Healthcare is continuously changing. This has never been more evident as it is now for residential health care facilities. What we used to think was a highly regulated business is quickly becoming an even more scrutinized industry. Changes put into place aim at amalgamating quality and reimbursement. These changes have required providers to re-examine the manner in which they focus their efforts.
One area worth looking into is Therapy services. Claims for therapy services, both Medicare A & B, need to include sufficient documentation to enable a reviewer to determine whether the services provided were considered reasonable and necessary. One growing area of focus for auditors is the therapy screens. What used to be seen as the first step in beginning a therapy program is no longer the first item examined when a resident’s chart is being audited. Instead, auditors are now looking to see if there was at least a few days of nursing documentation focused on the specific change seen with the resident’s function. Once the change has been identified and documented, then a therapy screen should be completed with the specific functional/cognitive changes.
Once residents are placed on therapy programs documentation on the nursing units continues to be crucial. The documentation found on the units should illustrate the degree to which the resident is accomplishing goals made in the plan of care. Ultimately, the nurses’ notes should reflect the transition of the skills learned/gained in therapy and how they are translating to what the nurses see on the units.
Moving forward consider if your facility has processes in place to ensure proper documentation before and during a therapy program. If so, does the documentation reflect the functional/cognitive area being worked on?