Who’s watching your In- House Therapy Program?

It is crucial for an Administrator in a SNF to have a competent management team that can assist with successful day to day operations.   From a nursing stand point this team is led by a Director of Nursing but often in a skilled nursing facility, this includes an Assistant Director of Nursing (ADON) along with several nursing supervisors. This vast management team from Nursing allows the Administrator to focus on countless other areas of the facility, knowing they have a competent team from nursing ensuring that resident care needs are being met.

Unlike nursing, therapy generally has only one member of management, a Director of Rehab (DOR), who is responsible for all aspects of therapy management in addition to often providing patient care. This person generally is promoted to this position because they are a good clinician and well-liked by their peers.  They often have minimal to no management training and or experience.  That being said, most therapy team members have little interest in the additional responsibilities involved in taking on this roll.  This leads to concerns regarding: Who is responsible if the DOR is out sick, or on vacation? What if the facility has an inexperienced DOR, or worse yet an incompetent DOR? Who in the organization is overseeing their work, ensuring that therapy is addressing the clinical, financial and regulatory aspects of the therapy department?

When an organization decides to utilize an in-house therapy model there are usually good reasons, ranging from financial considerations, to service-related issues with their contract therapy provider. However, unless an organization is large enough to appoint someone with therapy experience to oversee therapy at a corporate level, therapy is often left with limited oversight and management. An experienced DOR certainly can be trusted to run the therapy department, however, that does not absolve a NHA of responsibility for making sure therapy is performing satisfactorily.

Successful operation of an In-House Therapy Program requires managing, monitoring, and accountability.  Here are some key aspects of therapy that any Administrator or other corporate leader should monitor on a regular basis.

Financial Impact

  • Staff Productivity -below average productivity can cost thousands of dollars a year in added labor costs.
  • PRN Utilization – poor productivity or labor management can lead to an overuse of PRN staff which costs more on an hourly basis.
  • Wages – in-house programs often end up hiring staff at higher than market wages because of inefficient recruiting processes. HR should follow best practices for recruiting therapist, set a competitive range for salary and then monitor.


  • Patient Outcomes – the focus should be on trends rather than individual patients and how outcomes might be impacting admissions.  Delivery of care in relation to outcomes should also be monitored to ensure that there is not an over or under delivery of care to meet the patients’ clinical needs.
  • Length of Stay – this is particularly important when you have hospital partners that are participating in bundled payments where this is a big focus
  • Patient and Family Satisfaction—Word of mouth is an important referral source.  What are patients saying about your therapy program when they leave the facility.
  • Clinical Competencies—Do any of your therapists have certifications that should be marketed to increase referrals or is there a clinical skill deficiency that needs to be addressed in your therapy team to better meet the needs of your patients.
  • Long term Care Needs—Does your DOR have a process for monitoring and addressing changes in condition and/or function of your long-term care residents?
  • Communication- Does your DOR communicate effectively to the facility (nursing, DON, MDS) clinical changes or needs of the patient.


  • Documentation Audits – the DOR should regularly review the quality of the documentation to ensure that there is justification to support the therapy services being delivered and provide a written report with feedback regarding the findings.
  • ADR Request—Are you receiving any?  What is the process? What is your facilities success rate?
  • Billing Practices—Is your DOR monitoring for accurate billing and providing education on a regular basis regarding compliant billing practices.
  • Regulatory Changes—Does your DOR have a process of monitoring and implementing any regulatory changes that impact the delivery of therapy services.
  • Monitoring- Does your DOR closely monitor that patient treatment frequencies are being met as written in the orders? Are they monitoring for timely completion of recertifications, progress notes, and 10th visit notes?


Therapy plays an important role in driving resident and family satisfaction along with a facility’s reputation within the community. Given the importance of therapy it is critical that management at the facility and corporate level provide regular oversight of the clinical, financial and regulatory aspects of therapy. Nursing home administrators and other management should have a checklist of items that are regularly reviewed to ensure success of therapy.