NURSING HOME SURVEILLANCE UPDATE

Transcription

1 NURSING HOME SURVEILLANCE UPDATE May 3, 2017 Sheila McGarvey, Deputy Director Division of Nursing Homes and ICF/IID Surveillance Center for Health Care Provider Services and Oversight Office of Primary Care and Health Systems Management

2 May 3, Today s Discussion Topics: Regional Office Contacts New Requirements of participation Phase 1 Phase 2 New Survey Process LSC changes

3 May 3, Today s Discussion Topics Con t: Discharge Transfer Requirements Emergency Preparedness DOH Quality Improvement initiatives Immediate Jeopardy

4 May 3, Division of Nursing Homes and ICF/IID Surveillance Director: Shelly Glock Director Bureau of Quality: Tarrah Quinlan Capital District Area Office, Director: Kim Valente Central New York Regional Office, Director: Nancy Finnigan Metropolitan Area Regional Office, Director: Toni Herman Assistant Director: Leah Ryer Western Regional Office, Area Director: Vacant

5 May 3, The Nine most Terrifying words in the English Language I m from the government and I m here to help President Regan 9/12/86

6 May 3, Requirements of Participation

7 May 3, Phase 1 Implementation Effective November 28, 2016

8 May 3, Highlights of Phase 1 Newly Mandated Policies and Procedures Grievances Resident Visitation Rights Return/Readmission Admissions Inclusion of exploitation in Abuse Policy and Procedure Use and Storage of Food Brought to Residents by Family/Other Visitors Drug Regimen Review

9 May 3, Highlights of Phase 1 Resident Rights The predominant theme in this section is Person-Centered Care, and the facility s responsibility in supporting residents in exercising those rights. Resident/ Resident Representative involvement in planning care, access to records How/ when a Resident Representative is chosen and implemented by the resident Residents visitors Significant changes in handling grievances

10 May 3, Highlights of Phase 1 Freedom from Abuse, Neglect and Exploitation Strengthens existing protections Clarifies definitions

11 May 3, Highlights of Phase 1 Admission/ Transfer/ Discharge Transfer and discharge notice content The facility must send a copy of the discharge or transfer notice to a representative of the Office of the State Long- Term Care Ombudsman Program

12 May 3, Highlights of Phase 1 Comprehensive Person-Centered Care Planning (This is an entirely new section) Baseline resident care plan within 48 hours of admission, with instructions for providing effective and person-centered care Include specialized services based on PASRR recommendations Nurse aide and a member of the food and nutrition services staff are added as required members of the interdisciplinary team that develops the comprehensive care plan Significant changes in discharge planning

13 May 3, Highlights of Phase 1 Pharmacy Services Newly mandated Policy and Procedure Pharmacist must document (on a separate report sent to the Medical Director, attending physician, and Director of Nursing) any irregularities found during the drug regimen review Irregularities must be acted upon

14 May 3, Phase 2 Effective November 28, 2017

15 May 3, Phase 2 All Phase 1 requirements Renumbering of F tags New survey process Interpretative guidance Effective November 28, 2017

16 May 3, Highlights of Phase 2 Facility Assessment basis for determining compliance in key areas such as adequacy of nurse staffing and staff in-service training, Quality Assurance and Performance Improvement (QAPI) activities, compliance efforts and emergency preparedness.

17 May 3, Highlights of Phase 2 Psychotrophic Drugs and Medication Review Definition of psychotrophic drugs is more narrow to include anti-anxiety meds, antidepressants, hyponotics. Permissible duration of prn orders-14 day limit (must reevaluate for appropriateness)

18 May 3, Highlights of Phase 2 Transfer & Discharge (Additional Requirements) Final rule does not require that a physician, physician assistant, nurse practitioner or clinical nurse specialist conduct an in person assessment of a resident prior to any unscheduled non-emergency transfer to the hospital The transfer or discharge must be documented in the resident s medical record

19 May 3, Highlights of Phase 2 Baseline Care Plans The developments of an interim baseline care plan (CP) within 48 hours of admission. The baseline CP must include: Initial goals based on admission orders Physician orders Dietary orders Therapy services Social services and PASARR recommendations, if applicable

20 May 3, Highlights of Phase 2 Quality Assurance and Performance Improvement (QAPI) The QAPI program must be data driven, address all systems of care and management practices and focus on clinical care, quality of life and resident choice. The program must be deigned to monitor and evaluate the performance of all services and programs including contractual services Facilities will provide surveyors with a QAPI plan during each standard health survey (on or after 11/28/17) and as requested during other surveys and to CMS upon request QA committee will be required to coordinate and evaluate the QAPI program and report directly to the facility s governing body

21 May 3, Highlights of Phase 2 Antibiotic Stewardship Program Phase 1 facilities establish and maintain an Infection Prevention and Control Program (IPCP) Antibiotic stewardship program includes antibiotic use protocols and a system for monitoring such use.

22 May 3, Highlights of Phase 2 New Survey Process QIS, Traditional and Regulatory changes Computer based Two parts Sample selection: 70% offsite and 30% onsite Investigation New F-tags Coding System

23 May 3, Highlights of Phase 2 New Survey Process Day1 Entrance conference and kitchen tour Surveyors report to assigned units Observation of staff and resident interactions No formal staff interviews Eight resident interviews per surveyor and three family interviews per survey Three closed record reviews: death, discharge to community and hospital

24 May 3, Highlights of Phase 2 New Survey Process Day 2-5 Finalize sample: may be 50/50 split based on data Medical record reviews and investigating concerns Facility tasks: Medication storage, dining, QAPI review, demand bills, staffing Emphasis on Hospice (Notification) and Dialysis Resident Council interview group and review minutes

25 May 3, Highlights of Phase 2 New Survey Training CMS Regional Office (RO) Ambassador training early July 2017 CMS RO surveyor training early mid-july 2017 State Agency (SA) trainer-subject matter expert training July 31 through August 3, 2017 SA surveyor training webinar August 14 through August 18 refresher training in October 2017 Federal training suspended from 6/20/17 through 1/20/18. Advance copy of interpretive guidance May 2017

26 May 3, Highlights of Phase 2 Provider Training CMS Webinar and National Provider Calls, new tags, interpretive guidance and survey process CMS site for questions and comments: NHSurveyDevelopment@cms.hhs.gov Department will set up provider training via webinars DOH site for questions and comments: NHROP@health.ny.gov

27 May 3,

28 May 3, HISTORY 5/4/2016 CMS adopted the 2012 NFPA 101 Life Safety Code (LSC) and 2012 NFPA 99 Health Care Facilities Code (HCFC) by final rule. 7/5/2016 regulation effective date. 9/2/2016 CMS on-line transition course made available to LSC surveyors. 11/1/2016 date mandated by CMS for state agencies to begin surveying facilities for compliance with the 2012 codes.

29 May 3, What s New? New mandatory code references Maintenance of patient care related electrical equipment (PCREE) Door Inspections Fire Safety Evaluation System (FSES) New allowances for items in corridors Open kitchens allowed if specific requirements are met.

30 May 3, Mandatory Code References Chapter 2 of the LSC states, The documents referenced in this chapter, or portions of such documents, are referenced within this Code, shall be considered part of the requirements of this Code, The most notable change from the 2000 LSC is the adoption of the entire document of NFPA 99, the Health Care Facilities Code 2012 edition.

31 May 3, Maintenance of Patient Care Related Electrical Equipment (PCREE) Facility must have a policy and procedure. The service manual for each piece of PCREE must be on hand. A maintenance plan based on the manufacturer s recommendations must be developed for each piece of PCREE. Documentation of all maintenance and servicing must be kept. Equipment must be serviced by qualified personnel can be a facility employee, but the facility must provide initial and ongoing training. Leased equipment should also be addressed in the P&P. All of the above applies to leased equipment; the manual must be on hand, the equipment must be serviced according to manufacturer s recommendations and the service records must be on hand. Any resident owned electrical equipment or non-pcree must be visually inspected when first brought into the facility. Records should be maintained.

32 May 3, Door Inspections The following doors must be inspected annually: Fire-rated doors (in accordance with NFPA 80, 2010 edition) Smoke doors (in accordance with NFPA 105, 2010 edition) Doors equipped with panic hardware Door assemblies in exit enclosures Electrically controlled egress doors Door assemblies with special locking arrangements The inspection must be done by a qualified individual can be facility employee, but must be trained. Documentation of inspection must be maintained and available for review.

33 May 3, Fire Safety Evaluation System (FSES) CMS has adopted the 2013 edition of NFPA 101A, which provides an alternative method of demonstrating that a facility meets a level of fire safety that is equivalent to passing a life safety code inspection. Facilities considering completing an FSES should ensure that they use the 2013 version of the form Form CMS 2786T (10/2016), which is available on the CMS website. Point values on the 2013 form are different from the 2001 version. Some facilities that formerly passed their LSC survey via FSES may not pass using the new form. Facilities that do not pass must either make the needed fire/safety/environmental changes or can apply for a time limited waiver through BAER.

34 May 3, Changes That Are Less Restrictive Open kitchens facilities are now allowed to have kitchens that are open to the corridor providing they meet the specific requirements found in sections / of 2012 NFPA 101 (LSC). There is now an allowance for wheeled equipment and fixed furniture in corridors. The requirements of / must be met. Direct-vent gas fireplaces are permitted within smoke compartments containing sleeping areas provided specific requirements are met. A slight increase in the quantity of alcohol-based hand rub within a smoke compartment.

35 May 3, Disclosure The previous slides are not all inclusive of the changes in either the Life Safety Code or the Health Care Facilities Code. These are just the highlights. If you have any questions, please call your DOH Regional Office. Questions to:

36 May 3, Discharge/Transfer Requirements

37 May 3, Discharge Planning Starts on Admission MDS Section Q (civil rights guidance) If the resident wishes to return to the community (regardless of staff beliefs about potential ) a referral to New York Association on Independent Living ( NYAIL ) Open Doors Program is required by all nursing facilities-10 business days. Contact Information: www. ilny.org, INFO@ILNY.ORG Presentation available by Public Health Live!: Money Follows the Person Program: facilitating Return to Community based Settings

38 May 3, Regulatory Reasons for Transfer/Discharge The transfer or discharge is necessary for the resident s welfare and the resident s needs cannot be met in the facility: The resident's health improves sufficiently so the resident no longer needs the services of the facility. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. The facility ceases to operate.

39 May 3, Regulations (Cont.) The facility may not transfer or discharge the resident while the appeal in pending.

40 May 3, Required Medical Record Documentation Clinical record must be documented by MD or physician extender and must be communicated to the receiving facility/prover and include: Reason for transfer/discharge; Detail specific resident needs that can not be met at the facility; Document all attempts to meet resident specific needs and; The services available at the receiving facility to meet the resident s needs.

41 May 3, Facility is Required to Provide the Receiving Provider: Contact information of the practitioner responsible for the care of the resident; Resident representative information including contact information; Advanced Directive Information; All Special instructions, precautions for ongoing care, as appropriate; Comprehensive care plan goals; Copy of the resident discharge summary; Any other documents applicable to ensure safe transition of care.

42 May 3, Discharge Notice Timing Written notice must be given 30 days before the resident is discharge or transferred. Notice may be made as soon as practicable before transfer or discharge if: Health and safety of resident or other(s) is a concern; If health has improved to allow a more immediate transfer; Resident has urgent medical needs; Resident has not resided in the facility for 30 days; Notice is required to be given to resident, resident representative(s) and a copy to the Office of the State Long-Term Care Ombudsman Program.

43 May 3, Date of issue Discharge Notice Required Contents Reason for transfer (regulatory); Effective date for transfer or discharge; Location to which the resident is transferred or discharged; A statement of resident appeal rights including contact info and information on how to request assistance with completing and submitting Contact information(name, address, and phone number) of the Office of the State Long Term Care Ombudsman; Justice center contact information (mailing and address and telephone number) for facility residents with mental, intellectual or development disabilities or related disabilities.

44 May 3, Discharge Notice (Cont.) If information in the notice changes the facility must update the recipient s notice. In cases of facility closure, the administrator of the facility must provide written notice and receive approval from the Deputy Commissioner prior to notifying State Long-Term Care Ombudsman, residents of the facility and resident representatives. The facility must also submit a plan for the transfer and relocation of residents. This includes closure of ADHCPs

45 May 3, Discharge Planning The facility must provide and document sufficient preparation to residents to ensure safe and orderly transfer or discharge from the facility. This must be provided in a form and manner that the resident can understand. Examples: Involve resident and family in DC planning; Trial visits if possible; Secure possessions so they are not left behind or lost; Alert the new location to needs of resident; Provide appropriate referrals for follow up care.

46 May 3, Short Term (Rehab) vs. Long Term Stays The regulations do not recognize subacute as a separate program, therefore subacute units fall under the LTC regulations. Nursing Home beds are certified as LTC beds. There is no delineation between short term or long term beds. All NH beds in NYS are dually certified Medicare/Medicaid A facility can not require a resident to transfer/discharge to a different facility when a short term care stay is converted to a long term care stay.

47 May 3, Quality Improvement Initiatives

48 May 3, % 14.2% NYS Pressure Ulcer Rates 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 9.4% 8.3% 8.0% 7.6% 7.5% 7.1% 0.0% Source: Centers for Medicare and Medicaid Services (CMS) through 9/30/16 *

49 May 3, Gold STAMP Program to Reduce Pressure Ulcers Establishing STANDARDS THROUGH: ASSESSMENT MANAGEMENT PREVENTION

50 May 3, Gold STAMP Program to Reduce Pressure Ulcers Overview Collaborative Toolkit Physician Toolkit Online Education

51 May 3, CMS ANTIPSYCHOTIC INITIATIVE 2012 CMS FORMED THE PARTNERSHIP TO IMPROVE DEMENTIA CARE, AN INITIATIVE TO ENSURE APPROPRIATE CARE AND USE OF ANTIPSYCHOTIC MEDICATIONS FOR NURSING HOME RESIDENTS GOAL- ENHANCE THE USE OF NON-PHARMACOLOGICAL APPROACHES AND PERSON CENTERED CARE PRACTICES. INITIAL FOCUS-REDUCE THE NATIONAL RATE OF ANTIPSYCHOTIC MEDICATION USE IN PERSONS LIVING IN NURSING HOME BY 15% BY THE END OF 2012, NEW GOAL OF 25% REDUCTION END OF 2015 (15.97% NYS), 30% GOAL BY END OF 2016 (13.6% NYS) DISTRIBUTED TO ALL NURSING HOMES THE HAND IN HAND TRAINING SERIES THAT EMPHASIZES PERSON-CENTERED CARE, PREVENTION OF ABUSE AND HIGH QUALITY OF CARE FOR RESIDENTS

52 May 3, REDUCING THE USE OF ANTIPSYCHOTIC MEDICATIONS IN NURSING HOME RESIDENTS NYS DOH ANTIPSYCHOTIC INITIATIVE NYS DOH IS FOCUSING ON INCREASING KNOWLEDGE AND SUPPORTING SURVEYORS TO DETERMINE COMPLIANCE AND EVIDENCE OF ALTERNATIVES NYS CURRENTLY RANKED 11 NATIONALLY FOR Q (LOWER=BETTER) DATA DEMONSTRATES 36.1% RELATIVE IMPROVEMENT

53 May 3, Q ( Oct. Dec. ) 13.6%

54 May 3,

55 May 3, efinds needed to: provide ongoing awareness of the current location of each evacuated person, across all movement, capture essential care needs information for the person, and capture key contact information for their loved ones and care givers.

56 May 3, efinds Supplies DOH Provided Wristbands replenished upon use Originally distributed, currently used, sticker-type wristbands Scannable (PDF) Barcode Log Newer style, clip wristbands, expected to be used going forward for ACFs & NHs Scanners: white for use at facilities where more stringent disinfectants are used

57 May 3, Each Facility must have a plan to Use efinds, that is part of their existing evacuation plan Lessons Learned from ~ 30 Actual Events Didn t know how to use system; no protocol in place Too few staff trained/able to access efinds; none present at time of emergency/on all shifts Didn t know where supplies are stored or lost them Removed wristbands from evacuee; couldn t register Didn t realize need to repatriate returning evacuees in efinds Didn t know how to track shelter in place persons in the system

58 May 3, Planning Considerations: Be ready to access the HCS and efinds Ensure a cohort of staff, on each shift, are trained to use efinds and the HCS. Access is free; Training is free and widely available on line and in person Each efinds user must have their own, active, HCS accounts (Absolutely NO Account Sharing is allowed!) Ensure each user knows their account IDs and passwords Ensure each prospective efinds user is assigned to the appropriate efinds role in the HCS Communications Directory

59 May 3, It is Absolutely Critical: that business and emergency/after hours contact information for facility administrative and emergency response staff, is kept up to date in the HCS Communications Directory

60 May 3, CMS Final Rule for Emergency Preparedness:

61 May 3, All providers/suppliers required to establish an emergency preparedness plan addressing four core elements Based on HOSPITAL requirements but tailored to unique needs/operations of each provider type 1. Risk assessment and planning: Facility based and community based assessment prior to creating a plan: all-hazards approach; develop scenarios 2. Policies and Procedures: to implement/execute the plan based on assessment/plan Continuity of Operations (COOP); shared resource management; collaboration with key agencies; patient/resident/staff tracking; SiP, safe evacuation, S-R arrangements; Coordination across stakeholders; continuity of care; vulnerable pops, transportation 3. Communication Plan: key contacts (staff, agencies, physicians) redundant/alternate means of communication; patient/resident data sharing/documentation 4. Training and Testing: facility develop and maintain an emergency preparedness training and testing program for new and existing staff. Demonstrate competency via Annual exercises (2): a full scale, community exercise and a facility based drill

62 May 3, Emergency Preparedness Requirements for LTC Facilities Develop and maintain an emergency preparedness plan to be reviewed and updated at least annually (annual plan review is already required): Develop/document, a facility-based & community-based risk assessment using an all-hazard approach, including missing clients; consideration of facility s physical location, geographical area and client population Reach out to the HPP, regional healthcare coalition(s) in their jurisdictions Share with client/family/representative appropriate information from emergency plan CMS considers the risk assessment activities already required to be facility centric and must be reviewed/ revised as necessary to meet response to larger scale emergencies.

63 May 3, Emergency Preparedness Requirements (cont d) Revise and, if necessary, develop new policies and procedures to ensure they align with the new plan and incorporate the following, already required under current regulations: perform drills, evaluate the effectiveness of those drills develop improvement plan take corrective action for any problems maintain procedures for safe evacuation from and return to the NH Tracking during and after the emergency of on-duty staff and sheltered clients. Document emergency preparedness communication plan, review annually;

64 May 3, Emergency Preparedness Requirements Continued: Emergency Power Systems Must implement emergency and standby power systems based on emergency plan Generator must be located according to requirements found in NFPA 101, 110, 99 codes and TIAs when a new structure is built or existing one is renovated.** Comply with emergency generator inspection and testing and maintenance found in Health Care Facilities Code NFPA 110 and Life Safety Code** Must maintain onsite source of emergency generator fuel and have a plan of how to keep emergency power systems operational during the emergency, unless it evacuates

65 May 3, Interpretive Guidelines and Surveyor Checklist/training expected to be available sometime early 2017 Cross-walking existing requirements with new requirements and NYCRR for all provider types Convening training workgroups to identify most useful/relevant/current templates and training materials to streamline training/planning toolkits for each provider type Working with healthcare trade associations to communicate information regarding impact & understanding of new regulations, provide assistance to providers More training once interpretive guidelines and surveyor guidance is received

66 May 3,

67 May 3, ,000 5,446 5,745 5,370 5,726 5,993 5,920 5,000 4,000 3,000 2,000 1,000 0 FFY-2011 FFY-2012 FFY-2013 FFY-2014 FFY-2015 FFY-2016 Series 1 5,446 5,745 5,370 5,726 5,993 5,920

68 May 3, Survey Performance Top 5 Citations, FFY-2016 (Represent 24% of Citations Issued) 4.4% 4.3% 4.8% 5.1% 5.1% F0309 PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING F0225 NOT EMPLOY PERSONS GUILTY OF ABUSE F0371 STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS F0323 FACILITY IS FREE OF ACCIDENTS HAZARDS F0441 FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

69 May 3, Common Complaints By Third Parties Care issues-family reports symptoms to staff, no action taken Development of pressure sores Medications not available (especially pain meds) Staffing concerns Medication use of particular drug or overuse of psychoactive medications Not assisting with toileting, incontinence care and eating. No call bell response. Abuse allegations

70 May 3, surveys resulted in IJ citations during FFY surveys resulted in IJ citations during FFY surveys resulted in IJ citations during FFY 2014 During FFY 2016, 24% (4) of the IJ citations were identified during abbreviated/complaint surveys

71 May 3, Top Immediate Jeopardy (IJ) Citations F323 Accidents F224 Facility Prohibits Abuse F309 Provide Care/Highest Well Being F371 Store /Prepare/Distribute Food under Sanitary Conditions F441 Infection Control Program *F490 Effective Administration and F520 QAA routinely cited with IJ

72 May 3, Immediate Jeopardy Most Immediate Jeopardy is due to noncompliance in one or more of the following: Process system failures (assessing, planning, implementing, evaluating) Underlying structure system problems (record systems, supply systems, etc.) Failure of leadership/management (philosophy, mission statement, planning, staffing, supervising, delegating, controlling, appraising staff performance) Failure of QA/risk management(assessing, planning, implementing, evaluating) Lack of staff knowledge, skills, or motivation

73 May 3, Immediate Jeopardy Unsafe smoking Unsafe water temps/food temps Exit door egress Advance Directives Siderails Resident to resident abuse Unsafe smoking Background checks Infection control Fire alarm system not functioning Empty O2 tanks

74 May 3, Abuse Prevention Facility policies and procedures must include the following in their Abuse Prohibition Protocols: 1. Screening 2. Training 3. Identification 4. Resident Protection 5. Investigation 6. Report/Response 7. Prevention

75 May 3, Common Pitfalls During Investigation Abuse has not been ruled out (especially with injuries of unknown origin). Facility documents occurrence, or discovery of a bruise, but lacks investigation to how it may have occurred- Re-enactments not done. Investigation is not initiated immediately. The accused continues to have access to resident.

76 May 3, Common Pitfalls Resident or other residents are left unprotected. Staff statements are of poor quality lacking any information, and not signed or dated, no title. Documentation of the facility investigation does not support the conclusion. Facility investigation is inconclusive.

77 May 3, Common Pitfalls Identification of a need to change the plan of care, as a result of the incident and it is not implemented. Lack of appropriate training or supervision of staff, or lack of skill development. Resident has a history of occurrences, such as falls, but the care plan does not address these. Occurrences, such as falls, are added to care plan, as documentation, but, without a plan to prevent further occurrences.

78 May 3, Common Pitfalls Staff is unaware of POC changes that were made / CNA card does not match POC. Care plan says reminders not to stand educated to but resident has dementia with memory loss and cannot retain information. Interviews not done- only statements obtained. Injuries are not described in the documentation.

79 May 3, Advance Directives 79

80 May 3, Advance Directives Advance Directives IJ s have consistently been in the top IJ findings Immediate Jeopardy regulatory tags cited in either: F155- failure to identify or know resident wishes F309- failure to act correctly IJ cited in both standard and complaint surveys The Department expects that nursing facilities will have in place systems, policies and procedures that ensure that resident advance directives regarding basic life support will be identified, known, and honored.

81 May 3, What Surveyors look for A written policy and procedure regarding advance directives Each resident has an identified decision maker, when they can no longer make their own decisions Residents and their representatives are provided with Advance Directive education (both verbal and written) and are being provided with the right to formulate an advance directive choice. This should be done as soon as possible following admission. A physicians order is obtained and is the same as the resident s chosen advance directive. The advance directive is documented and communicated to staff Facility staff knows how to access the resident advance directive information in routine and/or urgent situations Facility is trained, react appropriately and deliver care as directed by the advance directives

82 May 3, Advance Directives Findings: The system to identify Advance Directives is not current and/or consistent with residents wishes Staff are unaware of the system to identify residents wishes Staff are not aware of the guidance regarding CPR Systems are convoluted and confusing (multiple inaccurate lists, confusing color coding dots, etc) Complications: Resident has a change in status or condition Resident or legal representative change decision about directives Best Practice: Obtain Advance Directive status on admission and follow through on documentation to support residents wishes Have documentation of residents Advance Directive wishes easily obtainable 82

83 May 3, Questions?

84 May 3,