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PTA Blog Talk

Bubble-Wrapped Profession
by Jason Marketti

I get tired of reading and hearing about the audit triggers in our profession. It's part of the business we're in and if people don't want to risk an audit, they shouldn't be in our field. It's like an audit from the IRS -- you don't want one, you don't know why you were chosen, but if you can back up all your data and information it shouldn't be a worry.

Multiple design changes have improved our electronic documentation, which better shows the skilled nature of what we do. If auditors really want a job to do, they should go back three to five years and read all the handwritten SOAP notes in clinics and facilities to figure out where the skill was and whether the treatments were justified. That's where the big repayments are for CMS.

Fortunately, for now, some of the audits have stopped (I heard they ran out of budgeting money) so businesses should have a short relief. But even so, if we're able to clinically justify what we do and why we do it, there's no need to be afraid of an audit. Good clinicians should have better data to support treatments and justification of time needed to get the patients back up and moving.

What I see in some facilities is the therapists doing the minimal amount of work and documenting a safe amount so they don't trigger any audits into what they do and why. Therapists may be afraid to try something outside of their comfort level, so the half effort is the safe bet to hide under the radar of scrutiny. If we're not able to clinically define an activity and give a true justification as to why we are or aren't doing a certain procedure, then we shouldn't be doing any therapy on any patient.

Too many therapists will take the safe road so they don't have to explain themselves to anyone in regard to what they're doing. We get paid a lot to do what we do and if we can't, won't or aren't willing to explain and justify our services to those who pay us, maybe an audit is just what we deserve.

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Supervision of Patients
by Jason Marketti

When a PT is in the facility, that person becomes the de facto supervisor for me. That means I can make his day very easy or a nightmare. I could easily present him with a long list of issues and clinical concerns that I feel need to be addressed with each of the 10 patients on my list or I could wait until the regular PT comes back and then discuss the issues with him.

Any therapist or health provider who tells me they don't know the patient, yet they are the supervising provider for that patient's care is a danger to patients. If one wishes to be a supervising provider of care to patients, that person should at least become familiar with each resident he is in charge of. If a patient is injured because of negligence, it's usually the supervising provider who has to explain his role and the role of others regarding why and how a patient became injured. A statement of, "I was filling in for the regular supervisor and didn't know the patients" should go over real well with a jury; it seems like a legitimate excuse.

The clinical portion of what I do is to report any changes in condition or relevant data to the supervising PT so he can be aware of any issues that need his skills and attention. If I fail to report data, then I too as a PTA could be directly responsible for a patient injury or death. What a supervisor does with this data is not for me to decide. I report results of testing and the condition of patients but it's up to the PT to interpret that data and make appropriate decisions. Allowing a "fill-in" supervisor to make these decisions doesn't seem right, but ultimately that person is the responsible party for every patient on the therapy list. And some places consider the evaluating therapist the supervisor of that patient, so trying to get another therapist to make a clinical decision regarding care can be difficult.

I'm not sure if there's a way to adequately resolve who is the actual supervisor versus the acting supervisor for patients. Either way, if a person is in charge of patient care, he needs to "therapy up" and make a decision.

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Disagreeing with Discharge
by Jason Marketti

Disagreeing with someone is not something new for me. I will freely voice my opinion (usually supported with data and anecdotes) to anyone who will listen and objectively discuss an issue with me.

In the case of discharging a patient from therapy, the decision is ideally the PT's; however, as a patient advocate I have the responsibility to ensure patients receive the best care to maximize their potential. No health provider has a crystal ball to determine whether a patient will advance any further from his current functional status. There have been too many incidences where patients do progress and eventually go home when most providers had given up hope.

All clinical decisions should be based on educated evidence (and supported by data), not on whether a patient and family is liked or disliked. A decision to discharge a patient isn't necessarily about whether the patient will make progress in the future. It's about whether he is making progress today with therapy intervention and if that intervention so skilled, only a therapist is able to provide the care. If one wishes to debate a discharge, I'll be happy to quote CMS and state regulations and if a therapist doesn't like the rules, then he shouldn't play the game.

The phrase, "I'm the PT and I make the clinical decisions regarding patient care," means absolutely nothing to me when I'm the advocate and make a couple of calls to the ombudsman, state therapy board, and Office of Inspector General. I'll allow the experts to determine whether discharging a patient is equivalent to abandonment of care and I would love to see the data a therapist presents while trying to defend this.

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Collecting Data
by Jason Marketti

When United Parcel Service (UPS) began to collect data on drivers and their trucks, there were some improvements. These included no more key locks in doors because they slowed the drivers down and use of a computer clipboard that also held data on how the truck was loaded and the best routes to take to deliver the packages. Productivity went from 90 package deliveries a day to 120. The sensors in the truck also monitored how often drivers were backing up and at what speeds they were going. These changes increased their productivity, enabling them to deliver packages and complete their jobs efficiently throughout the day.

In the hospital and SNF setting we often backtrack because a patient isn't ready, get delayed by nursing because medication was not given, or have to leave a treatment because family has arrived and the patient asks (demands) we end so they can visit. These things kill our normal productivity levels, so maybe we can learn from UPS.

Putting sensors on a therapist seems feasible to track movements throughout a facility to see how many times we try to see patients. The sensors could monitor when we are in contact with a patient and exactly how long we spent treating the person. This information could be relayed to a number cruncher, who could then set up our schedules and let us know the best times to see patients and quickest routes to get to each room. Our productivity should improve based on this model.

Except we are dealing with humans who are ill and there are too many variables to contend with. But it might be worth an attempt to have the sensors placed to prove we are on the move all day looking for patients to work with. When the number crunchers see that we are moving all day, maybe the productivity demands now in place will go away. Then we can concentrate on our treatments and not how long we're in the facility doing our job.

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Growing a Program
by Jason Marketti

It's not like you can plant some therapists in a gym and suddenly the department is busy. To adequately have a therapy program develop into the future, the way business is conducted today has to change. When looking at more cuts in reimbursements, hiring another person doesn't seem logical, but it is.

A good PT aide will get patients up and ready and will have the patient in the gym as you walk through the door and clock in for the day. If therapists are scheduled to come in a half hour apart, the PT aide will have the first person ready to work as the next therapist walks in the door.

And each successive patient will be promptly ready to participate while the therapists waste no time in the gym. If all goes according to plan, therapist productivity will increase because they won't have to locate the patient, get multiple refusals, talk to three nurses to medicate each patient, and locate linen and clothing items.

To grow a program, you also have to let some people go. One therapist can deflate the morale of the whole department with negativity. Letting the person go is a difficult decision; however, if a therapist is negative maybe the place he is now is not the best setting for him. By freeing him to explore other options, maybe he can become happier.

If a facility is actively involved with all things therapeutic, there should be no end to referrals from nursing staff. OT and ST referrals should be apparent with dressing, bathing, eating and swallowing pills on a daily basis. Nursing staff should be addressing these issues and asking for orders if a patient has any apparent change in status. For PT, every fall should get a referral. Every patient who has ended up on the floor, whether from a staffing error or an attempted self-transfer, should be seen by the movement specialists, us.

If there hasn't been a referral from nursing in a week, something is wrong. In a SNF there are numerous missed opportunities for therapy to intervene to prevent falls and improve ADLs, thus helping nursing reduce the amount of assistance needed to transfer patients and get them ready for the day. Not every referral will be appropriate but that's why we are paid so well, to make clinical decisions based on a patient's functional limitations.

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Leave of Absence
by Jason Marketti

I have heard nursing staff, therapists and even social services tell patients they are not allowed to leave the facility or they'll lose their benefits for Medicare. Simply not true, and, in fact, Medicare makes it clear facilities should not tell patients that leaving the facility will lead to loss of coverage.

Patients can leave the facility for the purpose of attending a special religious service, eating a holiday meal, family occasions, going on a car ride, or a trial visit home. Patients can also leave for overnight stays without losing their Medicare coverage. The stipulation of an overnight stay is that the patient may be billed for a bed hold at the facility.

Perhaps people get the home health rules mixed up with the SNF rules. Home health rules limit outside activity when a patient's condition keeps him from leaving or it isn't recommended by an MD and leaving the home takes a considerable and taxing effort. These rules do not apply to the SNF. And by definition, a patient could leave the facility every day for a "short leave of absence." The "holiday meal" is awfully vague too when a patient requests to leave for Arbor Day, Valentine's Day, St. Patrick's Day etc. Technically the facility has to allow the patient to leave because of the way Medicare has worded it. And who am I to tell patients they shouldn't celebrate those days with a meal when I have the therapy room decorated for almost every "holiday" on the calendar.

I wasn't able to clarify what exactly a "family occasion" is according to Medicare either. Birthdays, funerals, christenings, third-grade graduations? The rules are not clear. However, if a patient's condition is improving enough to go out of the facility every day, I would assume a push for discharge is in the works. Essentially it would be up to the therapy department (the PT, OT, ST) to decide whether skilled care is still necessary for the patient's condition. And depending on how adamant a facility is about discharging patients who like to enjoy their Medicare benefits for 100 days, this may cause some problems.

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Getting Political
by Jason Marketti

If multiple Presidential administrations can find money for wars and conflicts to participate in, certainly there should be money available to feed, house, clothe and provide basic medical needs to the poor who live in the United States. When America can provide billions of dollars in aid to other countries but lacks basic health services to large groups at home, I scratch my head and wonder where the priorities are. Please look into the shanty towns and tent cities across America and ask yourself whether the people living there need medical, food and housing aid too.

I've read about how hospitals will airlift foreign patients to their native country once they're stable enough to be transported because it would cost the hospitals too much to care for the person. The person's country of origin may not have the medical infrastructure to provide adequate care for the patient, but that doesn't concern the hospitals because they're looking at cost of care. I'm not sure if social services get involved but transporting patients like this does not seem like an ideal "next level of care" situation to me. And this practice of transporting people is legal under our current system of government.

If the 7 million people who have enrolled in "Obamacare" decided to disenroll tomorrow and not pay the fines imposed, do you think the jails and court systems could handle all the cases? And by enrolling, are Americans accepting and agreeing to the new rules and costs for insurance? If a law says I have to do something that I don't agree with, either the law is flawed or I need to rethink my position. There have been several people throughout history who have instituted social change and brought attention to laws that needed to be updated or were simply wrong laws to begin with. Mahatma Gandhi, Dr. Martin Luther King Jr., and Cesar Chavez come to mind in a non-violent, more peaceful way. They each recognized a situation that needed to be reformed and took action. Are people like this still in existence? Maybe that group Anonymous with the Guy Fawkes masks comes close.

With all this revolutionary talk, someone might think I've been reading books that were once banned or gearing up for a Che Guevara-style attack. I've simply been studying our current health system and recognize there needs to be a change. The first changes would be to eliminate any cap on therapy services and allow more than 20 visits a year for OT, PT, and ST services, which most insurances have as their limitation. I wonder if I could get 7 million followers who agree with me like the government did, although I don't pass laws forcing people to do so.

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One-Trick Pony
by Jason Marketti

While interviewing for jobs years ago, I met a therapist who primarily treated knee patients. He was looking for an experienced PTA to assist in this specialty. I ultimately declined the generous offer so I could explore other interests. I had difficulty understanding how an experienced therapist would only treat one body part. The human body interconnects, and yes, after knee surgery the muscles and structures are weakened but so are other parts of the body.

When I was an outpatient PTA, the policy was to treat one body part at a time. So although a patient might have upper-body weakness from a disability, we could not address that until the patient's back was better. There were exercises the patient was unable to do to mend his back because his UEs were too weak. I could understand that we simply didn't have the time to treat every body part that was weak and achy on every visit, but it seemed ridiculous not to instruct or send some HEPs home with the patient to strengthen the weakened area.

These and other experiences finally led directly or indirectly to where I am now, in a SNF. I have the freedom to treat the "whole person," provided I stick to the plan of care and address the patient's goals set by the PT. If I see the patient has difficulty with certain arm motions that will ultimately allow him to increase function and attain a goal, I can discuss the issue with the OT and PT. I don't have to wait until the patient's surgery site is at maximum improvement to progress the patient and I usually see greater improvement faster.

Most therapists will see patients with a variety of ailments and treat accordingly, but those who specialize in one area are either setting themselves up for a great niche market or limiting themselves professionally. I have yet to determine which.

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To My Dissenters
by Jason Marketti

I have been accused of being ageist, burnt out and one anonymous reader said I should work in a fast food restaurant as a favor to the patients I see. A state licensing investigator even contacted me for something I wrote because a reader or two did not agree with my opinion. Perhaps I should stick with feel-good stories about how the PT and I held hands singing "Kumbaya" while skipping down the hall. Then a cornucopia of brightly lit rainbows appeared as we were treating the patients next to a babbling brook while Strawberry Shortcake and My Little Pony played close by.

My opposing views and questioning of how things are done are not new. If I question the current state of thought in the therapy community and how state licensing boards operate, I'm told I shouldn't be in the profession. Perhaps there are therapists who want complacency and like their little slice of pie that's doled out by the insurance companies. Heaven forbid a therapist questions a decision by an unlicensed, non-medical person from the insurance company who decides how much and when he will get paid.

And we better not question the licensing boards because they can deny a license or investigate you. That hasn't stopped me from investigating them and learning more about them on social media sites than I would ever care to learn. You realize there are therapists on the state licensing board who still believe in the tooth fairy. I would encourage everyone to investigate your state licensing board members on social media and find out what kind of people are deciding who gets a therapy license and who doesn't. Also, ask your state licensing board if they sell or give away your information (address, professional license, employer) to vendors. Should state boards be allowed to do this or is there an "opt out" so your name isn't on the list for everyone to find out where you live?

And if a state licensing investigator is going to investigate me, he should at least contact the five or six supervising therapists I was working with. Apparently, the investigator did not and the licensing board tried to get me to comment on information unrelated to the original complaint against me. By the way, the state board protects people who make a complaint even if that complaint has no merit and wastes money. Perhaps costs related to cases where there isn't a valid complaint should be reimbursed by the person making the complaint. That could reduce the amount of investigations and costs every year. What a novel idea to save money, make sure the person making a complaint has evidence a violation occurred. And don't waste time and money on investigating me regarding an article I wrote as an opinion piece.

I know, I have a different idea about how things should operate and there are those who don't appreciate an opposing view. Maybe we should all think and act the same, but first let's all agree on which treatment choice and approach works better than others when it comes to post-surgical back care. Good luck with that.

I do enjoy the feedback, email me at ptablogtalk@gmail.com.

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Addendums, Amendments, and Late Entries
by Jason Marketti

Our documentation is being held to a higher standard and scrutinized more frequently by insurance carriers. This can cause some concern among providers to ensure all pertinent information gets conveyed through the electronic health records. I was not able to find a time limit concerning when information can effectively be added to a patient's medical record except that it must be "timely recorded".

Addendums add information to the original record or entry. Amendments clarify health information after the original health record is completed, and late entries are entered after the point of service is completed. Understand though if information is added to a health record, it may be further scrutinized and more questions may be asked than anticipated. As providers of therapy services, we should document during a therapy session. But how can we expertly justify spending 3-5 minutes to document a note when we are not actively engaged in a therapeutic procedure with the patient?

If I have a patient on the mat table doing SAQs and I sit next to him while using my laptop to write a note, thereby not engaging the patient for 3 minutes, does that qualify as therapeutic minutes being spent with the patient? Three minutes can be the difference between a RU and an RV reimbursement rate. Multiply that by eight patients a day and clearly there is some serious money at stake. On the other hand if I wait until the end of the day to do my documentation, do all the notes have to be late entries?

To further darken the waters on documentation, do I have to be in line of sight of the patient or even in the same room for my minutes to count with the patient? What if the patient is getting dressed behind a curtain and I document my therapy session at a table across the room, do those minutes count? And is a curtain considered a separate area (room) from where a therapist is documenting? Or would it be easier for me to put an amendment or addendum attached to the medical record later, clarifying my intent during the therapy session.

In the world of insurance providers and paying for therapy services, a couple of minutes can be the difference between several hundred dollars in reimbursement claims. We should not expect an insurance provider to pay us simply because we are standing in the same room as a patient.

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Falls and Staffing Issues
by Jason Marketti

Reducing falls in a facility is about quick response times to answer call lights and having adequate staffing ratios to ensure the patients' needs are being met. To save money, some facilities will decrease staff to a minimum level and those who are working will have to simply pick up the pace to meet the demands of care.

As reimbursements continue to decrease, limited staffing may now be the norm even though every indicator tells us the quality of care decreases and higher fall incidences occur with fewer staff to attend to patient care. To reduce falls at night, floor lighting of different hues has been used. The soft yellow glow seems to work best, and does not disrupt the circadian rhythm as much in certain patients. But this doesn't resolve the dilemma of staffing issues as a whole.

I'm certain if patients and family members would sue a facility every time a fall occurs, changes in staffing would happen. If family members would then bring a class-action suit against their insurance carrier for being the responsible party directly related to a fall, reimbursements may go back to prior levels where adequate staffing could ensure safety to the high-risk patients. Of course, all this legal maneuvering could be avoided if insurance carriers would stop decreasing reimbursements and facilities would staff appropriately based on the needs of the patients, not the needs of the bottom line. There is finger-pointing about who is responsible every time a patient falls, but little is done to resolve the larger issues.

There have been times when a patient will have a fall and no therapy is recommended. Therapy can play an instrumental role in staffing education and patient safety to reduce the risk of falls, but some facilities underutilize the best resources that are available to ensure patient safety. Front-end staff, the CNAs, should be used at every opportunity to glean ideas from a patient-safety perspective and about how to appropriately staff any given facility. If facilities are concerned enough about patient care, they need to take steps to ensure every resident is safe and has the care required before reducing staffing levels.

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Truth in Treatment
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Since therapy has been focused on science-based evidence, I thought I would examine two treatments that are embraced by "leaders" in the therapy community. The first is visceral manipulation. The APTA took a hit for including this in the Section on Women's Health and I wanted to find out why. Jean-Pierre Barral, the French osteopath and PT, states visceral manipulation will assist with functional and structural imbalances. Sounds good enough to me, so I kept reading.

Unfortunately he lost me when the organs stored emotions and needed to be released. And since insurance companies have included this as an experimental treatment, I will pass on learning more for now. To give kudos to Dr. Barral, Time magazine ran a story about him and this alternative treatment.

The second "treatment" is craniosacral therapy. I've written about this before but wanted something more in depth and even though insurance companies find this experimental, I thought I'd once again examine the treatment and see if I believe in it. Like visceral manipulation, the concept sounded alright but when I got to the part of the energy cysts and movement of fused bones, Dr. John Upledger lost me. I won't disagree totally with this but I'll need to see and read more about it. I have to give praise to anyone who steps out of the given line of thought and devises a concept that might otherwise be overlooked and dismissed.

Many other treatments that can restore function to patients are proven, without doubt, and are reproducible in almost any clinic. When physical therapists are on the edge of holistic treatments and theories of ideomotor activity with inconclusive results, I scratch my head. But I don't totally discount any treatment that will help improve a patient's mobility and function. Now all we have to do is get the national organization behind legalizing marijuana because of all the positive effects it has on the body. But wait, there's controversy with this, kind of like endorsing visceral manipulation.

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Is 'ASPT' the Answer?
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‘ASPT' should be the new designation for PTAs who have an associate's degree in physical therapy. The PTAs who have successfully challenged the testing and don't have a degree as a PTA should not be allowed to use this. These new letters will denote we have an associate's degree in physical therapy and will practice and be licensed as a physical therapist assistant.

This new degree designation may combat some insurances that have stipulations preventing PTAs from seeing their patients. If a degree in physical therapy is required to treat a patient, the ASPT will fill that role so PTAs may qualify. This new designation wouldn't change anything in regard to a state's practice act or interfere with supervision levels required.

Some may argue that a PTA's degree is physical therapy assist, or is it physical therapist assist? But that makes no sense. This would mean I'll tell people I have an associate's of applied science degree in physical therapist assistant. Or is my degree in physical therapy assisting? Maybe I should get my degree out of storage and take a peek. My wallet license says physical therapist assistant but that doesn't mean that is the degree earned.

We should look at the PT degree designations. There was a certificate as a PT, then a BSPT, an MPT, a MSPT, a DPT, a PhD PT etc. All of those denote the degree level earned, which makes them eligible to practice and become licensed as physical therapists. As a consumer of healthcare, all the levels of degrees for a physical therapist seem confusing. Maybe PT schools should add the habilitation degree and the higher doctorate degree for physical therapists too just to have some fun with the public.

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PTA Justification
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If you've been working in therapy for a while, you'll know there are some patients who are more appropriate for a PT to see than a PTA. It's usually the PT who determines this based on the clinical and medical needs of the patient. But why even use a PTA or any assistive personnel if there's a question about acuity levels in patient care? What's the reasoning behind using supportive staff to treat patients in any setting?

The PTs will be able to answer this question better than anyone else. And there should be a clinical and medical reason behind it. If the reasoning is to see more patients in the clinic or to grow the department, that's not valid for using any assistive or supportive personnel. Cost and because state laws allow it are not clinically valid reasons either.

If PTAs and other supportive workers weren't used, patients wouldn't get seen and wait times would be greater than what they are now. But this isn't a medical or clinical reason to have a PTA treat a patient, it's a consumer convenience to have them seen for treatment as soon as possible. A stipulation on the number of patients seen in a therapy setting would keep PTs from over-utilizing PTAs and aides and allow more one-on-one time between the patient and PT. But this would severely impact a clinic financially that depends on vast numbers of patients rotating through the place. And it still won't answer the bigger question of why use a PTA if there's no clinical or medical need to?

At this point, am I talking myself out of a job? Not really. The supply and demand for services are still in our favor and according to the BLS handbook, they will be for some time. But I would like to hear from PTs on why they use PTAs or supportive staff even if there isn't a justifiably appropriate reason to do so.

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EMS and Home Assessments
by Jason Marketti

National Public Radio recently did a story on Dr. Kevin Munjal, who is in charge of EMS at Mt. Sinai hospital in New York. His idea to put the EMS system in the forefront of preventative medicine is interesting. Rather than the EMTs and paramedics simply picking up or dropping the patients off, they should inspect the home for loose wiring, throw rugs, grab bars etc. and look at the safety of the home to prevent and possibly decrease the need for EMS. And looking longer-term, to allow EMS to choose the best place to bring the patient after an acute event rather than the ER.

Right off the bat, I'll pose a question to the PT community. Does EMS have the knowledge and experience to do home assessments and make a determination on whether the patient is safe to return there?

I doubt many PTs and PTAs are home-assessment certified so what makes us any more expert at home assessments than any other provider of patient care? Not a whole lot, to tell you the truth. If EMS has a checklist like me when I enter a home, they can simply check off whether the patient does or does not have rugs, grab bars, smoke detectors etc. and then recommend the patient makes changes before returning home.

The big difference is whether the patient is able to maneuver around the home safely. This is where our therapy expertise and knowledge come in. The initial assessment would come from EMS, who would refer to therapy if a follow-up is required based on the environment and mobility of the patient. Yes, this could potentially be another referral resource for home health agencies who desire to expand their business.

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About this Blog

    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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