Making Vital Signs Vital

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource
We have been focused on why it is so important to measure vital signs as part of our clinical practice. Not only does the data help us with early detection of sepsis, identifying patient instability, having comparative baselines during exercise, and knowing when to stop an activity, but it also helps us make better clinical decisions around patient care. Now, therapy teams need to also focus on capturing measured vital signs into our daily documentation practices.

Measuring and documenting vital signs starts at the evaluation to ensure treatment plans are designed to address challenges with varying diagnoses and to ensure we provide interventions accordingly.

Next, vital signs are measured during treatment sessions to support decisions around interventions being provided. The key for us as therapists is to capture the data from vital signs as a guide to what interventions we will provide, or stop providing. In other words, we need to do more than simply take and record vitals. We need to use vital sign data as tools to make clinical decisions.

For example:

● Mr. Smith has O2 weaning as a goal. OT is documenting patient is SOB during activity; however, no vitals were recorded at evaluation or in TENs. Data was only entered into PCC. Here is why capturing vitals in our clinical documentation is also needed: Documentation is further enhanced when the OT documents how many liters the patient is on and levels of O2 before the activity, five minutes into the activity, and after the activity. This documentation is specific to the therapy session and needs to be recorded in the TENs as it supports what physical activity the patient can tolerate as part of decisions around O2 weaning and overall improvement with ADLs.

● Mr. Jones has precautions with BP risk identified on the PT evaluation. However, upon review of daily TENs, BP is not captured in the documentation pre-, five minutes into, and post-exercise. BP was entered into PCC, which is great for simply recording data. However, using the data in a meaningful way in our TENs supports the clinical judgment of a therapist (i.e., what decisions during treatment were made based on BP readings?) and further supports medical necessity for care.

● Mr. Romero had a CHF exacerbation and the hospital record noted he has 45% ejection fraction and he has SOB with walking greater than 75 feet. Documented vitals are paramount to ensure that his treatment with functional activities or prescribed exercise are keeping his HR between 25-35% of his target HR.

Other Examples:

● Pt. “V” has SOB and needs to rest frequently. What do the vital signs tell us and do we change direction in treatment due to those measures?

● Pt. “I” is on 2L O2. PT is working on ther ex and gait. Does O2 change with exercise? How long does it take to get them to recover?

● Pt. “T” is medically complex and post-septic. What do we know about pts who have been septic? How are we ensuring we are monitoring for s/s of sepsis while in therapy? What vitals are recorded in our documentation to support our clinical treatment decisions?

● Pt. “A” is doing breathing exercises with SLP due to COPD. What is the patient’s respiratory rate pre-, during, and post-breathing exercises? What are the O2 levels? How do we know the interventions are working?

● Pt. “L” is a cardiac patient. How are vitals documented during treatment sessions to support exercise prescription? How do we know our plan is working?

Please continue to work with your teams to not only measure vitals, but more importantly, integrate the data into evaluation and treatment documentation to support skilled intervention decisions, capture clinical judgement, and demonstrate medical necessity of our services.


Therapy to ED Leadership 

By Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource
Next up in the series of interviews of our former DORs turned ED is the one and only Amy Gutierrez! She is not only a former DOR, but served as a Therapy Resource as well. Amy is currently the ED at Treasure Hills in Keystone. She was kind enough to share some of her thoughts with us:

As a DOR/Resource, you were in a good place in your career. What kinds of things were you thinking about when the thought of being an ED came up?
Jon (Anderson) was actually the one that brought it up in October of 2018 at the Leadership Summit meeting. Prior to that, I never really wanted the responsibility lol! I suppose that was when the seed was planted. Throughout that time period I considered taking my boards to becoming an Admin, I started asking questions to the other administrators. One of the most frequent questions I had was, “Is it fulfilling?” As a therapist and a resource, I know we make a difference and felt I had a purpose. I didn’t know if I would have the same sense of fulfilment as an ED. I was naïve to think that it wouldn’t be.

How did you come to the decision to push forward into the AIT/CIT program?
To be honest, I kind of jumped in. The position was offered to me at the beginning of October with the acquisition scheduled to happen in November. At that time, I was still in my Hybrid role as a DOR and Resource. I was fortunate enough to attend an AIT boot camp, which helped to solidify the decision I made in becoming an ED. As an Administrator, we are given an opportunity to change the lives of many. And where we do that as therapists and Resources, we have the opportunity to do it on a much broader stage. All of those little changes we want to make, or we wish the Admin would do, is now on us. I learned rather quickly nothing is ever as easy as it appears. We are entrusted with so much, at times it could feel overwhelming, but it’s in those moments you begin to see growth as a leader.

What do you think is the most important characteristic of a successful leader?
This is a hard question to answer. I admire so many of our own leaders but for different reasons. One of the most common traits they all have is their openness to give and receive feedback. They surround themselves with the right people. They share what they know and want every single person around them to be just as successful.

If you were to talk to a therapist about the ED role in general, what is the most important thing you would talk to them about?
Being open and honest about the things you don’t know. Ask questions, lots of them. I find myself calling my partners and resources multiple times a day. It’s OK not to have the answers. One of my mentors shared that with me early on. And it has saved me a million times over.

Any other thoughts for a therapist who might be thinking about becoming an ED?
You have to be ready for anything. I have been in my role for eight months now, and I can honestly say, I never expected to be an Administrator under the world’s current circumstances. But you do everything in your power for the people under your leadership and those entrusted to your care. Times and positions like these are what therapists are made for.

Think Thin! The Path to Thin Liquids

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource

A new clinical campaign for our SLPs and IDT is the “Think Thin! A Path to Thin Liquids” approach. There is so much supporting evidence that promotes thin liquids over thickened liquids. When thick liquids are needed, then we need to consider utilizing the free water protocol.




Reasons to Think Thin:

Preventing Dehydration: Dehydration can lead to a variety of negative health consequences including:
• Changes in drug effects
• Infections
• Poor wound healing
• UTI’s
• Confusion
• Constipation
• Altered cardiac function
• Declining nutritional intake

Improving Quality of Life:
Traditional thought holds that aspiration of any material into the lungs can lead to aspiration pneumonia so many patients who have difficulty swallowing are placed on diet restrictions that avoid thin liquids.
However, a confounding evidence in the literature suggests that pulmonary aspiration of differing materials may not present an equal risk for the development of aspiration pneumonia. Aspiration will result in pneumonia only if the aspirated material is pathogenic to the lungs and the host resistance to the aspirated material is compromised. Research also discovered: “The risk of developing aspiration pneumonia was significantly greater if thick liquid or more solid consistencies were aspirated.” (Holas, DePippo, & Redding, 1994)

Being able to have Thin Water: Free Water Protocol
If a patient must be on a thickened liquid for any duration of time, research using a free water protocol found that fewer residents had UTI’s and dehydration and that when paired with proper positioning and oral care, there were no incidents of aspiration. Additionally, providing patients with thin water:
• Improves quality of life
• Improves Resident satisfaction with meals and less reports of thirst (Over 35% of patients are noncompliant with thickened liquids)
• Decreases risk of dehydration, UTI’s and pneumonia

Additional training information and materials will be coming over the next few weeks as we work to Think Thin!

CODE SEPSIS: Understanding the Sepsis Pathway and COVID

Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource

The Mission:
Improve Sepsis identification early to improve patient outcomes.

The Why:
Sepsis was 20% of our Medicare Readmissions as an Organization in Calendar Year 2019.
With every hour that treatment is delayed for sepsis, the mortality rate increases by 8%. Understanding and educating our facilities on SIRS and a focused vital-sign campaign with an SBAR-specific focus will improve our care delivery and reduce readmissions, improve our patient satisfaction, and help with our change in condition process.

COVID-19 and Sepsis: A Physician’s Lens
While there is still a lot to uncover about the pathology and presentation of COVID-19, we have learned a great deal about this virus and its potential impact in our post-acute care facilities. During our experience at one of the early COVID-19 outbreak facilities, it was discovered that an early presentation of many COVID-19 patients was the presence of a fever. Unfortunately, these fevers were managed with the typical order for acetaminophen and cooling measures, effectively masking the fever and avoiding any further escalation of care until the patient reached a point of medical instability.Sepsis POSTette

As with any patient in a post-acute care facility presenting with fever, even before COVID-19, timing is absolutely critical. Other changes of condition such as chest pain or possible stroke have led to long-standing, conditioned responses to immediately send patients out via 911. Fever is often the hallmark sign signaling the beginning of a patient experiencing sepsis — a diagnosis that carries a much higher chance of mortality, especially in the post-acute care population, but up until now has not received the attention it deserves. Oftentimes a febrile episode is masked or ignored, leading to a cascade of events leading to further demise, accelerated by a virus that now has the potential to spread like wildfire.

We are now at a point where identification of fevers (and other changes of condition) should signal a “code” event, essentially alerting the clinical team to provide immediate identification, isolation, and intervention. With every hour that a fever is ignored, the mortality rate for a potential sepsis patient increases by 8%. This simple, yet widely underappreciated clinical practice can prove to be a pivotal step in reducing the mortality in not just our COVID-19 patients, but in any patient who is on the path of developing sepsis. — Dr. Pouya Afshar

For more information, click here for our Sepsis POSTette

Documenting Justification of Skilled Therapy Services, Part 2

Symptomless CVAs?
By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource

A pattern that our PDPM deep diving partners have found is hospital document and/or therapy documentation that reports a history of CVA that then goes…nowhere. Despite this history, no residual speech, language, swallowing, cognitive or neuromotor findings are reported in the therapy assessments (or anywhere else). Yet according to the National Stroke Association, only 10% of people who have a stroke will make complete neurological recovery. This means that many individuals with long-term sequela are going unidentified in our setting.
According to the CDC, the most common long-term symptoms after a CVA include hemiplegia, cognitive impairments, speech and language impairments, dysphagia, incontinence and depression. Most of those symptoms, when properly identified and managed, will trigger PDPM components.

Step 1: Identify the sequela.
Obvious hemiparesis, dysphagia or aphasia will seldom be overlooked. But even minimal impairments can affect a patient’s balance, skin integrity, weight, mood and cognition. It’s critical that when a CVA history is present that the most sensitive assessments are completed to ensure that subtle impairments in symmetrical strength, righting response, complex reasoning, word retrieval, mood or swallowing are not missed.

Step 2: Identify how the patient is impacted.
It’s very unlikely that a long-term residual sequela doesn’t impact the patient’s function, the therapy treatment plan, or both. In addition to therapeutic interventions that may be need to be incorporated into the specific therapy treatment plans, the ways they impact a patient’s function should be part of the patient’s comprehensive care plan. Here are some examples:
• Hemiparesis that affects gait stability or righting response should be careplanned under fall risk management.
• Hemiparesis that affects sensation should be careplanned under skin intergrity.
• Hemiparesis that causes joint instability should be careplanned under risk for injury.
• Apraxia can affect ADL function, gait stability or speech and should be careplanned in the appropriate area.
• Aphasia or dysarthria that effects either comprehension or expression should be careplanned under risk for communication breakdown.
• Dysphagia that requires any degree of adaptation (including supervision or compensatory swallowing technique) should be careplanned under nutritional risk.

The better the assessment, the better the patient’s therapy and care plan can be customized to their needs. The more patient-focused the care, the better the patient will respond to it. And an extra bonus is that CMS recognizes the impact that long term neurologic sequela have on a patient’s care and they’ll reimburse accordingly. So we call that a win!

What’s So “Vital” About Vital Signs?

Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource, Flagstone, Pennant, Sunstone, Milestone, Endura, Monument

Vital signs are the objective measurements of temperature, pulse, respirations, and blood pressure as a clinical means to assess general health. Additionally, many include Pain and Gait Speed as the fifth and sixth vital signs.

Vital signs are critical indicators of patient status, both at rest and during exercise/activity.


Therapists treat patients with many complicating conditions, such as:

  • Respiratory conditions — pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis, etc.
  • Cardiovascular conditions — CHF, hypertension, etc.
  • Metabolic conditions — renal failure, diabetes, etc.
  • Infection conditions — sepsis; Systemic Inflammatory Response Syndrome (SIRS), etc.

Taking consistent vital sign measurements will help ensure therapists have good data related to respiratory function, cardiovascular function, endurance, and a patient’s ability to tolerate functional activity.

As clinicians, it’s not only important to take vital signs, but also measure them against exercise/activity. In other words, vitals should be taken:

  • Before the exercise (to establish a baseline);
  • 6 to 8 minutes in the exercise; and
  • 5 minutes after the exercise (recovery).

This information will allow clinicians to determine if target heart rates are being attained, any changes in condition, and/or if treatment adjustments need to be made, etc.

Consistent vital sign measurements also help detect medical condition changes. For example:

Sepsis early warning signs (these changes need to be reported immediately):

  • Temperature higher than 100.4° F or lower than 96.8° F
  • Heart rate greater than 90 beats per minute
  • Respirations greater than 20 breaths per minute

Respiratory rehab considerations:

  • A resting HR > 100 bpm is a relative indicator of patient instability.
  • If lower than 90%, there is an inadequate oxygen supply, and less than 70% is life-threatening.
  • Normal resting respiratory rate is 12-20 breaths per minute. “Normal” respiratory rate for an individual with pulmonary disease may fall outside these parameters. It is important to establish what is “normal” for each patient. Respiratory rate needs to be monitored before, during and after exercise.

Using vital signs to determine exercise termination:

  • Significant blood pressure changes
    • o BP>200/110
    • Lightheadedness; BP drops >20 mmHg
    • No more than an increase of 20mm Hg with activity
    • Oxygen saturation <90%
  • Severe shortness of breath
  • Noticeable change in heart rhythm

It’s important to know the normal ranges for each vital sign along with considerations for an aging population. Additionally, it’s also important to know what medications patients are taking and if those medications may interfere with vital sign measurements.

For example:

  • The medicine digoxin used for heart failure and blood pressure medicines called beta-blockers may cause the pulse to slow.
  • Diuretics (water pills) can cause low blood pressure, most often when changing body position too quickly.

Take time to ensure every member of the Therapy team is taking vital signs consistently and throughout treatment sessions as recommended. Consider hosting a training lab if any skills need to be refreshed. Ensure team members have access to vital sign equipment (consider vital sign kits for each team member).

For more information on the details of vital signs, please refer to the Vital Signs POSTette, Pain Management POSTette, and Clincally Complex POSTette.

For training tools, check out these resources:

• Training video on taking blood pressure:
• Training video on all vital signs:
• LMS video available on Vital Signs: How to Measure Vital Signs REL-PAC-0-HMVS 1 hour

Therapy to ED Leadership

Submitted by Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource

As you all know and have heard, our organization considers itself a “leadership development company that happens to be in healthcare,” and we are always looking to develop the best and right leaders. On previous Therapy Leadership calls, we’ve had guest speakers who were former DORs who took on the challenge of becoming EDs, quite successfully we might add! Our organization recognizes how special our therapists and therapy leadership are and the potential that many of you possess.
In a continuing effort to tap into that potential and to foster and grow any thoughts you may have or have had about becoming an ED, we are starting a series of interviews with our former therapists/DORs turned ED, to get some further perspective. Here’s the first of the series from Stephanie Anderson out of Rock Creek of Ottawa in Kansas.

Thanks for taking the time to check out this interview, and if you want to talk further or have questions about becoming an ED or the AIT program, we encourage you to take the next step and start talking to folks. There are many ways to get more information and insight, such as your ED, Market, therapy resources, Clay Christensen, and/or any of the former DORs who are now successful EDs. If you’d like to talk further with Stephanie or any of our other former DORs, let us know and we’ll get you their contact info!

Question: What is your favorite part about being an ED?
Stephanie: I love that I am able to really take the time to focus on staff and residents. I get to spend my day “people-ing,” as I like to call it. Being on the floor, problem solving, getting to know the staff and residents on another level, and really driving the culture and vision I have for the building all make my day so enjoyable. The impact I can have as an ED in taking our building to the next level is what motivates me each and every day.

Question: As a DOR, you were in a good place in your career. What kinds of things were you thinking about when the thought of being an ED came up?
Stephanie: Can I really do this? Do I want to do this? How will my relationships change with my peers and team if I make this switch? I love this building, as it is in my hometown and I’ve seen the changes that have happened over the years. I joined Rock Creek of Ottawa during the acquisition in November 2018. Prior to the acquisition, the building didn’t have the best reputation, so I love that I can be part of fixing that. I took the DOR job with every intention to change the reputation here. As the ED, I feel I have more impact and push to continue to change. Me stepping into this role allows the community to continue to build trust in us.

Question: How did you come to the decision to push forward into the AIT/CIT program?
Stephanie: Our market lead actually approached me about the idea. My ED at the time had been telling me for a while that I would make a great ED someday, but that day came faster than I was anticipating! It was a little unconventional as I still served as the DOR while I was going through the AIT and I was able to complete the AIT in my home building. There were long days, but I was able to make my AIT experience a positive one. You really are the one responsible for making your AIT program great. My therapy department was operating well and I felt like I needed more. I was also able to connect with other EDs within Ensign that were DORs previously and went through AIT.

Question: You’ve been transitioning to this role during this rough time of the pandemic. Are there qualities or characteristics you took from being a DOR that have helped you with your transition during this time?
Stephanie: How to enhance culture across departments, clinical skillset as far as infection control and isolation room practices, implementing strategies to enhance residents’ quality of life and functional abilities, LTC programming, creative ways to drive revenue, seeing the business side of how the operation works, building a strong team and having the right people on your team to be successful, driving culture.

Question: What advice would you give to a therapist if they are thinking about becoming an ED or even just about the ED role in general?
Stephanie: I’ve been told that DORs who transition to EDs are the most successful. ☺ If you’re considering making the jump, I encourage you to reach out to people who have done it and gain perspective. The beauty about Ensign is that our culture and processes allow awesome things like this to happen!

Documenting Justification of Skilled Therapy Services, Part 1

By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource
Of the many exciting and challenging things our therapy teams look forward to doing every day, it is probably safe to assume documentation is not at the top of anybody’s list! Yet, in spite of the wonderful work that is done in our gyms, patients’ rooms and hallways — what we choose to document about those services may result in a denial of payment for your facility down the road.

Some of the most common reasons for claim denials include:

  • Ongoing services did not meet the requirements of medical necessity and reasonableness per Medicare criteria.
  • Documentation did not support the requirement that services shall be of such a level of complexity and sophistication or the condition of the patient shall be of such that services required can only be safely and effectively performed only by a therapist.
  • By (Date) the PT and OT plans of care did not document any significant changes or interventions that were needed or could only be done by or under the supervision of a licensed rehabilitation therapist.

The best defense for these types of denials is a good offense. We must proactively document the medical necessity and skilled interventions provided by our therapy staff.

Although a patient’s medical diagnosis or recent surgical intervention may play a strong role in determining whether skilled intervention is needed, it cannot be the only factor supporting medical necessity.

POC Justification Opportunities:

  • Reason for Referral should make it clear why treating discipline is involved.
    o Sub-optimal: “Physician Order.” “Routine admission evaluation.” “New admit.”
    o Optimal: “Pt. referred by nursing due to increasing weakness noted with recent falls in the patient’s room.” “Pt. referred to PT by physician due to new onset of weakness and reduced activity tolerance with increased assistance needed from caregivers for bed mobility, transfers and gait.” “Pt. referred to ST due to increased episodes of confusion with decreased memory for safety precautions while completing ADLs.”
  • PLOF should be a detailed summary of performance levels of the patient prior to becoming ill and should tie to functional areas addressed in both short-term goals and long-term goals.
  • Clinical Impression should specify areas where deficits were noted on assessment.
  • Reason for Skilled Services based on identified deficits (Clinical Impression) what specific interventions are needed that can only be provided by a therapist? What will happen if skilled interventions are not provided?
    o Sub-optimal: “Pt. would benefit from skilled occupational therapy to improve activity tolerance and strength.”
    o Optimal: “Skilled OT treatment interventions to include instructing and training patient in energy conservation techniques, positioning maneuvers, proper body mechanics, safe transfer techniques, safety precautions and use of assistive device(s) in order to facilitate safe return home alone.”

UPOC Justification Opportunities:
Continued Skill should describe the reason why therapy services need to continue based on the patient’s response to treatment. If the patient is progressing towards their goals, this case can be easily made as progress made before is the best prognostic indicator of more progress to come.

However, if patient is not progressing, this can be more difficult to document and the therapist must modify goals and/or approaches with the expectation that the patient will respond to those changes in the Updated Plan of Care. Sometimes new areas of focus arise during the course of treatment and those new areas are incorporated into the UPOC. These are all examples of why the skills of a therapist are needed to adapt and adjust the therapy plan.

Stay tuned for our next FlagPost when we’ll review how to make the best justification in a progress note and a TEN. We know you can’t wait!

Respiratory Rehab Using EStim

Submitted by Cory Robertson, Therapy Resource, Idaho

Did you know that electrical stimulation can be used for more than a really fun demonstration in high school physiology class? Yes, it is great for that, but the evidence-based applications of electrical stimulation are myriad. A recent meta-analysis (yes, a meta-analysis, the king of the hierarchy of scientific evidence) concluded that e-stim effectually strengthens quadriceps and enhances exercise capacity in moderate to severe COPD patients.

A large barrier to therapy for those with respiratory conditions is their tolerance. They fatigue quickly and get short of breath and struggle with dyspnea. That is in part due to the changes in muscles when the ability to deliver oxygen to them decreases. There is an increased reliance on less fatigue-resistant muscle fibers. One method to address that barrier is the use of neuromuscular electrical stimulation to activate those muscles most important to functional activities. But how do you do it?

Like most therapeutic interventions, there is skill involved, and if done incorrectly, at best it is a placebo. The goal is to use the NMES effectively to get the best outcomes as evidenced by the meta-analysis and many more research articles. Please check out article for Respiratory Rehabilitation EStim from the portal for a refresher on how electrical stimulation works and some best practices. It will help to get the therapeutic dose to the target tissue, leading to great outcomes, while enhancing the tools in your therapy tool bag.

Let’s use the tools available to us, supported by evidence, to best treat those who rely on us to improve their function and quality of life. Electrical stimulation can be more than a last resort, or why Mr. Wilson gets the best reviews in his physiology class.


Skill in Place Considerations

By Kelly Alvord, Therapy Resource – Sunstone

Goal of the Waiver: To keep beds open at the hospitals for more critical patients

Three things to consider to skill in place; however, please refer to our Ensign Affiliates Skill In Place Tool Kit that is available on the Portal for more detailed guidance:

1. Did the episode or change of condition occur after March 1, 2020, when the waiver went into effect? We are getting further away from this date, so this isn’t going to be as relevant.

2. Does the patient need Daily Skilled Services? 7x/week of Nursing Services and/or 5x/week of Therapy Services. This hasn’t changed for Medicare Daily Skilled Criteria. Therefore, keep in mind what is medically necessary to meet Medicare Part A criteria to assist you in determining if the resident is appropriate to be Skilled in Place.

3. Qualified Hospital Stay Considerations impacted by the COVID Emergency (keeping the hospital beds open)

● Bypass/skipping the hospital for bed access or to avoid exposure to COVID

o In the past, would we send or the provider send the patient to the hospital due to the change of condition? This needs to be an IDT discussion with the ultimate decision made by the physician. (See additional questions and considerations below.)

● Signs of or close exposure to COVID
o Are we isolating the patient and nursing is providing daily skilled care to assess the patient due to COVID, whether or not the patient has been tested positive to COVID?
o If we are waiting for the COVID test results, use the Med Dx of R09.89 and Z20.828.
o If the patient has a positive test or physician has diagnosed the patient with COVID, use the Med Dx U07.1 (only if the date of the test results or diagnosis is after April 1).

● Dislocation due to COVID
o Facility to Facility transfer due to the COVID emergency
o Caregiver Breakdown. Patient unable to stay home due to caregiver being exposed or positive for COVID.

Here are additional questions and things to consider:
Q: What if it’s already our practice to provide high acuity, daily interventions in order to avoid the hospital? Can we still apply the waiver?
A: Yes. The fact that you already have the necessary skills and policies does not preclude you from applying the waiver when the goal of those services is to avoid hospitalization.

Q: How can we tell if what we’re doing is routine, or applicable to the 3 day QHS waiver?
A: The decision is ultimately up to the physician (who must then write the order to initiate a skilled level of care). Collaborate with the attending doctor to reach a decision about whether the patient’s circumstances are impacted by the emergency as required by the waiver.

Final note: Many needs may arise due to decreased out-of-room activity, decreased community access and isolation from families. While these are emergency-related and should be treated, initiating a skilled stay requires that the needs rise to the level of requiring daily skilled interventions, and documentation must incontrovertibly support this. Most of these needs are properly managed with less than 5-7x/week interventions, and frequency should not be inflated in order to artificially justify a Part A stay.

Keep in mind that the skill in place process is new and has many factors to take into consideration. We have many resources available on the portal; please click on this link to take you to our Ensign Affils SIP Took Kit on the portal:

Your MDS and Therapy Resources are ready to help!