Skilled Nursing Facility Primer- Part 2

Editor's Note: This text-based course is a transcript of the webinar, Skilled Nursing Facility Primer- Part 2,  presented by Kathleen Dwyer, OTR/L, CHT.Learning OutcomesAfter this course, participants will be able to apply improved therapy documentation for skilled nursing facilities.After this course, participants will be able to clearly define appropriate goals for skilled nursing facilities.After this course, participants will be able to list items needed for a ready-to-go toolkit for treatments in a skilled nursing facility.IntroductionThanks Fawn, and appreciate you having me back, as well as everyone joining us today. So, let's just dive right in. As I would like to first go over my disclosures. So, there they are. And today's goals, so I'm really glad that we were able to separate this into two parts. And today's really more focused in on how you apply your learning from part one into your documentation and making sure that we are ready to go from a treatment perspective, so our goals for today are for you to be able to apply improved therapy documentation to clearly define appropriate goals and to list the items needed for our ready to go toolkit, all for working within a skilled nursing facility. And as I will shorten that into the term SNIF throughout this presentation as I did in the last presentation. So quick review from part one, if you were there with us, you learned quite a bit about the expectations of skilled care defined by the Centers for Medicare and Medicaid Services, also known as CMS. So in order for our services to be considered skilled, first of all, they need to be reasonable and necessary, they need to be consistent with the illness or injury, and they need to be delivered in an appropriate duration and quantity. Finally, our services should be promoting the patient's therapeutic goals. So today, we will take these lessons learned and apply it to our documentation to be sure that they are in fact skilled. The information that I'll be presenting today, primarily comes from chapter eight of the Medicare benefit policy manual. So we, in the course of part one, we talked a lot about different payers, and someone even asked about what are the expectations of other payers, so I just wanna add that Medicare is typically the most strict when it comes to guidelines and expectations. So, today's presentation, as the first one, is all about Medicare, but just so you know that typically Medicare gives us the most strict guidelines as far as making sure our documentation reflects that skilled care. I've had a lot of therapists over the years ask me the question, just tell me what to write, tell me what to write so that my services won't be denied. And I think that that's a valid question, because you might have worked for a lot of different facilities or different levels of care and the expectations are different. So what we're gonna review today is what I wanna consider best practices moving forward and using chapter eight as our guideline. I really wanna give you some tips throughout the today's presentation to make sure that you understand words and theories that you can put into your documentation that really will help it define your skilled services. I noticed in our polls today that we have quite a few registered occupational therapists and I'm glad because we're going to start with evaluations, but for the assistants who are on, don't tune out, because I think it's important for you to also know what are the expectations for the evaluations. So first of all, I'm gonna say this a lot today, we need to be painting the picture of our patients in front of us. Everything that we write down, whether it's in our vals, our progress notes, our daily notes, all has the likelihood of someday being reviewed by somebody else. And sometimes that review happens years later, and it's our responsibility as therapists to make sure we're painting that picture so that anyone who reads our documentation, whether that's an auditor, another therapist, maybe perhaps a non skilled case reviewer, all of these people need to be understanding how the services that we provided are skilled and how are they meeting those requirements. So let's paint the picture through the evaluation. First of all, it must describe the medical history. So, we need to set the stage for why this patient is requiring our skilled services. It's important that in our medical history we're including those comorbidities, because obviously those are going to impact how we approach the patient. But we also need to be talking about that reason for skilled care. So typically, the diagnosis gives some background of proof that they do require the skilled nursing level of care. And typically, not always, but typically the diagnosis that we're bringing forward in our documentation is what they were also treated for in the hospital. It might not always be the case, but that is what's typical. But we wanna make sure that our diagnosis is supporting that they need skilled care. It's also important that our documentation includes any pertinent characteristics that are gonna impact how we provide our care. So examples of this would be if the patient is hard of hearing, or if the patient presents with a cognitive deficit, because we would obviously be changing our approach to how we care for them. And it should be documented so that as our plan of care gets transitioned to different assistants or different treating therapists, that we all are well aware of any of those pertinent characteristics. Obviously, precautions and contraindications are extremely important for the same reason. And also, we should be painting the picture of the patient's prior level of function. So what was this patient able to do prior to the onset of this disease or illness or condition. And if the patient is unable to tell you what their prior level of function is,...