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    APTA Comments on CMS Proposed Polices for Skilled Nursing Facilities

    On Monday, June 27, APTA submitted comments to the Centers for Medicare and Medicaid Services on the Skilled Nursing Facility (SNF) Fiscal Year (FY) 2012 proposed rule. In the proposed rule, CMS seeks to make significant payment cuts to SNF payment amounts and to substantially revise the provision of group therapy, the completion of therapy assessment requirements, and policies governing student supervision.

    In its comments, APTA recommended that:

    • CMS delay its large cuts to the SNF PPS and conduct further analysis of RUG-IV claims data
    • Rescind its proposal to narrowly define group therapy as 4 patients, revise its proposal regarding the allocation of minutes for group therapy, and reexamine the 25 percent limitation on group therapy
    • Remove line-of-sight supervision for therapy students and clarify levels of student supervision in the RAI manual
    • Revise, clarify, provide more information, and/or conduct further research on its proposals concerning therapy assessment requirements
    • Revise, clarify, provide more information, and/or conduct further research on its proposals concerning therapy assessment requirements

    Concerning the therapy assessment requirements, APTA seeks better flexibility and less redundancy for SNFs’ requirements to complete Other Medicare Required Assessments (OMRAs) for Start of Therapy (SOT), End of Therapy (EOT), End of Therapy-Resumption (EOT-R), and Change of Therapy (COT). APTA specifically called for withdrawal of the proposal for COT OMRAs, requesting instead further analysis of the situations that CMS raised in the proposed rule to come up with a more appropriate and less burdensome requirement.


    Comments

    There are several problems with the current format including the minute rule and exclusivity requirements.A physical therapist is entirely capable of treating more than one patient at a time effectively and ethically. Th impact of the new guidelines have placed more limitations on patients, therapists and organizations. It does not appear that the "rulemakers" really understand how an exceptional therapist is able to be effective, ethical and productive. The end result is that patients are effected the most
    Posted by Jeff Parks MS,PT on 6/29/2011 1:28 PM
    Having worked in skilled nursing for more than17 years I feel I have a good overview of what has occurred and what is occurring in the SNF setting. The current rules are often quite detrimental to our patients. The very fragile, medically compromised patients often gain much more from a theapy session that can be slower paced and spaced out over more time with MANY rest breaks. i.e. a. 30 or 45 minute tx. spread out over 60 or 90 minutes for two low endurance patients is often the best and most effective pattern. With the current rules and the current high productivity requirements this option is no longer available as a tool for treating therapists. This is a disservice to our clientel.
    Posted by Anne Cunningham on 7/2/2011 1:37 PM
    I have recently graduated as a PTA from St. Catherine's University in Minneapolis, MN. I am currently seeking employment as a PTA in a SNF environment. Many of my "clinical experiences" during school were in the SNF environment. My opinion is that there can definitely be effective treatment(s) of more than one patient at a time. Certainly planning of activities and treatment(s) is required - but my ability to perform this, even at my initial experience level, is quite "do-able". I am aware of, and have observed,experienced PTs or PTAs performing this effectively while remaining within the scope of regulations. I would ask a question regarding this "format"...why would it NOT be ethical and effective? If patients can be treated effectively, timely, and within the parameters of the SNF timing/scheduling requirements, it should be encouraged rather than disencouraged. There are many benefits from this that people may seem to overlook. Please allow us to become decision makers, within the prescribed format, rather than promulgation followers. We are intelligent people. We do not make decisions at random, nor should we be subject to additional legislation which limits our decision making ability. We care about our patients. We want to do the best we can for ALL of them. If we didn't, we would not be in this field...
    Posted by Paul Marinello on 7/2/2011 8:43 PM
    I have worked in SNF settings for almost ten years and the majority of therapists I have worked with are more than capable of working with more than one patient at a time. Currently, the SNF I am affiliated with has low level patients, many with dementia and cognitive deficits limiting their ability to participate in group sessions. These types of patients do much better with one-on-one treatment in order to enable them to focus on task. CMS is putting these stringent rules on our organizations and ultimately on the therapist to come up with "excuses" to have group sessions when they are totally inappropriate. We are being forced, in a sense, to babysit groups of demented patients who are not getting the benefit of group treatments which would be more beneficial to patients in an orthopedic rehab setting. Someone needs to look at the whole physical therapy practice and the differences in healthcare settings.
    Posted by Barbara Boetsch, MSPT on 7/4/2011 4:21 AM
    Simple fix, just penalize SNF's that are abusing the system. The red flags are easy to see. Also if PT's in these settings limit their caseloads to the truly medically, skilled therapy appropriate patient, overutilization would not be such a concern of the federal government. The overregulation of SNF's primarily hurts ethical therapist who will have to jump through the hoops while unethical therapist will continue to ignore them without much fear of retribution.
    Posted by Shonda Hazel on 7/4/2011 8:32 AM
    I am with you Shonda...its is easy to see which of these SNF, rehab companies & therapists are "bleep" the system. Seen it too many times & in fact acted on it to no avail. It is an aggressive cancer we are fighting & sadly, even with these changes they are making, its still spreading....and you know why...these entities are blinded with the thought of either being invisible or protected. After all, they are overlooked by the SNF & rehab staffing management so as long as they are productive in paper. Most sad to note is that recent graduate therapists I have met are more adaptive to the wrong ways, feeling that this is the way of the therapy world. Much can be said & must be done. Let's start with truly penalizing the very people who's caused all these problems...and let's start it with the bigwigs & not the small fishes. Small fishes are easier to scare when they see that the "used to invulnerable" are penalized.
    Posted by C. R. Sasedor on 7/4/2011 4:09 PM
    Since my last post, I have resigned from working the SNF and moved on. The company I worked for as the only Physical Therapist was "encouraging" me to justify Medicare B patients continuation on therapy. There became that fine line of "an ethical dilemma" when, after all the Medicare B payments were exhausted, my demented patients were then placed into Hospice care and rarely lived more than another few weeks. I resigned! SNFs can be a terrible environment in which to practice with a clear conscience.
    Posted by Barbara Boetsch on 7/6/2014 5:07 AM
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