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COTA Thoughts

Is It Friday Yet?
September 5, 2014 8:59 AM by Tim Banish

A question every worker asks sometimes as early as Wednesday, maybe earlier depending on how the week has gone. Even in my last few years working as a COTA, only working part time, I asked that question more than a few times.

Were you aware that in the past Medicare recognized holidays and week-ends? Therapy was a Monday to Friday thing, the only time weekend therapy was done was to make up a missed treatment for a patient who requested it. Holidays were just written off, no treatments were made up nor any therapy done.

Of course then along came the numbers game. It is all about profits and saving a few dollars in hopes of moving a person out of skilled care a few days earlier. However it seems like every provider tries to maximize the dollars they can pull out of Medicare and will push to use all a patient's 100 skilled days up.

I can't tell you how many times I've seen a patient show enough independence to return home only to have the supervisor increase goals because the patient has several more skilled days of Part A to use. The sad part of this is what happens if there is another need for therapy in the near future? The patient is then responsible for any therapies provided, and as you know that isn't cheap.

So my thoughts here? Friday can now be any day of the week, depending on a therapists work schedule. Holidays, weekends, and birthdays are all the same now, just another day on the calendar. So when your Friday comes around, enjoy it. When you end up in Long Term Care there will be no more, the only day you'll want to see is that 100th.

Until next time, hope all your "Thoughts" are Good-


What is Occupational Therapy?
August 29, 2014 11:39 AM by Tim Banish
At one time or another you probably had to answer this question if you attended school to become an Occupational Therapist. I'm still not sure if there is an easy answer to this question as there are so many areas where OTs work. The real confusing part is much of the information found via an internet search. I've found some of that information to be misleading, and only a few places where the subject matter is close to the actual work involved as a COTA.

One site I frequent had COTA salaries posted in the 90K per year range at one time. That's way off unless you're working two jobs. In my best years before Medicare cuts I never earned anywhere close to that. I do know a few OTRs who make near that amount, but they are working one full time job and one or two part time jobs.

A site I just found  has some pretty good information about Occupational Therapy although much more could be added to it. Many of the topics they cover have links to pages with additional information, but again more could be added. Then there are some places where information needs to be deleted, especially information about aides. I haven't seen/worked with an OT aide in years, and doubt there is anyone working in that capacity anymore. Another site found  has good general information on it, but it really lacks any in-depth explanations.

So what is your definition of Occupational Therapy? I've always said it's helping people become a person again following an injury or illness. Short and simple, but I'll add more detail if the questioner is interested. Again with so many areas covered by OT there could be several correct definitions, but the main focus remains the same, to help people gain independence with life skills.

Until next time, hope all your "Thoughts" are Good-


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A Milestone
August 20, 2014 1:44 PM by Tim Banish
A milestone is defined as an action or event marking a significant change or stage in development. Dealing with our patients as a COTA we often see their progress in small increments, but when they were able to finally achieve one of their long term goals I always liked to call it a milestone.

Well today my blog has hit a milestone. This is the 100th blog I have written since returning back to COTA Thoughts. One hundred weeks of my ranting, passing on news of the therapy world, and changes with Social Security and Medicare.

I have enjoyed bringing my views to all of you Advance readers, and hope to continue and reach another milestone. I have had comments posted from not only COTAs, but OTRs, PTs and PTAs as well. For those who have posted comments I say "Thank You" for sharing your views with us.

My thought today is it would be nice to hear from a few more of you. It's easy to post a comment to any of the blogs here on Advance. You don't need to register or sign up for anything, and you can be totally anonymous. With the demands on our profession changing rapidly, the voice of many is always stronger than the voice of one.


Until next time, hope all your "Thoughts" are Good-


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Hooray for AOTA
August 15, 2014 9:13 AM by Tim Banish

I'm sure most of you know I'm not a big supporter of AOTA (American Occupational Therapy Association) ever since the changes back in 1998. And as much as I'm not a member, never signed up for any emails or communication from them, an email arrived yesterday that surprised me.

I think one of the biggest issues in Occupational Therapy currently is the productivity standards. Too many therapists are being coerced to work off the clock and jeopardize their ethical standards all for the sake of some company's profit margin. This is an issue I've blogged about numerous times, and during my years of working only saw the numbers go up. 70%, 80%, and now most places want 90%.

Of course what I see as the main problem is a management heavy chain of command. Many companies seem to have a manager, supervisor or other office person for every detail. One company I worked for had a national, regional, state, state district and facility manager. Each had their own staff of office people, and a nice salary. None of them ever saw a patient, some were not even therapists. If you count up all the salaries going to management and convert that into how many therapy minutes it takes to make that money you'll be shocked!

Anyway, my kudos to AOTA for announcing they will begin to look into productivity. Although they state it's a new issue to deal with in the workplace, as far as I remember productivity standards have impacted therapists for over fifteen years now. Anyway, check out their blog where you can join the conversation and leave your comments. Many interesting comments have been posted already.

My only thought is will this really lead to addressing the issue, or just be a place for therapists to vent?


Until next time, hope all your "Thoughts" are Good-


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Dealing with Death
August 8, 2014 10:08 AM by Tim Banish

One thing anyone working in Long Term Care (LTC) will have to deal with is people passing away. During my years as a COTA I had several people I was currently working with die. It was never easy to deal with, but it's a fact of life.

Since most people in a nursing home have already had some sort of illness or injury they are already compromised medically. Most are in their later years as well, making death even more impending. Losing a person you knew and worked with is always a sad occurrence. Having a patient you've watched almost fully recover then have another episode take them is even sadder.

One lady I do remember was making great strides with her recovery following her stroke. Her stroke occurred from clots and blockage in the carotid arteries. She was scheduled for surgery as soon as she got a bit stronger, which would almost eliminate the possibility of another stroke. She was the sweetest lady, always grateful for anyone's help. We had seen her go from hardly able to lift an arm to doing household tasks with just stand by assist. One night another clot must have broken loose; she was gone before the ambulance arrived to transport her. The next morning some of the staff still had teary eyes.

As you should have been taught in school, don't become personally attached to your patients. There will always be the few who leave an impression on your heart, but in some ways it's good to not know what happens after they leave the facility. Just knowing you were a part of returning them back to their life at home is the therapist's reward.

I don't really have any further thoughts on death, but I know none of us will avoid it. I hope I'll be like that sweet lady, able to touch people's hearts in a short time to the point they are sad when you're gone.


Until next time, hope all your "Thoughts" are Good-



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Let Them Eat Cake
August 4, 2014 9:13 AM by Tim Banish

Yes, it's kind of a strange title this week. What I'm referring to is working with people who are nearing the end of their days on this earth. That's something every COTA working in Long Term Care (LTC) will have to face sooner or later.

I remember one patient who liked his brandy every night before bed. After his hospitalization and entering the nursing home he hadn't had any in several weeks. Of course the doctors ruled out giving him any with all the medicines he was taking. After a few weeks, when they realized he was not going to be with us much longer, one doc came to visit and gave the family permission to bring him his brandy. I hear he enjoyed it the first night, and the second night. The next night he refused it. He passed away by morning.

There are other patients I remember who asked for something they considered special. The diabetic who wanted a chocolate bar, the cancer patient who wanted one more smoke, or the bachelor who wanted to have one more fling. All were close to death when they requested their treat. The families and doctors were all great to grant what seemed like a final wish; unfortunately they couldn't grant the bachelor his request.

I'm pondering this subject not only remembering some of the people I worked with, but also because of a recent experience. My father-in-law just passed away, but in his last week we were able to visit, spring him from the hospital and take him to a family reunion. That was something he excitedly talked about as soon as he got word of the plans, but began to lose hope of making it as his health continued to fail. Yes, it was some work, but the bottom line is he got to see lots of family just a few days before he passed.

My thoughts here range from the sadness of losing someone close to you, to the joy of being able to give someone one of their final wishes. I hope when it's my turn to ask for that final wish someone is kind enough to grant it.

Until next time, hope all your thoughts are good!

Tim Banish, COTA Retired

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July 25, 2014 10:06 AM by Tim Banish
I still receive emails from people asking about COTA jobs and schools. I had one just recently asking about entering the field into pediatrics. As much as I hated to steer someone away from entering the profession, I had to make them aware of the few opportunities available in peds for a COTA.

With 86% of all COTAs employed in Long Term Care (LTC), that is where most find employment. A few will continue their education to specialize in one area of Occupational Therapy, not necessarily to advance their degree but to gain the skills and knowledge needed for their selected niche.

So where do COTAs work? Here's some information from my experience:

Nursing Homes or Long Term Care (LTC). Most facilities provide therapy to their residents under Medicare or other insurance. In this setting a COTA would be responsible for patient education on dressing, bathing, transfers, strengthening, adaptive equipment training and more as the OTR determines. Basically the COTA addresses dressing and bathing of the person while educating them on adaptive techniques and equipment in an effort to achieve more independence with these daily tasks.

Hospitals are another place a COTA can find employment. In this setting the routine will be similar as a nursing home. The big differences are that the patient's may be more complicated (illness wise) and their length of stay will be shorter. As they become more stable they will probably be moved to a LTC facility. Depending on the hospital you work at you might have patients who are on oxygen, feeding tubes, IV's and other similar live sustaining devices. In my experience I find the pace in a hospital to be fast, usually having just 30 minutes to complete a treatment and move to the next patient.

Outpatient Clinics. Although my experience tells me that very few COTA's work in outpatient clinics due to insurance and/or Medicare regulations, the patients seen here tend to be higher functioning. Most are typically recovering from a surgery, fracture, or other sort of non-life threatening injury or illness. The pace is more relaxed, and treatments are scheduled for a specific duration depending on the therapy needed.

Home Health is an area that has expanded recently, meaning more jobs for COTA's. Insurances prefer to have the person at home to save money rather than leaving them in LTC. Be prepared to almost live in your car though, because you will be traveling from house to house. One drawback that I note with Home Health is that any needed equipment has to travel with you. In my days of Home Health my car(s) looked like a rolling office with bags of equipment, paperwork files, and splinting materials. I also mentioned cars, as in multiple vehicles. Think about this before you leap into this area. The price of gas, car maintenance, and insurance costs can put a dent in your earnings. A major breakdown of your vehicle can mean no work as well as a big repair bill or needing a new car.

Schools. In this setting the assessments typically focus on the specific skills the child needs to succeed in the school environment, such as seating posture, grasp and control of classroom tools, self‐regulation, and the development of sensory motor skills. Employment in this area will demand some experience and additional education.

Mental Health Settings can range from a facility similar to a nursing home, a group home, or a hospital-like facility where people with mental handicaps reside or attend on a regular basis. This is the area where OT began years ago, doing crafts with the mentally handicapped to teach them job skills. Additional education beyond the required degree would be beneficial in this setting.

Education only--a small percentage of COTA's work as educators or teach at a college. As AOTA changes requirements for educators I see this area being closed to COTAs who do not hold a Bachelor's degree.

My final thought today regarding COTA employment is that almost anyone who has a compassionate heart will find their niche in OT. Some areas will definitely entail more physical work while other areas will require more mental exertion. If you want to work as a COTA the two year program is not that difficult to complete, and there are many types of settings to find a job you are happy with.


Until next time, hope all your "Thoughts" are Good-



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All for Profit
July 18, 2014 9:21 AM by Tim Banish
I'm not sure if anyone has seen the latest reports on fast food chains, but their greed for profits has decreased their overall ratings. One of the largest chains scored in the teens as far as quality of food and customer satisfaction. Some are trying to close smaller and less profitable stores to maintain their presence, but this may only be a short term solution. There have been other businesses try this, only to suffer the inevitable bankruptcy or closing of all stores.

So what does fast food ratings and health care have in common? I'm looking at trying to increase profits in any manner possible. Although not a fast food restaurant there is one large chain slowly disappearing due to their greed for profit. They went from freshly prepared food to frozen pre-packaged items, and their sales fell off dramatically. A number of their stores have closed this year, and there are more on the list scheduled to close.

My thought here is profits and remaining a viable business. If you get too greedy the bottom line suffers. That makes people not happy with what they get for their money, and they tend to stay away.  Seeing healthcare headed the same route I wonder what the future holds.


Until next time, hope all your "Thoughts" are Good-


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July 11, 2014 9:25 AM by Tim Banish
Today the word "benefits" refers to your paid days off, medical coverage, and maybe a 401K. A major benefit of years past was a company pension plan.

A pension plan was typically funded solely by the company. The amounts placed in each account usually depended on how many years you've been employed and the companies yearly profits. I doubt anyone has a pension plan anymore. My father had one when he retired from a small company as a machine repairman back in 1982. His pension plan also included medical for life.

A 401K is now the best option out there for saving for retirement. These are partly funded by the company, partly funded by you. Some companies will add a certain percentage of your contribution; others have a set amount they place in accounts each year. Options can include choosing which funds you care to invest in to how much you can put into it each payday.

Some companies have taken the retirement savings one step further by enrolling current employees in their 401K plans. The recent recession did slow down growth of many 401K plans, but they are now reported to be making the best gains of any investment.

My thought here is if you have access to a 401K plan, or other retirement plan, get in it. The few dollars you save now will grow over the years. It may not get you enough cash to live in luxury, but added to any savings and Social Security it will make retirement better.


Until next time, hope all your "Thoughts" are Good-


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Productivity and Pay
July 4, 2014 11:09 AM by Tim Banish
For those who work in Long Term Care (LTC) we've all been troubled at one time or another with that nasty word productivity. I still can't believe it's expected to maintain such high numbers when the job entails dealing with people and all the things that occur during a typical day in a nursing home.

The concept of productivity came about back in 1998 after Medicare cutbacks. I remember working my first job right after productivity standards came about. My entire month of work totaled twenty two hours, and then my boss told me my productivity was 13%. Since I was the manager at the time, attending meetings and training new employees was part of my role. That didn't fly with the boss though, it was like I was expected to attend meetings and train new employees off the clock. Yes, I quit then and there.

My next job was even more surprising concerning productivity. After my first day on the job I turned in my log sheet. I'd been at the LTC facility for close to eight hours. The boss totaled up my therapy minutes and said "Well you got five and three quarters hours in today, nice job." "What?" I said. He went on to explain that the new rules meant we only got paid for actual therapy minutes completed, not hours in the building. The next day things were very hectic, having two different doctors doing quarterly visits on top of a big activity program happening. I got kicked out of three different rooms in the middle of a treatment and probably walked several miles up and down hallways trying to find an available patient for nine hours that day. Turning in my tally sheet the boss says "Not so good today, only four and a half hours." That was my last day working there.

I believe there was a group of therapists in California who sued their company for the same practice of paying only for therapy minutes completed. Expecting an employee to do paperwork, transport patients, and dodge doctors and nurses while trying to do therapy and not being paid for it is absurd.

My thoughts here? I think a new law should be approved to place productivity standards on all government workers. The budget bill needs to be passed on time, long waiting lines in government offices need to be shortened, and our veterans need the care they were promised.


Until next time, hope all your "Thoughts" are Good-


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What Social Security Means
June 27, 2014 11:05 AM by Tim Banish

Once you retire and begin to draw Social Security benefits many things can change for you. You may be set financially at first, but as the months roll by and those small checks arrive you may find your bank account shrinking.

Lots of retirees work now days to supplement their income. I know several who have retired, then returned to work. Many don't have a retirement fund, others only a small pension. However depending on where money comes from a portion of it could be taxable. This is where you need to know all the rules as you withdraw from retirement pensions, IRA's and the like.

One thing I've noticed since retiring is our change in shopping styles. We look for bargains more now than before. We use more coupons than before. Occasionally we pass on something that we would have purchased before. Major purchases are something we have to take a close look at to see if the budget will allow. We also store hop, buying sale items we use at one store then finish buying essentials at our usual store.

As far as work, I've always assumed I'd work until I can't. Work now may be easier and at my own pace, but it also doesn't begin to match the income level we were at before retirement. Other than my blogging here, I also repair computers and create web sites. We also just took on a new part time job working concert venues, mainly to have extra money to enjoy our hobby of camping and fishing.

My thought on retirement? The hours are great but the pay stinks.

Until next time, hope all your "Thoughts" are Good-


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The Revolving Door
June 23, 2014 9:34 AM by Tim Banish

One thing I used to see working Long Term Care therapy was the repeat offenders, or the Part B patients that seemed to need therapy every few months. Some would have a hospital stay which placed them back to Part A, or skilled status patient. But it seemed like no matter where I worked there were nursing home residents who could not stay healthy.

I remember a few residents who would not adhere to their diabetic precautions, and continued to eat all kinds of sweet treats. A few who were a fall risk yet refused any interventions. There were the ones who refused their medications for one reason or another. Then there were the ones who were just physically challenged and continued to lose skills in areas that therapy was supposed to fix.

There was one person who gained more than forty pounds in twelve months. This necessitated two new wheelchair backs, a new arm trough, several new wheel bearings, and then finally a whole new wheelchair. Not only did this cost the facility over two thousand dollars, but the person's health suffered as well. Yes, this person was a diabetic whose family continued to bring in donuts, candies and the like despite being educated with the problems it causes. Therapy had to intervene several times one year.

Another resident refused to use a personal alarm despite the fact that they were unsafe with any transfer, and had fallen several times. They ended up in the hospital from injuries from one fall, and were back in therapy for the fourth time one year.

One patient would refuse her medicine thinking it was poison.  The poor nurses tried everything to explain how the meds were important, but nothing seemed to work. The person would get so sick they had to administer meds through an IV, no refusals taken. After each episode therapy would be ordered so she could regain her strength.

Another issue was the residents who were just so physically challenged that they continued to lose skills little by little. When they couldn't complete simple tasks therapy would be ordered. Usually therapy had already been there, done that, but once again ordered to give it another round. When every reasonable method had been tried and failed, you would hear things like "therapy doesn't work" or that therapy was only ordered to make the home money.

My thought here, no I wouldn't deny any of these people therapy. The issue was always the length of time they stayed on therapy. You would know they've reached their maximum potential but goals would be altered to keep them on caseload.  There were many whose benefits were exhausted, and then another incident would happen.


Until next time, hope all your "Thoughts" are Good-


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June 13, 2014 9:56 AM by Tim Banish
From my first experience with a therapy company recruiter I found out what type of person they are. Over the years there are a few recruiters I grew to detest greatly, and to this day one in particular. Even though I've been retired for over a year, pulled all my resumes off the internet and put my licenses into retirement mode the recruiters continue to call and email me.

Back when I was a newbie to the field I didn't know how things worked. A recruiter contacts you, tells you all kind of good things about the company they are hiring for, then sets an appointment for you with one of the company management. For the simple referral alone they receive a commission. Of course if you ask questions about benefits, salary, 401K, etc. you'll get answers you want to hear most of the time. If you interview and decide to hire on with the company the recruiter gets another commission. One recruiter actually said to me "We get paid big bucks to refer and recruit therapists."

The recruiter for the first company I worked for told me everyone received a cost of living raise annually on top of our performance raise. When my first year performance review was finished the manager told me the percentage increase of my raise. I added that to the cost of living for the year and expected my salary to increase by that amount. When my next check arrived it was a shock to see how little of a raise I actually got. The boss confirmed there was no annual cost of living raise, but by then that recruiter was already working for another company.

My detested recruiter is one who made numerous calls to our therapy department phone. When he called he asked if anyone was looking for a job. Hmmm, you're calling us at work wondering if we need a job? Anyway one busy day he called, for the second time, and I told him to stop calling and hung up on him. The phone rang again in seconds. It was him asking if I hung up on him. I replied "Yes, and I'm going to again." as I hung up on him.

It was irritating to be disturbed by phone calls when you're trying to do therapy. Recruiters who tactics include calling a therapist at work is tacky to me. Not only are they wasting your time, but stealing patient time as well. My only thought is be warned when dealing with them. Get any of their promises in writing, on a contract, or walk away.

Until next time, hope all your "Thoughts" are Good-


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Do More With Less
June 5, 2014 10:47 AM by Tim Banish

I'm sure at one time or another you've been told to increase your productivity, add minutes to a patient, or screen more residents to fill the caseload. As a therapist in a long term care facility, especially a smaller facility, you are made aware of it in an almost constant system of reminders.

Notes and emails from nursing or MDS coordinators can sometimes indicate a resident who could benefit from therapy. Normally this would be a long term resident who has shown a decline, usually due to their diagnosis, but more often it seems like they were expecting therapy to produce a miracle. Of course when that type of person is picked up on caseload the next question is how many minutes do you think can you get with them? Or the MDS coordinator will adjust their reference date to bump them into the next higher category. That usually includes adding minutes too.

Of course there are the reminders from upper management to increase productivity in the building. Some like to make it a competition, but pitting a small 100 bed facility against a huge facility with its own 50 bed rehab wing isn't really fair. As a prn COTA I tended to always be placed in the smaller facilities with low productivity. After a while the numbers didn't mean much when your building was always last.

Another issue begins when you have a patient that requires a special piece of equipment.  There are always the questions of why, it's purpose and is there anything cheaper. These questions usually come from management, who are not therapists and don't think like a therapist. These questions always made me think I had to prove I knew what I was doing. Then once you convinced them the item was needed it often took weeks for it to show up.

 Years ago one administrator allowed me access to the company account to order anything I needed without her approval. That's something never to be seen again. This is just another reminder that therapy today focuses on dollars and not their patients. One therapist I worked with used to say "We have done so much with so little for so long; we are now qualified to do anything with nothing."

Therapy productivity really begins with the admissions coordinator though. If they bring in lots of people, there are bound to be a percentage appropriate for therapy. If admissions are few and far between, therapy is pressed even harder to add inappropriate people to the caseload or extend therapy time with current patients. With few admissions into the facility, the lack of needed equipment and managements constant reminders about productivity my only thought is you have to do more with less.


Until next time, hope all your "Thoughts" are Good-


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Are They OK at Home?
May 30, 2014 10:58 AM by Tim Banish
If you work in Long Term Care (LTC) you've probably had patients that talk about nothing but going home. There are some who fulfill that desire, some who don't. Then there are the ones who you really think shouldn't go home alone but with help they should be alright.

It is the person's choice after all, to make the decision if they will be able to manage once they leave a facility after rehab. Of course if there is a blatant issue which would definitely create an unsafe situation for a person to be at home there are state agencies that can intervene. I just think about a few I've seen go home during my years as a COTA, and wonder how some managed. The best is when you do get to find out how a former patient is doing.

One lady was so affected by arthritis she could barely open her hands, was wheelchair bound and required moderate assistance to transfer on her best days.  She was going home with her husband, but he suffered from spinal problems and couldn't lift. They did have aides, but not 24 hours a day. As much as family was there to support too, I always wondered how this ended up.

I also think of the lady who was going back to her apartment alone after her stroke. She could do almost anything, but still had issues with balance and impulsiveness. Her answer was the Lifeline connection. As much as she did return home, within three weeks she had used the Lifeline call so much they disconnected it. She came back for more rehab, but never left again.

The other side of this story is the lady who entered the LTC facility to rehab because of balance issues. She had several falls the first few weeks, none serious thankfully. By her fourth week she was doing much better, and didn't have a fall for the next two weeks. When she thought it was time to go home nursing tried to talk her out of it. She had been fall free for almost five weeks now, and knew the daily routine of exercises to help remain that way. Then she fell one night and nursing became more adamant about her staying in LTC. "Why?" she asked. "When I fell no nurses were there to catch me, so no different than home."

Point well made, and she came back about six months later to let us know she was doing fine.

My thoughts on this subject are strong. My 91 year old mother had a fall recently and suffered a fractured femur. Her desire to get back to her apartment carried her through rehab, as much as I figured the rest of her days would be in LTC. She is back home and doing fine. There will always be the few you may be concerned about, but if a person can survive safely at home, let them go. With all of today's technology and agencies available to assist, being home is always better than being confined to a nursing home.


Until next time, hope all your "Thoughts" are Good-


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