We all know about the rumored, accepted and commonly used practices that relate to rehab in the skilled nursing Facility, but do we really know if they’re valid and supported by a regulation?

Yes, speech therapy can be the only skilled intervention for those patients who need it.

No, progress is not a criterion for skilled services under therapy.

But there’s one more that keeps popping up.

I recently read an article by a well-known MDS expert, who imparted great volumes of her wisdom and experience, most of which I was interested to read, but then I read this show-stopper:

“…after a 3 days [sic] refusal – we have to dc therapy according to Medicare…”

In my multiple decades of working in skilled nursing as a treating therapist, Rehab Director, and Regional Director, I have been fighting and refuting this myth. I have seen patients who are validly and objectively sick, running a high temperature, leaking from various orifices and wounds, who are unable to participate in any meaningful and skilled therapeutic activity, yet who are unceremoniously discontinued from therapy “because of the Medicare requirement.”

This is not a Medicare (or any other kind of) requirement, and should not be acted on unless the patient has stated he wants to discontinue because he’s not interested in participating further. There are those patients we see (infrequently) who are just not interested, and probably need to be given an “out.”

If the patient is on a valid hold (an actual physician’s order is required to hold therapy, not just advice from the charge nurse), or states three (or five or nine) days in a row that he’s too sick to participate, we can offer to discontinue or we can wait for the resolution of whatever the illness is, and pick up where we left off. Caveat: As long as PPS survives, an EOT or EOT-R assessment will need to be completed. But the Plan of Care does not change if there has been no change in the patient’s needs. If the patient has had an extended illness, a re-evaluation may be required, as the patient’s therapy needs may have changed.

Think about your Medicare Part A patients during last winter’s flu season. Mrs. Sneeze tests positive for the flu, it’s too late for the Tamiflu, and she’s contagious and when she’s vertical she coughs until she vomits. Can we force her to accept therapy for the next five days in the name of the RUG? She’s going to need it when she recovers, but for now we need to stop and pick up when she’s better.

So what happens under PPS to her category? The rehab category is not going to work. She will revert to a nursing category for the time off therapy, and we will do a COT or SOT when she’s feeling better and able to participate.

Medicare has a lot of black-and-white rules. This isn’t one of them. It is expected that our patients will have setbacks and come back from them. Our population is sick, older, and debilitated. Stuff happens. We have to be ready for whatever approach is needed to make their lives better and get them healthy. A non-“rule” about taking three days off for a valid illness shouldn’t be one of them.

Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.