Skill in Place Considerations

By Kelly Alvord, Therapy Resource – Sunstone

Goal of the Waiver: To keep beds open at the hospitals for more critical patients

Three things to consider to skill in place; however, please refer to our Ensign Affiliates Skill In Place Tool Kit that is available on the Portal for more detailed guidance:

1. Did the episode or change of condition occur after March 1, 2020, when the waiver went into effect? We are getting further away from this date, so this isn’t going to be as relevant.

2. Does the patient need Daily Skilled Services? 7x/week of Nursing Services and/or 5x/week of Therapy Services. This hasn’t changed for Medicare Daily Skilled Criteria. Therefore, keep in mind what is medically necessary to meet Medicare Part A criteria to assist you in determining if the resident is appropriate to be Skilled in Place.

3. Qualified Hospital Stay Considerations impacted by the COVID Emergency (keeping the hospital beds open)

● Bypass/skipping the hospital for bed access or to avoid exposure to COVID

o In the past, would we send or the provider send the patient to the hospital due to the change of condition? This needs to be an IDT discussion with the ultimate decision made by the physician. (See additional questions and considerations below.)

● Signs of or close exposure to COVID
o Are we isolating the patient and nursing is providing daily skilled care to assess the patient due to COVID, whether or not the patient has been tested positive to COVID?
o If we are waiting for the COVID test results, use the Med Dx of R09.89 and Z20.828.
o If the patient has a positive test or physician has diagnosed the patient with COVID, use the Med Dx U07.1 (only if the date of the test results or diagnosis is after April 1).

● Dislocation due to COVID
o Facility to Facility transfer due to the COVID emergency
o Caregiver Breakdown. Patient unable to stay home due to caregiver being exposed or positive for COVID.

Here are additional questions and things to consider:
Q: What if it’s already our practice to provide high acuity, daily interventions in order to avoid the hospital? Can we still apply the waiver?
A: Yes. The fact that you already have the necessary skills and policies does not preclude you from applying the waiver when the goal of those services is to avoid hospitalization.

Q: How can we tell if what we’re doing is routine, or applicable to the 3 day QHS waiver?
A: The decision is ultimately up to the physician (who must then write the order to initiate a skilled level of care). Collaborate with the attending doctor to reach a decision about whether the patient’s circumstances are impacted by the emergency as required by the waiver.

Final note: Many needs may arise due to decreased out-of-room activity, decreased community access and isolation from families. While these are emergency-related and should be treated, initiating a skilled stay requires that the needs rise to the level of requiring daily skilled interventions, and documentation must incontrovertibly support this. Most of these needs are properly managed with less than 5-7x/week interventions, and frequency should not be inflated in order to artificially justify a Part A stay.

Keep in mind that the skill in place process is new and has many factors to take into consideration. We have many resources available on the portal; please click on this link to take you to our Ensign Affils SIP Took Kit on the portal:

Your MDS and Therapy Resources are ready to help!