Continue to document the individualized essential details, what the plan is, and what the expected outcome is with the following additions to differentiate the need for Skill in Place:

• Does the Reason for Referral differentiate why the resident is Skilled in Place?
  • “Pt demonstrates an acute decline in…….resulting in……..”
  • Restricted mobility?
  • Social isolation? “Pt is currently socially distancing and isolated d/t COVID-19 restrictions potentially contributing to decline and deconditioning.”
  • Weight loss?
  • Rehabilitation needs?
  • Confusion? “Resident unable to socialize with family and friends within current environment thus placing her at risk for increased depression and confusion.”
• Does the Therapy Necessity specify why the resident is Skilled in Place?
  • “Without therapy, the patient is at risk for increased risk for future falls, a further decline in functional mobility, reduced time out of bed, increased risk for medical complications, increased risk for hospitalization that could potentially expose patient to Covid-19 and a reduction in overall quality of life.”
• Is the resident in isolation? Ensure your documentation includes details regarding treatment and that all activities are being completed in the patient’s room.
  • “Pt currently in isolation in their room due to COVID-19 positive. All activities were completed in their room.”

Reason for Referral Examples that Differentiate

PT-Reason for Referral: Patient referred and screened for PT services following a most recent incident of falling in the bathroom. Patient demonstrates an acute decline in function resulting in difficulty in transfers and gait. Pt is currently social distancing and is isolated d/t COVID-19 restrictions, potentially contributing to decline and deconditioning. Pt presents with LE weakness L>R, reduced overall activity tolerance, impaired standing tolerance and balance, c/o chronic low back pain, diminished sensation to B lower leg, ankle, and foot, and visual impairment impacting ability to perform functional mobility tasks safely.

PT-Therapy Necessity: Therapy is necessary to increase core and LE strength, improve overall endurance and balance, reduce c/o pain, resulting in a minimized risk for falls and increase independence. Without therapy, patient at risk for increased risk for future falls, a further decline in functional mobility, reduced time out of bed, increased risk for medical complications, increased risk for hospitalization that could potentially expose the patient to COVID-19, and a reduction in overall quality of life.

OT-Reason for Referral: Resident referred for OT services by nursing staff due to increased assistance required for ADL and functional mobility due to recent quarantine caused by COVID-19 virus. Pt is currently social distancing and is isolated d/t Covid-19 restrictions potentially contributing to decline and deconditioning. Resident at risk for continued decline in endurance, coordination, balance, and strength affecting safety with ADL task and increased risk for falls.

OT-Therapy Necessity: Therapy is necessary to increase core and UE strength, improve overall endurance and coordination, and increase independence with ADL tasks. Without therapy, the patient is at risk for increased future falls, a further decline in independence in ADL task completion, increased risk for medical complications, increased risk for hospitalization that could potentially expose the patient to COVID-19, and a reduction in overall quality of life.

ST-Reason for Referral: The patient was isolated for an extended period due to COVID-19. This isolation has exacerbated her dementia and increased her confusion about her surroundings. Resident at risk for complications related to medical hx due to decreased socialization. Resident unable to socialize with family and friends within the current environment, thus placing her at risk for increased depression and confusion.

ST-Therapy Necessity: Therapy is necessary to increase socialization and communication with family and friends to decrease confusion. Without therapy, the patient is at risk for increased confusion, further decline potentially resulting in depression and weight loss, increased risk for medical complications, increased risk for hospitalization that could potentially expose patient to COVID-19 and a reduction in overall quality of life.