Did you know that there are Federal Regulations in the long-term care setting that mandate residents have services in place to maintain their highest level of function?

Did you know that there are Federal Regulations that state Medicare will pay for the skilled care a resident requires to either prevent or slow decline, or to maintain a condition?

Putting these 2 requirements together may open up opportunity for a skilled maintenance therapy program if reasonable and necessary, to ensure the needs of your residents are being met….while receiving Medicare reimbursement to do so.

Let’s look a little closer…

The Federal Regulations

The State Operations Manual spells out all expectations in long-term care, including the mandate for maintaining residents at their highest level of function.

F-675 Quality of Life states:

“Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident MUST receive and the facility MUST provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.”

State Operations Manual: F675 Quality of Life

F-676 Quality of Life is a bit more detailed and pointed at function, stating:

“The facility must provide the necessary care and services to ensure that a resident’s abilities in activities of daily living (ADL) do not diminish unless circumstances of the individuals clinical condition demonstrate that the decline was unavoidable.”

State Operations Manual: F676 Quality of Life

F-676 goes on to state:

“The facility must ensure that the resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified here:

Hygiene: bathing, dressing, grooming and oral care

Mobility: transfers and ambulation

Elimination: toileting

Dining: eating, including meals and snacks

Communication: including Speech, Language and other functional communication systems

State Operations Manual: F676 Quality of Life

 In addition to the F-Tags above, Quality of Care regulations also include Range of Motion and Contractures.

“The facility must ensure that a resident who enters that facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrations that this is unavoidable; or a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion; or a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.”

State Operations Manual: F688

When you put ADL, Mobility, Range of Motion, Communication and Swallowing regulations together, it is evident that physical, occupational and speech therapy must be part of “each resident’s plan,” in some way, shape or form, during the long-term care stay. Not every resident will require therapy services; however, many will require the skills of a therapist to establish a plan of care that will be followed by caregivers to allow the resident to maintain function, followed by a periodic reassessment to see if the plan needs modification.

Medicare Coverage

By now you have surely heard of the Jimmo v. Sebelius Settlement Agreement from 2013. When Jimmo won, it was a reminder to Medicare that the regulation states coverage is not based on diagnosis, progress or outcomes, rather based on the need for skilled care. The Agreement reinforced that Medicare will cover:

  • Skilled therapy to restore or improve a condition
  • Skilled therapy to prevent or slow decline a condition
  • Skilled therapy to maintain a condition

 Medicare only pays for skilled care….and with that, will pay for the skills of a therapist to:

  • Design and Establish a Maintenance Program, with the intent of passing the plan on to a non-skilled provider
    • What might this look like? Evaluating a resident and providing skilled therapy for xx # of visits to determine, for example: the safest method of transfer; or the safest ambulation distance due to cardiac history; or the least restrictive diet consistency; or a splint adjustment and new wearing schedule; or the best energy conservation techniques during an ADL routine.
  • Provide a Maintenance Program that cannot be delegated to a non-skilled provider because either the plan or the resident is too complex
    • What might this look like? Providing skilled therapy xx # of visits per week or month to, for example: provide manual techniques to stretch contracted hamstrings to allow enough knee extension to sit in a wheelchair; provide stretching and splint fit checks to a resident with a severe hand contracture and osteoporosis; or to provide standing activities to a resident with orthostatic hypotension to maintain LE strength to allow for the continued ability to stand safely with aides for bed and bathroom transfers….

The regulation further defines Maintenance Therapy as an example of Skilled Rehabilitation Services:

“When the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient’s needs, and consistent with the patient’s capacity and tolerance.”

42 CFR § 409.33 – Examples of skilled nursing and rehabilitation services.

Incorporating Maintenance Therapy into SNF Practice

The role of therapy in long-term care is to assist residents in reaching their highest level of function and then set up a plan to assist residents in maintaining their highest level of function, either through skilled means or unskilled means. Not all services provided by therapy are billable. However, many of the “things” we do as therapists to make sure our long-term care residents maintain their highest level of function, may very well be, and thus may qualify under skilled maintenance.

For example, are you “screening” residents on a routine basis to determine if the resident is stable or if the current care plan is effective? Could this screen at times be an evaluation? Depending on the existing “plan,” in many cases, the answer may be “yes.”

Upon completion of your evaluation, are you making recommendations to nursing for the “care plan” so that caregivers can provide care in a way that maintains highest level of function?  These recommendations can range from how to transfer a resident, adaptive feeding equipment needed, how often and how far to ambulate, and the most appropriate diet consistency.

Are you providing residents with home exercises? Range of motion programs? Splints and wearing schedules? Specialized pressure relieving devices? Are you recommending task segmentation strategies? Swallowing strategies?

Making recommendations, or “setting up a plan” for others to carry out utilizes your skills as a therapist, and Medicare is willing to pay for that skill.

These recommendations are the “plan” you are recommending for your resident, the plan that a non-clinician will be providing. Therapists must take responsibility for the recommendations they make. What is your follow up plan for the long-term care resident after discharge from therapy? Don’t wait for a referral from nursing to re-visit the resident. Establish your follow-up plan on discharge, especially if you are making any recommendations, or if the resident is at high risk for decline. Use your skill to determine when that next assessment should be. For some residents, it may be annually, for others, it may be quarterly. Your physician always schedules your next appointment at the conclusion of your current visit, right?!

Refresh yourself with OBRA ’87 and the resulting Federal long-term care requirements above to ensure your facility has a plan for each resident to attain and maintain his/her highest level of function. You may be able to integrate a solid skilled maintenance therapy program into your existing therapy services, which is a win-win for everyone.

So…..based on the above, what’s your plan?

In Your Corner,

Dolores Montero, PT, DPT, RAC-CT, RAC-CTA

SNF Rehab and MDS Compliance Consulting



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