states have indicated they will be gathering PDPM data for state Medicaid programs and on OBRA assessments.

Section GG

Items GG0130 and GG0170 headers updated to read “Start of SNF stay or State PDPM”

  • Completion instructions include: If state requires completion with an OBRA assessment, the assessment period is the ARD plus 2 previous days. Complete only column 1.

Section I

Item I0020 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.

Section J

Item J2100 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.

Contact your state’s RAI coordinator for item set questions.

CLICK HERE to view the MDS 3.0 Technical Information page.

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CMS Issues New Guidance on Nursing Home Visitation

The Centers for Medicare & Medicaid Services (CMS) issued new guidance for visitation in nursing homes during the COVID-19 public health emergency. The guidance below provides reasonable ways a nursing home can safely facilitate in-person visitation to address the psychosocial needs of residents.

Visitation can be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations.

Regardless of how visits are conducted, certain Core Principles of Infection Control must be maintained:

  • Screen all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
  • Hand hygiene (use of alcohol-based hand rub is preferred)
  • Face covering or mask
  • Social distancing at least six feet between persons
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
  • Clean and disinfect high frequency touched surfaces in the facility often, and designate visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care)
  • Resident and staff testing conducted as required in 42 CFR 483.80(h)

Guidance is provided for indoor, outdoor, and compassionate care situations.

Outdoor Visitation

Outdoor visits pose a lower risk of transmission due to increased space and airflow. Therefore, outdoor visitation is preferred, and all visits should be held outdoors whenever practicable.

Indoor Visitation

Should be accommodated and supported based on the following guidelines:

  • No new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing;
  • Visitors adhere to the core principles and staff adherence;
  • Limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space);
  • Consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and
  • Limit movement in the facility.

Facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site to determine how to facilitate indoor visitation:

Communal Activities and Dining

  • While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
  • Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). 
  • Facilities should consider additional limitations based on status of COVID-19 infections in the facility.
  • Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering.
  • Facilities may be able to offer a variety of activities while also taking necessary precautions.
    • For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission.

For additional guidance concerning compassionate care visitations, refer to the full article here.

CLICK HERE to view the press release from CMS.

CLICK HERE to view the nursing home visitation guidance.

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Tips for Preventing Falls

Falls can put you at risk of serious injury. Prevent falls with these simple fall-prevention measures, from reviewing your medications to hazard-proofing your living spaces.  

  • Remove tripping hazards such as books, papers, shoes and boxes from hallways, and secure area rugs.
  • Install grab-bars in the bathroom, both around the toilet and the shower.
  • Keep frequently used items within easy reach, so you don’t have to climb or strain for them.
  • Make sure that both the inside and outside the home has adequate lighting so you can see your path while walking.
  • Alert your care or maintenance team of any damage or repairs that need to be made to walkways or steps and.
  • Wear sensible shoes with nonskid soles and a proper fit.
  • Poor vision is a major factor in falls. Get an eye exam at least once a year to keep prescriptions current and eyes functioning their best.
  • Consider adding extra personal by using a mobile alert system with GPS to access emergency help at any time.
  • Medication errors are one of the main catalysts for falls. Talk with your caregivers about any potential side effects of the medications you take to see if any may increase dizziness or impact balance and ways to mitigate this
  1. Stay active! Even gentle exercise can increase strength and balance, healing to reduce the risk of falls.
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Interim Final Rule and Surveyor Guidance for Long-Term Care Facility Testing Requirements

CMS has released guidance outlining details on how to comply with the new interim final rule requiring COVID-19 testing of staff and residents.

Testing Guidance

CMS is requiring facilities to conduct three types of testing: 

  1. Symptomatic Testing: Test any staff or residents who have signs or symptoms of COVID-19 (facility must continue screening all staff, residents and other visitors).
  2. Outbreak Testing: Test all staff and residents in response to an outbreak (defined as any single new infection in staff or any nursing home onset infection in a resident) and continue to test all staff and residents that tested negative every 3-7 days until 14 days has passed since the most recent positive result. An admit already confirmed does not constitute a facility outbreak.
  3. Routine Testing: Test all staff based on the extent of the virus in the community, using CMS’ published county positivity rate under “COVID-19 Testing”, in the prior week as the trigger for staff testing frequency as outlined in the table below:
  • Facilities are guided to monitor their county positivity rate every other week (e.g. first and third Monday of every month).
  • Staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be retested for COVID within 3 months after symptom onset.
  • CMS provided guidance on staff who refuse to test:
    • Staff who refuse and have signs or symptoms must be prohibited from entering until the return to work criteria are met. CLICK HERE to review the CDC Criteria for Return to Work.
    • Asymptomatic staff who refuse testing should follow occupational health and local jurisdiction policies.
  • Facilities must maintain records of all testing for compliance and must be able to provide to surveyors.
  • Facilities that do not comply with the testing requirements will be cited for noncompliance with new F-tag, F-886.

CMS has also revised the focus surveys for nursing homes to ensure compliance with testing requirements, infection prevention standards, and compliance for infection preventionists.

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Take CARE with Infection Control

With frequently updated guidance from federal and state agencies, we are continuously hearing the most current information on how to protect our residents from COVID-19 with best practice infection control. Keeping all members of the team informed of the most recent processes may appear to be a daunting task; however, with the uptick in COVID-19 cases in nursing homes and CMS administrator Seema Verma stating concern, it’s a great time to review how we can keep our residents, staff, and selves safe.

Reliant has created a 4-step approach to Take CARE with Infection Control:

When considering implementation, identify appropriate hand hygiene frequency, PPE based on type of precautions, and items and equipment that need routine cleaning and disinfection.  Be attentive to sequenced steps and processes for hand hygiene, donning and doffing PPE, and cleaning.  In order to ensure reliability, commit to self and peer accountability and implementing PPE peers using return demonstration. To monitor effectiveness of implementation, assess and adjust processes as necessary.

Download and review CMS’ latest Infection Control Survey Guidance (released 8/26/2020) as a guide.

By working together as an interdisciplinary team and holding each other accountable for best practice infection control practices, we can minimize the spread of COVID-19 within our facilities.  Practice extreme diligence and caution with infection control and prevention processes.

CLICK HERE for more information on Reliant’s Take CARE with Infection Control initiative.

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Care Matters Spotlight – August 2020

Mrs. Mabary was admitted to Care Nursing and Rehab in Brownwood, TX, after a fall led to a hip fracture on her right side which also had a prior transtibial amputation.  Prior to her injury, Mrs. Mabary walked up and down the 20 stairs to her bedroom with her prosthesis.  However, due to weight bearing restrictions, the therapy team had to get creative with a technique for going up and down the stairs.  At first, Mrs. Mabary was unable to hop up and down even one step without her prosthesis.  After working hard in therapy, she is now more than halfway to her goal of 20 steps as she is able to hop up and down a step 13 times!

Her drive and determination didn’t stop there!   When Mrs. Mabary arrived at Care Nursing and Rehab, she had a great deal of pain and required moderate assistance for bed mobility and transfers.  Now she can perform bed mobility and transfers with someone just standing nearby for assistance, and with decreased pain.

Luckily for Mrs. Mabary, communication and training with her son (with whom she lives ) is easily achievable as her son is a certified nursing assistant at the facility. Mrs. Mabary has a follow up appointment next week, and the team is hoping for great news regarding her weight bearing restrictions. In the meantime, she will continue working hard to improve her strength and balance.

Thank you, Mrs. Mabary, for being a great example of perseverance while also encouraging the other residents to strive hard in therapy.  You are an inspiration to us all!

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OCR Alert – Phishing Scam Targeting Compliance Officers

The Office of Civil Rights (OCR) issued an alert on August 6, 2020 reporting postcards are being sent impersonating the OCR to coerce compliance officers into visiting a website regarding HIPAA risk assessments.  This is a marketing ploy to trick the victim into engaging in services under the guise of a directive from OCR.  A risk assessment is a requirement of HIPAA as defined in §164.308(a)(1); however, it does not specifically state how often it is needed or how it is to be done.  Best practice is to conduct risk assessments annually or when significant changes or threats occur within or to the environment.

It is recommended by OCR that all covered entities alert their workforce about this misleading communication.  For more information and an example of the postcard, CLICK HERE.

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MACs Resume Medical Review on a Post-Payment Basis

In the August 6, MLN, CMS announced Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs resumed with post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.

CLICK HERE to review the MLN Connects newsletter.

Although medical review has not been initiated at this time for dates of service during the public health emergency, future RAC and MAC reviews are forthcoming. According to an article posted on RAC Monitor on 8/25/20, high priority audits may include claims with

  • Positive COVID-19 diagnoses to ensure testing results are accurately documented. 
  • Remote patient monitoring codes

Providers should be reviewing claims and supportive documentation now to identify potential areas of improvement.

Additionally, the introduction of remote audits is anticipated. The remote audits allow for the current work-from-home, travel-restricted business climate.

CLICK HERE to view the article in its entirety.

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CMS FY 2021 SNF PPS Final Rule Released

Strengthening Medicare

CMS projects that aggregate Medicare program payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021 compared to FY 2020. This estimated increase is attributable to a 2.2 percent market basket increase factor, adjusted by a 0.0 percentage point productivity adjustment.

Updates to PDPM Clinical Diagnosis Mappings

In this final rule, in response to these stakeholder recommendations, CMS is finalizing changes to the ICD-10 code mappings, effective October 1, 2020.

SNF Value-Based Purchasing (VBP) Program

CMS made no changes to the measures, SNF VBP scoring policies, or payment policies in this final rule.  CMS announced performance periods and performance standards for the FY 2023 program year.

CLICK HERE to view the SNF PPS Final Rule.

CLICK HERE to view the SNF PPS Final Rule Fact Sheet.

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CMS Physician Fee Schedule CY 2021 Proposed Rule Released

CY 2021 PFS Ratesetting and Conversion Factor

With the budget neutrality adjustment to account for changes in Resource Value Units (RVUs), CMS reports the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.  CMS’ increases in RVU for Evaluation and Management (E/M) services codes in CY 2020 final rule are to take effect 1/1/2021. These increases are a positive for primary care physicians and some physical therapy and occupational therapy evaluation codes. However, the significant cuts to frequently used therapy intervention codes result in an overall 7-9% decrease in reimbursement for therapy services. CMS proposes these cuts to therapy as well as other critical care provisions in order to meet the budget neutrality requirements.

Advocacy efforts are underway to #fightthecut and protect our beneficiaries’ access to therapy, especially during this health care emergency.

Contact your congressman through your respective association below:

NASL

APTA

AOTA

ASHA

Additionally, comments can be sent directly to CMS here by October 5, 2020.

Medicare Telehealth

CMS is proposing to make permanent some telehealth provisions related to physician visits that have been extended as part of the public health emergency. Currently, a finite list of therapy services is reimbursable when provided via telehealth for as long as the public health emergency exists, and there is no proposal to make these therapy telehealth provisions permanent.

CLICK HERE to view the Physician Fee Schedule CY 2021 Proposed Rule.

CLICK HERE to view the Physician Fee Schedule Proposed Rule Fact Sheet.

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MDS Updates

On Oct 1 MDS version 1.17.2 will be used. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment. This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.

The updated item sets will not have a revised RAI manual released.  Contact your state’s RAI coordinator for item set questions.

For more information, visit MDS 3.0 Technical Information page.

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Emergency Declarations

Watch for more information from CMS regarding possible additional waivers for beneficiaries in Louisiana and Texas due to Hurricane Laura and in California due to the wildfires following declarations of public health emergency in those locations.

CLICK HERE for more information on the waivers when they become available.

CLICK HERE to read the press release regarding Hurricane Laura relief.

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COVID-19 Waiver Claims Review

Providers have begun receiving non-medical additional document requests for claims utilizing the benefit period waiver in response to the COVID-19 public health emergency. These reviewers are being flagged with a “7COVD” code and have primarily been reported under Wisconsin Physician Services (WPS).

These suspended claims may be the result of a billing issue. As such, review the proper guidelines below for how claims involving the waiver for the 60-day wellness period should be billed.

According to this Medicare Learning Network memo, to bill for the benefit period waiver:

  • Submit a final discharge claim on day 101 with patient status 01, discharge to home
  • Readmit the beneficiary to start the benefit period waiver

For admission under the benefit period waiver:

  • Complete a 5-day PPS Assessment. (the interrupted stay policy does not apply.)
  • Follow all SNF PDPM assessment rules.
  • Include the HIPPS code derived from the new 5-day assessment on the claim.
  • The variable per diem schedules begins from day 1.

For SNF benefit period waiver claims, include the following:

  • Condition code DR- identifies the claim as related to the PHE
  • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
  • COVID100 in the remarks – this identifies the claim as a benefit period waiver request
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Understanding Loneliness and Ways You Can Help

Loneliness and social isolation might seem like conditions that are just “in your head,” but it’s important to recognize the signs and help those who might be impacted.

Types of Loneliness

Emotional

When someone feels the lack of intimate relationships possibly due to the loss of a close partner or friend.         

  • Grief and bereavement support can help provide the tools needed to cherish that relationship and move forward to exploring new ones.
  • Incorporate activities to honor their loved one (e.g., make a scrap book or photo album).

Social

Lack of satisfying contact with family, friends, neighbors and other community members 

  • Engaging in social activities can help mitigate this one. Encourage the person to dine with others and find activities that inspire them to interact including music, games and other activities hobbies.
  • If appropriate for the resident(s), incorporate education in the use of smart phones or computers for communication with family and friends.

Collective

Feeling of not being valued by the broader community      

  • Lend a listening ear.
  • Coordinate a small support group within the community where participants can share their stories, encourage each other and identify opportunities for community involvement.
  • Facilitate activities that engage the resident and the community in which residents assist the community (e.g., shelling peas for a local farmer).

Existential      

The sense that life lacks meaning or purpose          

Often older adults feel they have moved from providing for their family to being becoming a burden on them. Help them find a new meaning and purpose such as the following:

  • Explore small chores in the facility such as:
  • Helping with a pet therapy animal
  • Watering or tending plants/gardens
  • Feeding the birds
  • Delivering mail or paper
  • Shower them with lots of appreciation for their contributions –                                                no matter how big or small.
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