Specialized Rehabilitation or Restorative Services Critical Element Pathway
By definition, specialized rehabilitative services include but are not limited to PT, ST, OT, RT, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth and are required in the resident’s comprehensive plan of care. Based on observations, interviews and record review, we ask ourselves: Did the facility provide the appropriate treatment and services as outlined in the resident’s plan of care to maintain, restore or improve the functional ability for the resident?


  • Observe resident receiving therapy services as required per their assessment and plan of care
  • Observations assess staff interaction, staff assistance, assistive devices needed, how pain is addressed by staff and modes of treatment


  • Family, staff, and resident interviews
  • Resident’s involvement in goals, treatment intervention and treatment
  • Does the resident ever refuse services? If so, why and how is this handled? How often and how is the resident assessed?

Record review:

  • Quarterly screens in place
  • Physician orders in place and followed
  • Pertinent diagnoses
  • Care plan (ADL assistance, premedication prior to therapy, therapy interventions or restorative approach)
  • RNA documentation (daily, weekly, IDT, frequency matching orders)
  • Skills competency checklists for therapists and RNA
  • Fall screens (determine appropriate therapy involvement)

Activities of Daily Living
We aim to provide the opportunity to achieve the highest level of self-care performance in order to complete tasks such as dressing, bathing, toileting, grooming, brushing teeth/denture care, and other personal hygiene tasks. Participation in an ADL/Grooming Program can enhance quality of life by providing the opportunity to develop and practice ADL skills and reduce/eliminate pain and frustration during ADL performance.


  • Changes with performance of self-care tasks
  • Difficulty participating due to physical or cognitive impairments
  • Reduced sequencing and/or recall skills to follow or participate in ADL’s
  • Visual field deficits (e.g. unable to see hygiene items on left side of sink)
  • Poor positioning/body alignment/balance or trunk control during ADLs
  • Poor functional activity tolerance
  • Desire to participate in independent self-care management
  • Potential to improve level of performance in self-care tasks
  • Fall(s) occurring during self-care tasks/toileting
  • Need for adaptive equipment/modifications
  • Recent change in pain status, altering ability to participate in ADL/grooming tasks

Resident interviews:

  • Any ADL limitations and/or frustrations
  • Prefer more independence with ADLs
  • Noticed recent changes with ADLs
  • Increased time to complete ADLs

Staff interviews:
CNAs, RNAs, licensed nurses, activities and other facility staff; ask specific questions related to resident performance with:

  • Inconsistently performing ADL tasks
  • Needing an excessive amount of time to complete ADLs
  • Expressing they would like to participate more in ADL tasks or do more for themselves
  • Distressed they are losing function
  • Talking more about what they used to be able to do
  • Not participating at their maximum potential or skill level
  • Not currently completing ADLs but who have the potential to participate

Record Review:

  • Care plan to address ADL limitation (ADL assistance, pre medication for pain if needed prior to therapy, therapy intervention or RNA approach)
  • RNA orders and documentation (daily, weekly, RNA meeting)
  • Quarterly screens in place
  • Fall screens
  • Physician orders in place and followed
  • Pertinent diagnoses
  • Skills competency checklist for staff completed annually

Positioning, Mobility & ROM Critical Element Pathway


  • Dining room during a meal
  • Hallways, lobby, during activities
  • Rooms: positioning equipment in place, clean and used per order and care plan
  • Splinting or other hand devices clean, in place and used per care plan
  • Equipment clean, position in chair optimal, leg rests present and appropriate, cushions appropriate and present
  • IDT referrals: skin tears, falls

Resident interviews:

  • Pain
  • RNA program in place? Happening regularly?
  • Positioning/splinting devices applied as ordered and appropriately
  • IDT referrals — resident report follow-up from incident

Staff interviews:
CNAs, RNAs, Therapists, Activities, Residents (IDT referral)

Record review:

  • Care plans for specialized positioning equipment
  • RNA orders and notes
  • ROM screening program in place and completed quarterly?
  • Follow-up completed/documented when COC noted on screen

Rehab Qualifications & Title 22

  • Licensed, registered or certified staff to provide services per state regulation
  • Rehab staff knowledge of the location and overview of P and P
  • Contract and liability insurance for independent contractor
  • Current licensed on file for PT, OT, ST and certification on file for other rehab staff as indicated
  • Annual PE and TB screened
  • Reference and background check per facility P and P
  • Copy of signed job description in file
  • Orientation (abuse, infection control, HIPPA, sexual harassment and skills competency checklist
  • Staff follows Infection Control techniques with documented cleaning of equipment
  • Rehab addressed safety modalities on residents with fall incident and participates on facility QA

View poster: Proactive Quality Review (PDF format)

Flagstone Therapy Resource Team