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Q&A: Assistance for Patients Who Aren't Receiving Skilled Services

Question: The issue in our facility is that patients are discharged from therapy and no longer require or receive skilled therapy services but want to participate in exercise and other groups (they are bored and there is no activities program). I am concerned about liability as there is no physician order or oversight when they use an exercise bike, for example. In addition, the rehab manager expects therapists to assist a person who is not in therapy to the bathroom/with toileting since there can be a long wait for a CNA. Should the OT and PT allow patients who are not receiving skilled services to be on the exercise bike or allow them to participate in the skilled therapy groups? Should the OT and PT assist these patients with walking to the bathroom and with toileting?

Answer: It is unusual that skilled therapists would want to perform unskilled tasks and basically substitute for aides or CNAs, thereby allowing the facility to avoid assessing and addressing the true needs of patients who have completed rehab but need/want to maintain their functional gains. There may not be “a law” prohibiting it, but you can certainly get an opinion from your fiscal intermediary and/or the state licensure board. If a patient needs to use the bathroom urgently and a therapist is there, he or she can assist, but this should not be a consistent expectation of the job. If the OTs want to function like aides (e.g., patients receiving skilled and non-skilled services are doing the same thing) there may be future questions about the need for skilled OTs at all.

You are correct that OT treatment requires a physician order. In addition, patients who no longer need skilled services but can benefit from a regular exercise or a group program should continue those activities as maintenance therapy and can be overseen by an aide, as these services are not skilled, nor are they documented or billed. The facility can form small groups or have pairs of patients who are doing the same exercise or activity work together, but separate from patients who qualify for skilled therapy where they must meet objective, measurable goals. The facility potentially has liability for all patients, whether they are in therapy or not: the issue is really what is most appropriate for the patients at their particular stage of function. This is different than walking into a patient’s room and helping him or her in the bathroom prior to or during a therapy session. OTs can design a maintenance program for patients who don’t require skilled services, which CNAs can oversee or carry out. The facility appears to be approaching this from the perspective of saving money and using OTs for non-skilled activities.