Physical, occupational, and speech therapy services are vital in skilled nursing facilities (SNFs) for resident recovery, rehabilitation, and quality of life. However, beyond achieving clinical outcomes, therapy departments must navigate a complex landscape of regulatory requirements and compliance standards.
Failing to align therapy services with these regulations can potentially lead to survey deficiencies and denied reimbursement.
This second article explores (Click here for Part I) some ways to integrate best practices to ensure regulatory compliance of your therapy team.
Best Practices For Regulatory Compliance of Your Therapy Team
1. Conduct Audits
- Establish regular chart audits to assess therapy documentation and compliance.
- Use audit tools that are aligned with CMS survey protocols and Medicare Administrative Contractor (MAC) expectations.
- A third-party audit can provide an objective overview of regulatory standards and provide other insights to risk areas.
2. Strengthen Documentation Standards
- Document therapy goals, interventions, and progress using clear, measurable language.
- Assure documentation meets CMS or other payors’ guidelines for coding and billing (using Local Coverage Determination from a MAC, for example)
- Ensure all sessions justify skilled intervention under Medicare guidelines.
3. Monitoring KPIs
KPIs related to therapy compliance may include:
- Length of stay
- CPT accuracy based on skilled notes
- Total minutes treated
- Mode of treatment documentation support
- Orders and Certification accuracy
- Section GG audit
4. Foster Interdisciplinary Collaboration
- Conduct regular care plan meetings that include therapists, nursing staff, and physicians.
- Review therapy goals and progress with the care team to ensure continuity of care.
5. Invest in Ongoing Staff Training
- Provide routine training on documentation requirements, PDPM updates, and CMS changes.
- Use case studies and real-world examples to reinforce learning.
Maintaining therapy compliance requires a thorough understanding of the regulatory landscape in today’s complex healthcare environment.
Create a thorough audit plan for review and audits, and work with the entire team to create a performance improvement plan (PI). An external therapy audit can be an integral part of a comprehensive compliance plan. Blue & Co. will complete audits, review findings, and provide training and education to staff as part of an improvement plan.
Blue & Co. offers a team of highly knowledgeable consultants dedicated to supporting your Post-Acute Care needs. Whether you require assistance with Therapy Operations, Clinical Reviews, Payroll-Based Journal (PBJ) reporting, 5-Star ratings, regulatory surveys, Value-Based Purchasing (VBP), or MDS support, our experts are here to help. Please contact a member of our Post-Acute Care team below or reach out to your local Blue & Co. advisor for personalized guidance.
Landon Hackett, CPA, MSA, Director
Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, QCP, Senior Consultant
