So many times, we get questions about how to “skill” a resident. Is she skilled if she’s getting IVs? Is he skilled because he’s getting wound care? What about the resident whose trach is capped? Is she skilled? When the rehab patient reaches the almighty “plateau”, and isn’t getting better, is he still skilled?

We need to remember what the S-word means (no, not that one.) “Skilled” in our arena is defined by the services that we are delivering to the client, not by what the client is or isn’t doing.

  • The patient with brain damage who is confined to bed and eats a diet of puree/honey-thick liquids needs positioning, caregiver training, inhibition of spasticity, and splinting. Nursing is giving PROM every day to all major joints, so this patient is no longer skilled, right?
  • The patient who is newly ambulatory and independent on his fractured hip with weight-bearing as tolerated, but still can’t do stairs because his old stroke has made him apraxic on stairs, is plateaued and no longer skilled, right?
  • The patient who bottomed out his sacrum on his alternating-air mattress and has a Stage 4 pressure injury that is healing and is now a Stage 2, is no longer skilled, right?




The patient with brain damage needs the skills of a therapist to position her and teach the staff and maybe the family on what to look for, how skin-on-skin contact can be detrimental, why turning and repositioning every hour is important (every two hours is pretty arbitrary), and how to ensure that her legs don’t contract into the fetal position. That education can only be done by a therapist.

The patient who’s walking independently with his cane after his hip fracture still needs the skills of a therapist (maybe in cooperation with a speech language pathologist) to work through the apraxia to master the stairs and get back home. Walking independently throughout the building is not a measure of the skilled care he still needs.

The sacral wound that’s healing continues to require the skills of a nurse to measure, dress, and monitor the medication and nutrition of that patient. Education of the staff and the family is still necessary to ensure that the wound doesn’t recur.

Caregiver education is part of the skilling criteria. Whether educating the staff or the family, the education is crucial to improve or maintain the standards that have been achieved. The education must be documented, and it must show exactly the skilling service that was provided.

Wait, what? Did I just say “maintain”?

Per Jimmo vs. Sebelius 2013, maintenance therapy is considered a criterion for skilling when it is documented and exhibited that the patient’s functional/medical status will decline without the service. There is not and never has been an improvement standard for skilled coverage. Does this mean that your claims won’t be denied because all the reviewers are on board? No, but it is our defense when those claims get denied, whether by Medicare, or Medicare contractor.

When defending the claim for skilling, I have often said to the reviewer, “I’m sure you’re aware of the Jimmo vs. Sebelius decision,” and the claim is always defended successfully. Without defensive documentation, your ability to defend the claim may be lost. It’s not enough to say that “wound care was done, dressing changed” without giving measurements, noting granulation and epithelialization. It’s not enough to say “pt walked 100 feet with wheeled walker and supervision” without saying that the therapist intervened for proper foot placement, safe gait pattern, and reminders to avoid objects. 

Our documentation can save lives and allow us to continue our excellent care for our clients. But the skilled services delivered must be documented, along with the patient’s status. Because as we know, if it’s not documented, it didn’t happen.

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