The QM, Functional Outcome & Reimbursement Perks of Restorative Nursing Restorative & PDPM

Several months into the swing of PDPM, some facilities are taking a second look at the benefits of restorative nursing programs.  In many cases, facilities may need to develop a restorative program from the ground up, and in others there may be significant opportunities for improvement in the existing program. According to the CMS provider impact file based on 2017 data analyzed for PDPM, more than 50% of skilled days fell into the reduced physical function nursing category.  Notably, those SNF resident days are eligible for restorative nursing case-mix payment end-splits under PDPM. The addition of restorative nursing services, when clinically indicated, not only promotes quality care and drives functional outcomes, but also includes a potential increase in reimbursement.  As represented in the table below, the addition of restorative for the nursing RUG PBC1 changes the RUG to PBC2 and increases the CMI from 1.13 to 1.22.  Respectively, the second table represents an example of the effect on the PDPM reimbursement rate.  In this case example, there was an increase of $9.10/day.  However, as we’ll discuss in this 2-part blog, the additional reimbursement is only one of several reasons to consider a restorative programming refresh in your facility.

Nursing Category Service Function





Restorative Nursing Services (2+)











Restorative Nursing Services (0-1)


11-16 BAB1 0.99



Restorative Nursing Services (2+)


0-5 PDE2 1.57
6-14 PBC2 1.22
15-16 PA2 0.71
Restorative Nursing Services (0-1) 0-5 PDE1 1.47
6-14 PBC1 1.13
15-16 PA1 0.66


PDPM Category Without Restorative With Restorative
PT TJ (1.42) TJ (1.42)
OT TJ (1.45) TJ (1.45)
SLP SA (0.68) SA (0.68)
Nursing PBC1 (1.13) PBC2 (1.22)
NTA NE (0.96) NE (0.96)
Rate $494.22 $503.32


What is restorative?

Before initiating a restorative program, it is important to understand the fundamental restorative requirements.  According to the State Operations Manual, restorative nursing is important for maintaining the “highest practical physical, mental, and psychosocial well-being” for patients. Facility leaders should consider how a comprehensive restorative nursing program can help them reach these goals, given that such a program can maintain or improve a resident’s function, improve quality outcomes, ensure regulatory compliance and reduce costs.

Regulatory Compliance

Functional decline can lead to depression, withdrawal, social isolation, and complications of immobility, such as incontinence and pressure ulcers/injuries. There are a multitude of survey deficiencies related to quality of care related to functional decline that can potentially be mitigated through a strong restorative program. In compliance with regulatory requirements, an effective restorative program focuses on achieving the resident’s highest possible level of function and prevents avoidable declines with physical, mental, and psychosocial functioning while ensuring resident-centered care.

Quality Measures Improvement

An effective restorative nursing program may assist in driving functional improvement impacting quality measures and the Five-Star QM rating reported on Nursing Home Compare.  As we all know, Nursing Home Compare is a publicly available representation of how your facility measures up to other facilities. Strong restorative programming can aid Five Star quality measure scores for increased ability to perform ADLs, reduction of falls with injury, and reduction of pressure ulcers. Depending on the individual resident’s needs, the restorative nursing program may also affect other quality measures including the resident’s ability to maintain or improve independence by helping reduce antipsychotic medication use, incontinence, indwelling catheter use, incidence of UTIs, weight loss, restraints, and pain and depression symptoms.  In contrast, poor performance in these areas can reflect negatively on your organization.

Cost Reduction

While restorative has the potential to impact the nursing component under PDPM and quality of care, it is also important to examine how restorative can potentially reduce costs. More dependent residents require more staff time. Resident successes contribute to both customer satisfaction and staff morale which may foster census stability and staff retention.  Costs related to falls and pressure ulcer care, as well as litigation expenses may be reduced.  According to the Agency for Healthcare Research and Quality, approximate costs for each pressure ulcer may vary from $37,800 to $70,000.  Implementation of restorative programming should be evaluated by your facility with an assessment of factors such as expenses (i.e. staffing, equipment) vs. return on your investment (i.e. optimized outcomes, reduced costs).

Restorative Requirements

Restorative nursing is valuable and essential but only if implemented correctly. The following criteria for restorative nursing programs must be met in order to code on the MDS in O0500:

Restorative Requirements
1.       Measurable objectives and interventions must be documented in the care plan.
2.       Evidence of periodic evaluation by the licensed nurse.
3.       Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity.
4.       A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program.
5.       Does not include groups with more than four residents per supervising helper or caregiver.
6.       At least 2 programs provided 6 out of 7 days for a minimum of 15 minutes per day.


Care Plan

The care plan should include measurable objectives and interventions while being individualized and person-centered.

    • PROBLEM: Restorative is not the problem, the reason for the restorative program is the problem.
      • Impaired mobility related to history of CVA with hemiparesis to right side, complicated by moderate to severe cognitive impairment
    • GOAL: is the task or function the program helps the resident to maintain.
      • Will not develop contractures to right arm, wrist, or hand x 90 days.
    • INTERVENTIONS: the specific restorative program.
      • Passive ROM restorative program to right arm, wrist, and hand 10 reps x 2 sets twice daily.

Nurse Supervision & Evaluation

The restorative program must be supervised by a licensed nurse. The licensed nurse must complete a “periodic” evaluation by reviewing goals and progress toward goals. The evaluation should go beyond a general statement of the resident’s current programs that will continue. The RAI does not define how often “periodic” is, but best practice is to define your facility policy and complete the evaluation at least quarterly with consideration to your state’s Medicaid documentation guidelines for case mix. Consider these factors:

    • Why is the resident on the program(s)?
    • Is the resident participating or refusing?
    • Include equipment used and amount of staff assistance.
    • Lists any concerns, limitations, or barriers.
    • Should the program(s) continue, change, or be discontinued?

Check out part 2 of this blog where we discuss Restorative Training, Performance and Documentation, Staffing and Best Practices


Blog by Kristen Wilkes, MSN, RN, RAC-CT, Proactive Medical Review

Learn more about Kristen and the rest of the Proactive team.