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9 Things to Consider Before Working in a Skilled Nursing Facility

If you’re a new therapist considering working in a skilled nursing facility (SNF), there are several important factors to look at before taking the job.

While there are great skilled nursing facilities to work for, there are also many facilities that can challenge ethical boundaries and take advantage of new graduates.

Because this is more common than not, I wanted to provide you with a list of what to look for during the interview process to ensure you’re working in an ethical facility. Working at an ethical facility will not only be the safest option for your license and career, but will also greatly reduce burnout.

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Without further ado, here is a list of 9 things to consider before working in a skilled nursing facility.

1. What are the productivity requirements?

Productivity is a fact of life in pretty much all occupational therapy settings. However, not all settings are created equal, and skilled nursing facilities are well known to have the highest productivity standards across all settings.

It’s not uncommon to see facilities with contracted for-profit rehab companies with productivity requirements of 85%-90% for OTRs and 95-100% for COTAs. These are unrealistic expectations given the amount of paperwork therapists have, plus any typical day to day tasks that are non-billable, like talking with staff, doctors, helping another patient out, etc. Not to mention being able to actually take bathroom breaks.

To stay sane, I recommend looking for an ethical SNF or company with productivity standards of no more than 80% for OTRs and 85% for COTAs. These positions may be hard to come by, but they do exist! If the expectation is considerably higher than this, beware!

2. If you’re a new grad, will you have a mentor?

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Many new occupational therapy graduates begin their career working in a SNF setting. You will definitely get a lot of experience working with a multitude of diagnoses and caseloads. If you’re a new grad, I recommend you have a mentor when you first start out working in a skilled nursing facility.

This is because working in any rehab setting is hard for new grads while they get their bearings. Having experienced occupational therapists and COTAs to bounce ideas and questions off of is so crucial for new clinicians.

If you’re thrust into a SNF setting without any support or other OTs, you are already at a disadvantage at the start of your career. From personal experience, I highly recommend the SNF you are considering has multiple other occupational therapists to help you in your first years.

3. What is the patient population?

If you’re interested in working with a certain patient population, like neuro or orthopedics patients, you can inquire about the general rehab population you’ll be working with.

You can also find out how many long-term Medicare Part B residents are typically on caseload.

4. Do your research on the company.

Again, not all SNF/subacute rehab companies are unethical and fraudulent! That being said, some for-profit companies have chosen to go the unethical route and have been sued for fraudulent practices, namely pressuring therapists to inappropriately bill for therapy.

Be sure to do a simple Google search of the rehab company you’re interviewing with to see if they’ve had legal action taken. If so, be very wary of working for them. It’s not uncommon for large rehab companies to continue fraudulent practices even after being sued.

You can also look up the SNF’s quality rating and results of your last state survey.

5. Shadow therapists in the SNF before taking the job.

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This one is key: Management may not cover everything during the interview, so when you are able to shadow for at least 2 hours you can really get a feel for how the job is going to be.

This will also give you time to talk with current therapists and COTAs about how they like the facility. You may get some good insight on how employees feel about the setting, particularly the productivity and management.

6. Find out what the policy is for low census.

Low census in any setting can be a problem for getting hours (and paid!), especially if the census stays low.

Generally, if caseloads are low, they pick back up, but you will want to know where you stand with hours and pay if the caseload stays low for more than a few days or weeks. For example, will you have to take off and use up your PTO? Or are you guaranteed full time hours if you’re hired on as full time?

Ask if there will be other facilities that you can float to when there is nothing for you at your main facility. How far are these other facilities and how many are there for you to choose from?

Also, will they expect you to pick up long term residents for (sometimes) inappropriate therapy services or keep rehab patients on caseload longer than is appropriate? This is something you’ll want to ask the other therapists as managers might not be as upfront with you on this.

7. Is therapy in the SNF in-House or contracted out?

When applying for your SNF position, you will also want to find out if the rehab unit is “in-house” versus a contracted company. Many therapists prefer in-house therapy units when working in skilled nursing facilities since this can means less ethical dilemmas than the for-profit contract companies.

If the rehab company is contracted, find out how many companies have been in the SNF. A lot of turnover is a bad sign and is risky for job security as well. Either way, as mentioned above, be sure to research the company for negative reviews and lawsuits.

8. What is the Therapist (OTR) to Assistant (COTA) ratio?

If you are an OTR, especially a new grad, it’s important to inquire about the therapist to assistant ratio. Meaning, how many COTAs will you be supervising? A low ratio is ideal but may be higher depending on the facility and state requirements.

Keep in mind the higher the ratio, the more difficult it is for OTRs to meet productivity requirements. More COTAs equates to more paperwork demands for OTRs.

If you are an OTR with a high COTA ratio, you will likely be doing mostly evaluations, progress notes, and discharges with very few treatments.

9. What are the benefits (if applying for full-time)?

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Once you’re offered a position (if full time), the main benefits to inquire about include health insurance, paid time off (PTO), holiday pay and requirements, and retirement contributions.

Some companies also might offer continuing education options and reimbursement as well as tuition reimbursement.

Keep in mind if you are applying as a PRN (as needed) therapist or COTA, you will not get these benefits but instead will get a higher hourly rate.

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This post will hopefully give you a good idea of what to look for when looking to work at a reputable SNF.

Remember, not all SNF’s are inherently “bad,” but you have to do your due diligence to make sure you have a positive career experience.

I want to thank the super helpful therapists of the following Facebook groups: the Geriatric OT, PT, and SLP Collaborative Group and the OT4OT group for their input and contributions for this post. I highly recommend checking out these groups for further insight on working in a skilled nursing facility!

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