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Competency Checklist for SNFs

Competency Checklist for SNFs

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Competency Checklist for SNFs

Do You Have What it Takes?


Often, it is not simply a list of credentials that will get you the position at a skilled nursing facility--it could be your motivation and attitude as well

Not everyone is cut out for the life of a therapist in a skilled nursing facility (SNF), and the unique challenges it holds.

"I think SNF therapists are some of the most creative and versatile professionals I've met," said Bob Thomas, MS, PT, director of ancillary services at Avamere Healthcare, which owns and operates SNFs and assisted living facilities in the Pacific Northwest.

Because of the complex nature of the SNF, directors often find it beneficial to compile and reference a competency checklist to ascertain whether an applicant has the professional expertise and emotional make-up to match the responsibilities they'll face in the SNF.

The Skilled Nursing Facility
By definition, a SNF is an institution, or part of an institution, that meets criteria for accreditation established by the Social Security Act. SNFs provide daily care that is a continuation of care begun in the hospital, and must be rendered by or under the supervision of professional personnel such as a PT or registered nurse.

In July 1998, the SNF Prospective Payment System (PPS) was implemented nationally by the Health Care Financing Administration (HCFA). Health care providers record the number of minutes of rehabilitation and nursing services on the Minimum Data Set (MDS) to classify patients into Resource Utilization Groups (RUGs). The RUGs breakdown determines the SNF's per diem payment reimbursed by the Medicare program.

While HCFA does not directly dictate a precise skill set for all SNF therapists, state practice acts and clinical guidelines such as the APTA's Guide to Physical Therapist Practice will influence a facility's competency checklist, Thomas explained. Federal and state survey guidelines force physical therapists to focus on areas of practice that often are unique to this setting, such as restraint management and contractures.

The Competency Checklist
Mike Koestler, senior recruiter at Paragon Rehabilitation Services, Nashville, TN, references a checklist devised by Paragon's clinical department to provide onsite PTs, OTs, SLPs and rehabilitation coordinators on a contract basis to SNFs across the country.

Paragon's checklist is broken down into three areas, which rates a therapist's skill level at varied tasks on a scale of one to five:

  1. Objective testing;
  2. Documentation;
  3. Treatment.

"I've been doing this long enough that I don't need it in front of me during an interview," said Koestler, who will keep a therapist's skill sheet on file until a rehab coordinator contacts him with an opening. After selecting an appropriate candidate, Koestler will refer him or her to the facility, which will likely have a more site-specific checklist of its own.

"Each director will have his own idea of what they want in an applicant," Koestler said. "The objective skills are pretty straightforward, but more subjective criteria may change from facility to facility. What an SNF is looking for in a PT today can be completely different from what they're looking for six weeks from now."

"Each SNF should profile their patient caseload," added Sheri Bjork, MBA, PT, president and CEO of JS Consulting, Tyler, TX. "After a facility has profiled the caseload, they should advertise and interview each therapist on their competency related to the profiles. Once the therapist is hired, it is up to the facility to establish a baseline competency checklist, utilize the checklist in the orientation process, then assist the therapist in updating their skills, if needed."

Objective Testing
Under Paragon's "objective testing" heading are such skills as muscle testing, goniometry, functional activities, and analysis of posture, gait and balance. Applicants are asked to rate their proficiency in gathering relevant information related to seven variables: strength, ROM, mobility, sensation, posture, pain control and skin integrity.

Another section asks for a PT's aptitude in analyzing technical, standardized, criterion-referenced and descriptive data to make evaluative decisions. Ability to identify symptoms, medical conditions and medications impacting the seven measurements outlined above is rated, as is the ability to interpret exam findings.

An ability to properly construct and maintain patient records, case histories, evaluations, plans of care and other forms of documentation is an essential component of a SNF therapist's repertoire. This makes up the second section of Paragon's checklist.

Recent changes in the Medicare environment have magnified the importance of this skill even further, Bjork explained. "The difference in today's environment is that it is being reviewed more frequently. With reimbursement getting tighter, the review process allows payment to be delayed and denied based on the documentation."

She added that the denial process within Medicare is three tiered-technical, statutory and coverage-and that inaccurate and/or unskilled documentation can flag a denial.

"[Documentation] is absolutely essential, and probably one of the most challenging aspects of practicing in the SNF setting," Thomas said. "Our documentation, to a large extent, dictates whether we get paid for our services. Understanding the Medicare review process, Medicare regulations and the appeals process is helpful in guiding a therapist toward good and appropriate documentation."

Koestler agreed. "In talking to rehab coordinators, a keen ability to document and keep records comes up time and again as something they particularly look for," he said. Paragon's section on documentation examines a PT's prior experience in evaluation, case histories, plans of treatment, progress notes, discharge and home visit summaries.

"Our documentation systems and expectations may also vary depending on the patient's payer source, which provides an even greater challenge," said Thomas. "As a result, I find SNF therapists know more about reimbursement and Medicare because they are forced to work directly with these issues on a day-to-day basis."

Paragon's third section includes clinical skills a PT might rely on in any setting, from modalities (ultrasound, e-stim, TENS) to massage, paraffin bath, whirlpool treatment, debridement and therapeutic ball exercise.

"From a treatment perspective, the work is not too much different than what they'd do in the clinical setting," said Koestler. "You're dealing with a different patient profile, to be sure, but the core responsibilities stay constant."

"Some clinical areas that are a large focus in the long-term care population include range of motion, skin integrity, wheelchair seating and positioning, management of falls, and fabrication of splints and other adaptive equipment," added Thomas, who oversees rehab operations, the home care division, and temporary nursing staffing at Avamere. Ambulation and swallowing safety are other skills that SNFs may desire in therapists who are treating an older and more enfeebled patient base.

While Thomas does not work from a set checklist, Avamere's rehab division has developed clinical protocols for specific patient populations, outcomes tracking systems and continuing education for therapists in areas specific to the SNF. Managers mentor therapists in areas where improvement is needed.

"Being comfortable with patients who have dementia is also a necessary skill, as so many of our population may be at some stage of cognitive decline," Thomas said. "The number of co-morbid conditions that our patients have provides another level of challenge."

"Although most therapists have the basic skills to provide good therapy," he continued, "we focus most of our training efforts in the areas of documentation, reimbursement, survey guidelines, clinical areas such as dementia care and wheelchair assessment and being flexible and adaptable."

Bjork agreed. "The use of physical modalities such as ultrasound, electrical stimulation, etc., are adjunct to a treatment plan to facilitate a functional outcome," she said. "The documentation process in the use of physical modalities to facilitate a functional outcome is the important factor."

Working with an older and often sicker population has its rewards, but is not without its downside. Emotional hardiness, then, is another desirable trait for SNF therapists.

"People can die on you, plain and simple," said Koestler, who recalled one PT who called him to resign after four patients under her care had died in the prior week. "They're working with a patient profile that they may not have experience with. We will try to give applicants as clear a picture as possible so they know what they're getting into."

Because of this attention, instances in which therapists are disillusioned about job functions are rare, Koestler said. Although he contracts for a carefully selected group of quality nursing homes, he realizes that the stereotypical short-staffed and depressing nursing homes still exist, and staffing them is difficult.

The upside, said Koestler, is seeing the end result of your hard work. "In long term care, therapists get to work with patients on a much longer basis than acute or subacute care, which may only last a matter of days," he said. "Here, the therapist has the luxury to set long term goals, and to see them realized. After that a new set of goals can be devised."

Subjective Qualities
Often more important than a compiled skill set is a therapist's willingness to add to it, by agreeing to be mentored or by attending continuing education programs. Bjork said that a therapist's accredited education and state license provide an adequate baseline for most of the challenges they'll face in the SNF.

And the condition of this education is improving all the time, Thomas noted.

"I believe universities are doing a much better job than when I attended PT school eight years ago in teaching students about skilled nursing facilities, geriatrics, and documentation and reimbursement issues," he said.

"It disturbs me when I hear some professionals say therapists in SNFs are not as skilled as in other settings," he continued. "I believe the exact opposite. Many facilities are under-funded, under-staffed, and have minimal equipment, which forces us to be creative in our treatment planning and clinical practice."

Koestler agreed, adding that a PT should not let a substandard skill-set deter him from seeking a position in an SNF.

"For the most part, the training they've received allows them to function on the job," Koestler said. "It's usually the attitude that will get them the position, not necessarily their training and experience. If they're motivated to learn, and the basic training is there, rehab directors have no problem teaching specialized skills to that person."

Jonathan Bassett is on staff at ADVANCE, and can be reached at


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