Diagnosis: Dementia
Prognosis: Poor
1. Does the individual have a mental impairment or
cognitive impairment as a result of their disability?
Please check the appropriate answer: Yes
2. Does the mental impairment or cognitive impairment
prevent the individual from being left alone?
Please check the appropriate answer: Yes
3. Are the behaviors described in individuals Hazard
and Injury Log consistent with the individual’s diagnosis?
Please check the appropriate answer: Yes
4. Can the individual’s disability be expected to
cause the kind of behaviors caused in the Hazard and Injury Log?
Please check the appropriate answer: Yes
5. Can the disability affect an individual’s judgment
regarding safety?
Please check the appropriate answer: Yes
6. Please provide a brief explanation of the above
answer and a description of the beneficiary’s functional limitations:
James C 93-year-old vulnerable patient who has long
history of vascular dementia s/t head injury. He has severe memory and
cognitive problems but is able to walk and that is why he is at high risk for
wandering. Family cannot leave patient alone at home due to he has been trying
to go out several times. In the past, he has wandered away from house and
become lost several time and law officers found him and brought him back
home. Three months ago, patient was
brought to hospital with burn of bilateral soles of feet due to walk on the
street with barefoot. After discharge from hospital, patient was transferred to
Buena Park Nursing Center until today. He always appears lost in a new or
changed environment and shows severe restless, paces or makes repetitive
movements. He has difficulty locating familiar places like the bathroom,
bedroom or dining room at home. Also, his gait is unsteady with severe balance
impairment and lower extremities’ weakness. However, he is not able to aware of
his physical limitation due to advanced dementia. Due to his advanced dementia,
he has poor judgement, confusion, poor memory, disorientation and lack of
ability to avoid the dangerous situations. His disabilities and impairments are
expected to cause him to experience confusion and an inability to self-direct him
behavior to keep himself safe and free from harm or injury. Therefore, he is at
risk from trying to do things beyond his capabilities such as turn on stove or
going out without supervision. Now, although IHSS provider and the family
members have been trying very hard to keep the patient safe at home, he needs
additional hours for protective supervision in order to avoid another
institutionalization.
Verification
Letter for Medical Necessity for Negative Wound Vac therapy
Note: This
certificate will be used in legal proceeding. The information this verification
contains must be based on my personal examination of the patient. Thank you for
your concern and cooperation.
Name of Patient: Hong Gil Dong (DOB: 12/01/1900)
Address of Patient: 1700 W. X St.
Apt A1 Los Angeles, CA 90001
I am writing on behalf of my patient to document medical necessity for NPWT (negative pressure wound therapy) for Stage 4 pressure ulcer on sacral region. I, Sojung Suk (Name of Medical Practitioner), located at 6350 Laurel Canyon Blvd #205 North Hollywood, CA 91606, am a nurse practitioner who have been visiting Hong, Since January 19, 2022. I have been performing face-to-face visit for hospice evaluation, wound care order, wound care education for skilled nursing and family members. The history of my involvement with the patient started upon her admission of U Hospice.
According to our wound record, her wound measurement has
not been significantly changed. As a matter of fact, before the wound vac
started, her wound size had been increasing by ¼ to ½ inch per month during
previous 12 months. However, after the wound vac started, her wound size has
been slightly decreasing or staying same. She used to be cared by mobile wound
care surgeon weekly but the wound care surgeon discontinued wound debridement and
discontinued the services because NPWT had been cleaning the wound effectively
and the surgeon did not need to visit patient anymore.
Patient’s History and diagnosis
Hong, is an 122 y/o male with significant history
of colon cancer with chemotherapy and radiation therapy, lung cancer with multiple
lobectomies, end stage Alzheimer’s disease with bedridden status. As a result
of the multiple diagnosis and comorbidities, patient’s wound healing prognosis
is guarded. However, the NPWT has been preventing the wound from infection. Without
the NPWT, patient’s wound size will be increasing and she will be high risk for
osteomyelitis and sepsis due to visible muscle, bone and tendons through a hole
in the skin and her wound is very near to rectum. NPWT has been preventing her
wound being contaminated from feces.
Since KCI stopped the services, her wound has been slowly
worsening and the patient needed wound debridement last Monday, April 25, 2022
by mobile wound care surgeon. If NPWT cannot be restarted soon, her wound
debridement will be needed weekly or more often.
Based on the above facts, I am confident you will agree
that NPWT is indicated and medically necessary for Mr. Hong.
If you have any further questions, please feel free to call
me at 818-xxx-xxxx. Thank you in advance for your immediate attention to this
request.
Sincerely,
Visiting NP Sojung Suk
Name of Patient: Kang, S (DOB: 8/20/1900)
Address of Patient: 1xxx Heaven St. LA 9xxxxx
I, Sojung Suk (Name of Medical Practitioner), located at
6350 Laurel Canyon Blvd #205 North Hollywood, CA 91606, am a nurse practitioner
who have been visiting Mr. Kang, March 14, 2022. I have been performing
face-to-face visit for her due to her homebound status. The history of my
involvement with the patient started upon his admission evaluation for Fast
Recovery home health. He was referred to Fast Recovery home health company with
severe anorexia, severe protein caloric malnutrition, dehydration, depression
and osteoarthritis. He is having difficulty in walking without walker. His wife Mrs. Kang has been suffering Alzheimer’s disease and unable to walk. I
have been visiting the couple several times and very familiar with their
medical history and functional limitations.
Due to documented disability, Mr. and Mrs. Kang have
physiological and intellectual limitations. In order to help alleviate their
difficulties and to enhance their ability to live in their residence, I
recommended that Mr. and Mrs. Kang’s daughter assist him to have reasonable
housing accommodation. I believe Mr. and Mrs. Kang have physical and mental
impairment that limits a major life activity. Housing accommodation for
mobility/hearing/vision disability unit is necessary for Mr. and Mrs. Kang because
they need assisted devices for mobility and also need assistant for bathing and
transferring.
If you have any questions, please feel free to call Fast
Recovery Home Health at 818-xxx-xxxx.
Sincerely,
Visiting NP Sojung Suk
Letter for Companion Animal
To Whom it may concern
G is my patient, and has been under my care since February 2017. I am intimately familiar with her history and with the functional limitations imposed by her disability. She meets the definition of disability under the Americans with Disabilities Act, the Fair Housing Act, and the Rehabilitation Act of 1973.
Due to depression and seizure disorder, G has certain limitations regarding SOCIAL INTERACTION/COPING WITH STRESS/ANXIETY, ETC. In order to help alleviate these difficulties, and to enhance her ability to live independently and to fully use and enjoy the dwelling unit you own and/or administer, I am prescribing an emotional support animal that will assist G in coping with her disability.
I am familiar with the voluminous professional literature concerning the therapeutic benefits of assistance animals for people with disabilities such as that experienced by G. Upon request, I will share citations to relevant studies, and would be happy to answer other questions you may have concerning my recommendation that G have an emotional support animal. Should you have additional question, please do not hesitate to contact me at 818-xxx-xxxx
Sincerely,
M (Josephine's grandmother) is under my care. She is on hospice continuous care and her death seems imminent. The patient's granddaughter, Josephine, needs to stay with the patient to support basic medical, hygienic, nutritional or safety needs, transportation, physical care, psychological comfort to the patient. Please excuse Josephine's absence during this family emergency.
Please feel free to contact me if you have question regarding the patient's condition.
Thank you
Sojung Suk, DNP
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