​While centers can’t force patients to stay or go, they can document what they have done every step of the way to help them set and reach reasonable goals. This documentation should show everything the center has done with the short-stay patient—goal setting, care planning, family discussions, what therapies and interventions were administered, daily progress, and ongoing efforts to revisit the care plan and prepare for the person’s discharge.

“Documentation plays a critical role,” according to Horowitz. It should include specific details about issues such as goals. For example, if the patient will be returning to a house that has four steps leading to the front door, the physical therapist needs to document what is being done to help the person climb the steps and what progress is being made.

Horowitz notes, “If the resident were to exceed that goal and was able to climb up 12 steps on discharge, even though his or her house only had four steps, it is important to document why it was appropriate or important for the patient to accomplish this. Being able to climb only four steps would hardly be adequate for a person who returns to the community and both needs to and is capable of negotiating additional steps in multiple community settings.”

In cases where progress is slower than expected or there are no improvements, that should be documented as well. This is especially so since a lack of improvement alone is insufficient to deny Medicare coverage, he says.

If the center is unable to meet goals established within the pre-determined time frame—or even if the patient actually exceeds the goals—documentation can help prevent survey citations, fines, or even fraud charges.

“It is perfectly acceptable to provide therapy that helps the patient regain or even exceed a prior level of functioning,” Horowitz says. “Additional guidance from the Centers for Medicare & Medicaid Services about how much therapy is appropriate should be forthcoming in the wake of an Aug. 18, 2016, court order in the Jimmo v. Burwell case.” In the meantime, adequate documentation is the best protection.