Declaratory Statements - Ethics

1. Ad for Annodyne Free Screen - Please clarify if a physical therapist can offer a free evaluation or screening and consulation in a newspaper ad for infared light therapy to persons with diabetes. Evaluating the person would allow the physical therapist to assess if they are a good candidate for infrared light therapy. If so, the patient could follow up with their physician and attain a prescription so treatment could begin.

   The Louisiana Physical Therapy Practive Act allows for screening and evaluation without referral. You would not be in violation of the Practice Act or Rules and Regulations in the situation you have described.

2. Marketing - Flat Fee - Is it allowed under the Louisiana Physical Therapy Practice Act to pay an individual a flat fee for marketing physical therapy services to a potential referral source?

   Solely for purposes of this response, the Board must make certain assumptions regarding the wording of your question. The "individual" as referenced by you can not legally be a referring practitioner, his relative, or business associate as clearly prohibited by the Physical Therapy Practice Act and the Board's Rules. Futhermore, the "flat fee" is assumed to mean a salary or hourly paid employee or independant contractor, and not a charge for or amount paid per patient or service rendered. Additionally, the Board is of the opinion that the salary or hourly flat fee is based on a resonable value for the locale or geographical market of the referral source.

   Again, the Board's response is limited to the assumptions stated herin. In the even these assumptions are incorrect, the Board reserves the right to amend this opinion. With that stated, the Board is of the opinion that the scenario as referenced in your letter is not in and of itself a violation of the Physical Therapy Practice Act, the Board's Rules or the Code of Ethics.

   Additionally, the Board's Response is limited to the Physical Therapy Practice Act, the Board's Rules and the Code of Ethics which are primary tools the Board uses to regulate the physical therapy industry. Please be advised that if other laws, whether Federal or State, are violated by your proposed business scenario, your license to practice physical therapy would be subject to sanction by the Board after due process rights were satisfied.

   Futhermore, as per our conversation, a physical therapist must comply with the Physical Therapy Practice Act, the Board's Rules and the Code of Ethics in the provision of physical therapy services to patients. In other words, should you persue a marketing/referral source which complies with the law, you are still obligated as per your license to practice physical therapy within the minimal standards of acceptable and prevailing practice, such as evaluation, referral, documentation, supervision, etc.

3. Patient Abandonment - Indigent - Is a PT required to treat indigent patients? If so, does that PT face potential patient abandonment?

   It is the Board's opinion that you are not required to establish a relationship with a patient if, in the business screening and financial intake, the patient had no third party payor and no ability to pay privately. If you establish a relationship with the patient by performing an initial evaluation, your treatment plan must be based on the evaluation findings and the patient's functional needs. The treatment plan should not be based on his ability to pay. Once you have reviewed the treatment plan with the patient, and if the patient voices his inability to pay for the services and therefore refused the treatment plan, you may offer less expensive options. This may include a home program, if appropriate to the diagnosis. All of this must be documented and copies sent to the referring physician.

4. PT Caseload - I am a PT currently working part-time for a nursing home. Our area manager told me about a concern regarding PT caseload. Here is an example: We, PTA and me, have a total of 10 patients which consists of three Part A Medicare patients being seen 5 times a week, 7 Part B Medicare patients all being seen 3 times a week except for one being seen 5 times. In our productivity report we have to count how many visits we do on a daily basis. Since we don't see all our patients on caseload everyday, the number of visits change daily and is not constantly 10. Today, our area manager told us that we have to report 10 visits a day. I explained to him we don't see all the Part B Medicare patients everyday but 3 times a week. He insisted that we count 10 patients daily for the reason of report writing to the owner/management company of the nursing home. I told him my position that I will only count the patients that I have seen daily. My question is, is this legal and what is your opinion on this matter?

   In carefully reviewing the inquiry, the Board is of the opinion that you may only report and/or bill for what is actually performed. Therefore, for you to falsely provide information in a productivity report would violate the Physical Therapy Practice Act and the Board's Rules. More particularly, Section 2413A(7) provides that a physical therapist or physical therapist assistant may be sanctioned by the Board if found guilty of unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practice, in which proceeding actual injury to a patient need not be established.

   Additionally, Rule 327E promulgated by the Board defines unprofessional conduct to include: 3. Making or participating in any communication, advertisement, or solicitation which is false, fraudulent, deceptive, misleading or unfair, or which contains a false, fraudulent, deceptive, misleading or unfair statement or claim; (Emphasis added.) . . . 6. Abuse or exploitation of the physical therapy-provider-patient relationship for the purpose of securing personal compensation, gratification, or benefit unrelated to the provision of physical therapy services.

   Furthermore, Section 2413A(l) of the Practice Act also provides that a physical therapist's and/or physical therapist assistant's license may be suspended or revoked, or otherwise disciplined, upon proof that the licensee practiced physical therapy in violation of the Practice Act and the Board's Rules and Regulations. In summary, a physical therapist and/or physical therapist assistant may be sanctioned by the Board for reporting and/or billing for services not rendered, or falsely, reported. Additionally, you may not render any treatments which the patient's condition does not warrant for the purpose of meeting productivity standards.

5. PT / OT treatment simultaneously - Question 1) Can I treat an OT patient and PT patient at the same time? For example, walk with one patient while the other is performing UE therex? Question 2) Can I treat one patient for OT and PT in the same time period, ensuring that they still get 1 hour of each? Or treat the same patient for OT and PT but at different times during the day? (still getting 1 hour of each) Question 3) I have been given different answers for this question from different PTs: What treatments are a PT tech legally able to perform under my direct and indirect supervision? For example, is it possible for the PT tech to assist a patient with gait training or therex while I'm assisting with dressing (OT) in a seperate room with a different patient?

   Response to Question 1) Yes, you may act as a PT with one patient and an OT with another patient as long as you comply with all requirements for documentation and supervision of support personnel for each type of service you provide.

   Response to Question 2) As a single person with both PT and OT qualifications and licensure, you can provide skilled PT and/or OT services during a single treatment session, or in separate sessions. You must document the distinctive skills you provided as two seperate progress notes or distinguish them in a single note. You cannot claim or bill double time for your session. The time you spent in a combined session must be split into the amount of skilled treatment for each specialized area.

   Resposnse to Question 3) You may utilize a PT aide/technician to assist you in your PT treatment plan on a limited basis. Please refer to the Board's Rules and Regulations (in your gray book) for supervision requirements. In Section 305.A. please see definitions for: * Continuous supervision, * On premises, * Physical therapy supportive personnel a) PT aide/technician - a worker not licensed by this Board who functions in a PT Clinic, Dept. or Business and assistants with preparation of the patients for treatment and with limited patient care. c) level of responsibility assigned to PT supportive personnel is at the discretion of the PT, who is ultimately responsible for the acts or omissions of these individuals. Supportive personnel may perform only those functions for which they have documented training and skills. The physical therapist shall only delegate portions of the treatment session to an aide/technician only after the therapist has assessed the patient's status.

   You must also be aware of billing limitations by various government and private payors. Some payors only pay for services provided by a licensed PT or PTA. Since the Board does not make or enforce billing issues, you should research this through your Business Office or the payors themselves.

6. Product Endorsement - Where does the Board stand on physical therapists endorsing products that they recommend to patients? The clinic is writing a column for a new web site and would like to sell 2-3 of the products they recommend most to patients for the general public (eg. Theracanes, massage oil.)

   The Board is of the opinion there is no prohibition in the Physical Therapy Practice Act or the Board's Rules regarding your proposed recommendation to patients with regards to Theracanes, massage oil, etc. It is highly suggested that you contact other regulatory boards which may have jurisdiction over certain items that you are recommending to patients. For example, the Louisiana Board of Pharmacy regulates certain over the counter items. as well as the Louisiana State Board of Examiners in Dietetics and Nutrition. Additionally, please keep in mind that any form of advertisement is subject to Rules with regards to fraud, abuse and/or deceptive practices.

7. Rules/Code of Ethics and Guides for Professional Conduct - Should licensees be ethically obligated to file complaints against individuals allegedly violating the Physical Therapy Practice Act?

   It must first be noted that the Act is a law which is enacted by the State Legislature. Pursant to the Act, the Board has the authority to promulgate a Rule in order to implement the provisions of the Act. In doing so, the Board adopted the Code of Ethics, Guides for Professional Conduct and Standards of Practice defined and used by the APTA. From a regulatory standpoint, the Act and Rules are sufficiently worded for a licensee to interpret the legal obligation to file a complaint, as well as the Board having the legal authority to enforce such requirement.

   There is a rule which requires a licensee to report alleged violations of the Physical Therapyy Practice Act.

8. Short Term Rehabilitation - When patients are admitted to a free standing short term rehab, s/p 20 years injury, noting they have been in/out of rehabs all their injured years, admitted to this facility with 6&7 FIM scores and therapist as well as physician recommend d/c administration doesn?t allow d/c what should therapist do? Patient is not progressing and goals are difficult to establish. Administrator says therapists need to Athink out of the box and be creative. The FIM scores remain the same for 3-5 weeks as Administrator continues to not allow d/c of patient although at each staffing d/c is recommended and documented. Therapists are then criticized for their ethical recommendation.

   Pursuant to the Physical Therapy Practice Act and the Board's Rules, a physical therapist is obligated to discharge a patient if there are no goals nor reasonable expectations of gain. If the physical therapist exploits the relationship with the patient, the Board would investigate and sanction such physical therapist's license for violations of the Physical Therapy Practice Act and the Board's Rules. The Board also wishes to suggest that the facility should be careful with regards to what qualifies for inpatient rehab. The appropriate state governing authority should be consulted by the facility with regards to this issue. Additionally, "thinking out of the box and being creative" as suggested in your scenario could very well constitute violations of the Physical Therapy Practice Act and the Board's Rules, as well as Medicare fraud, etc.

9. Short Term Rehabilitation 2 - Therapists work in a short term rehab hospital, but are told that certain patients are to be treated as a long term care patients, although when therapists want to discharge just to nursing care they are told by administration they can't. Is this legal?

   No. The therapist is obligated by law to discharge a patient when goals are reached or there are no longer any realistic goals. What the Administration is asking the therapists to do in this scenario could be construed as a violation of the Physical Therapy Practice Act and the Board's Rules, as well as other applicable healthcare laws.

10. Short Term Rehabilitation 3 - Can a quadriplegia patient be appropriate for short term rehab if the only reason for admittance is for a UTI? The FIMs are 6&7 and from week to week don't change.

    No. In order to qualify for inpatient rehab, a patient must require three (3) hours of skilled therapy per day. In the patient scenario described, the patient would probably not have functional goals nor meet the three (3) hour criteria.

11. Short Term Rehabilitation 4 - Is wound care alone reason to keep a patient in a short term rehab? FIMs again 6&7-never changing by status of wound.

    A patient could be a candidate for long-term care or acute care based upon a status of wound. However, a patient requiring only wound care with FIM scores of 6-7 in other functional activities would not qualify to be kept in short term rehab.

12. Short Term Rehabilitation 5 - If a patient is not capable of retaining compensatory strategies from one day to the next and therefore unable to progress with treatment, should they be kept in a short term rehab until their payor source is exhausted?

    In response, if there are no goals or no progress towards established goals, then the patient should not be kept in a short term rehab until their payor source is exhausted. To do otherwise would be a violation of the Physical Therapy Practice Act and the Boardýs Rules, as well as other applicable healthcare laws.

13. Short Term Rehabilitation 6 - Who should violations be reported to and how should this be handled?

    Violations should be reported to the Board, as well as to Medicare, the Louisiana Insurance Commissioner and the fraud and abuse section of HCFA for investigation.

14. Short Term Rehabilitation 7 - Who should judge if a facility transport vehicle is safe to operate? When therapists recommend vehicle straps on w/c to hold stabilized in transport vans are not safe, administration doesn't repair appropriately, but therapist is told that van is appropriate to transport patients. Transport vehicle is not safe, what should be done?

    The therapist is responsible for the safety of patients while in his care. If you knowingly place a patient in an unsafe situation and the patient is injured you could be in violation of minimal standards of acceptable and prevailing practice as well as liable from a malpractice standpoint. It is recommended that with regards to the safety of the transport vehicle, any concerns should be reported to the Louisiana Department of Public Safety as well as your own quality assurance department. It is also suggested that the risk management department of your facility's liability insurance carrier be notified.

15. Terminate - Patient Abandonment - Having never signed any type of contract and having given a two weeks notice to my employer, I am writting to inquire if I face any retubution from the Board in regards to patient abandonment. I feel as though the notice I have given should be sufficient.

    The Board takes the position that the physical therapist's depature with reasonable notice is acceptable if it is not detrimental to the healt of the patients which he treats. There are no rules and regulations promulgated by the Board with regards to a "time line" regarding notice and the termination of the provision of services by a particular physical therapist.

    Therefore, whether a physical therapist's termination of personally rendering services is detrimental to the health of the patient in a situation which must be reviewed by the Board on a case to case basis. Some of the factors which may be taken into consideration by the Board when reviewing a patient abandonment allegation are : (1) full-time v. part-time employment, or contract work; (2) availability of other physical therapists in the workplace; (3) physical therapist to patient ratio; (4) type of facility; and (5) acuity level of patients, etc.

    According to your narative, it does not appear that the care of the patients will be adversely affected by your departure. The Board is of the opinion that your conduct in this matter, as described in your letter, does not violate the Physical Therapy Practice Act, the Board's Rules or the Code of Ethics. However, the Board reserves the right to change or amend its opinion as set forth in this letter should additional and/or contradictory evidence come to light.

16. Treatments - Number of Patients per Hour. - I would like to know what is the opinion of the board when it comes to the number of patients that one therapist can treat per hour in an outpatient clinic. I know that Medicare stipulates the number of patients and the billing of group therapy when more than one patient is treated concurrently, but what should private insurance patients in an outpatient clinic expect? Please let me know where I can find written material so I can present it to facilities.

    The Louisiana Physical Therapy Practiice Act and Rules and Regulations are silent as to the number of patients a therapist can treat per hour. There is, however, a reference in the Rules and Regulations to the APTAs Code of Ethics and the Standards of Practice. Specifically, Principles 2, 4, and 7 appear applicable. The APTA Guide for Professional Conduct further explains these Principles of the Code of Ethics.

17. Unnecessary Treatment - A client wants to do only AROM, which she is proficient with as she displayed in acute rehab and with me during evaluation. She refuses to attempt gait and other activities, even though she was able to ambulate with a walker, SBA, 30 to 40 feet. I proceeded to tell her she was to continue performing AROM on her own but I could not justify performing this activity with her during our sessions and to bill her insurance for this. Is this correct?

    If you have attempted to implement a treatment plan without success, your options would be

    1) reassign to another therapist that may have better success in motivating the patient or 2) discharge with documentation that the patient was not complaint with the plan of care.