When a resident is in a skilled nursing facility for Medicare-based rehabilitative services (physical therapy, occupational therapy, and/or speech therapy), who is responsible for the plan of care? Is it the nursing or therapy department?
According to the “Semiannual Report to Congress” submitted by the Office of Inspector General (OIG), 37 percent of Medicare stays in 2009 did not have the appropriate care plan in place to meet the needs of the resident.
In addition, the study found that services either did not match the care plan or the facility provided too much care, resulting in harm to the resident. OIG reported an estimated $5.1 billion in overpayments for the reporting period. Getting the care plan right is essential to avoiding OIG scrutiny and payment loss.

Department Coordination Improves Care

When care coordination does not occur, not only does the chart lack proof of necessary care, but residents suffer. In an OIG podcast, Judy Kellis, an OIG team leader, described a situation found during an audit where a resident received intensive therapy five times a week for five weeks, even though he had terminal lung cancer and did not want the therapy.

In another situation, a resident received hours of therapy even though she had a dislocated hip. Treatment plans that are detrimental to the resident can be avoided when therapy and nursing staff work together holistically to assist the resident in achieving his or her rehabilitative goals, to provide pain control, and to support disease management.

As part of the required Resident Assessment Instrument (RAI) process, it is critical to link the Minimum Data Set (MDS) process to the care plan in a way that accurately reflects the needs of the resident. The purpose of the RAI process is to conduct an interdisciplinary review of the resident’s care needs that is holistic in scope.

In order to do this effectively, therapists and nursing staff must closely align their work in caring for the Medicare resident. Dialogue between therapy and nursing staff should clearly identify the resident’s baseline status, as well as his or her progress toward goals. Wasteful spending to the tune of $1.5 billion was blamed on the use of incorrect Resource Utilization Groups (RUGs) in establishing payment, the result of inaccurate MDS coding.

The OIG-identified culprit was inaccurate charting for therapy services and activities of daily living (ADLs), which OIG auditors reported was the result of upcoding.

Therefore, it is critical that nursing and therapy department staff coordinate appropriate Medicare services so that care is cohesively and accurately captured by the medical record, care plan, MDS, and billing claim.      

Pay Attention To The RAI Process

Tying the RAI process to care that is delivered in the therapy department can greatly enhance the coordination of care that needs to occur. The critical thinking involved in the RAI process helps facility staff determine appropriate interventions, address critical elements of the resident’s preferences and needs, and avoid providing too much care.

The nurse involved in completing the ADL Functional/Rehabilitation Potential Care Area Assessment should work closely with the treating therapist to enhance the integrity of the critical thinking process. This will enhance the likelihood of a comprehensive care plan that results in appropriate treatment provided by all staff involved in caring for the resident.

In addition to the RAI process, teamwork is essential when therapy starts and ends, when residents refuse treatment, and in between these times. Another way to put it: Teamwork and coordination should occur during the entire Medicare stay.

At the start of therapy, teamwork is essential to communicate the baseline and the goals. Nursing involvement in the resident’s ADLs contributes to supporting the need for therapy services by reflecting the resident’s deficits as well as showing the progress a resident is making as a result of the therapy services.
For example, nursing can show how a resident’s mobility has gone from non-weight-bearing, to weight-bearing with two assists, to weight-bearing with one assist, to guided maneuvering. This type of coordination of service paints a powerful picture of the benefit the resident is receiving from therapy services.

Don’t Forget To Review Residents’ Needs

When a resident refuses therapy, the best practice is for nursing and therapy staff to work together to assess the reason for the refusal and coordinate mitigating interventions. This coordination includes assessment of, and interventions for, pain, sleep needs, scheduling of daily activities, potential illness, mood status, and so on.

If the end of therapy always spells the end of the Medicare stay, then coordination of care may be lacking. Some residents require skilled nursing services after therapy ends.

A thorough review of the resident’s needs is necessary to ensure that residents aren’t precipitously dropped from Medicare when continued coverage is reasonable and necessary. On rare occasions, residents may need observation and assessment, teaching and training, management and evaluation of the care plan, or direct skilled nursing care.

For a resident on Medicare for rehabilitative services, an appropriate care plan is the responsibility of both the nursing and therapy departments and should include involvement by other interdisciplinary team members. Appropriate, well-documented care is essential to protecting the facility from adverse OIG audits. To achieve this, it is critical to dialogue openly about how well the nursing and therapy departments coordinate care services.

There should be no territorial overtones or departmental silos that prevent honest dialogue and thorough teamwork. Managers should take time to evaluate the communication and coordination that occurs between the nursing and therapy departments.

This action can make the difference between accurately providing each resident with the appropriate level of care and coming under scrutiny from OIG auditors.
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.