6.2 Vague daily-skilled need (the homebound-replacement failure)
The daily-basis rule
Coverage under Chapter 8 requires a skilled service needed on a daily basis that, as a practical matter, can be provided only in a SNF. “Continues to need skilled nursing” is the SNF equivalent of the home-health “remains homebound” failure — a conclusion with no evidence and no daily basis. Each day’s note must show a skilled service was required that day.
Before — does not survive
Resident continues to require skilled nursing. Will continue to monitor.
After — survives
Skilled nursing required today to assess a resolving aspiration pneumonia and titrate O₂ within the ordered parameters: RR 24, SpO₂ 90% on 2 L (vs 88% this morning), coarse right-base crackles decreasing. Bronchodilator given per order with reassessment (SpO₂ 90→94%); aspiration precautions reinforced at meals. Daily skilled observation and titration required because of the potential for rapid respiratory change, available only in this SNF on an inpatient basis. Ties to the care-plan respiratory goal; supports the Section O oxygen day.
