PDPM took away the day-3 alarm on refused therapy

Under RUG-IV, a resident who refused therapy cost you money that day. Minutes dropped, the RUG dropped, the rate dropped with it.

Under PDPM she can refuse for a week and your per diem never moves.

I don't think that made anyone care less. I think it took away the alarm that used to tell you something was wrong on day 3 instead of day 10.

Here's what I see on consult rounds.

Post-op hip, day 2. Therapy comes by. Not today. Day 3, same. Day 4, same. By day 8 there are nine refusals in the chart and someone has written poor motivation in a progress note.

It usually isn't motivation. She came over on a PRN that never got converted to scheduled, and nobody had revisited it since admission.

The way I read that week: days 1 through 3 are your NTA days, paid at three times the rate. PT and OT hold at full rate through day 20 and then start stepping down. She spent the most expensive days of her stay in bed, and the Section GG scores you report at discharge got written during the week nobody could get her up.

The payment signal went away. The cost didn't. It moved to flat GG change and the readmission that turns up in your VBP score four months later.

Your nurses catch this constantly. It's usually a physician-side fix.

If you run a building, pull last month's refused-therapy notes. How many have uncontrolled pain sitting underneath them?