Lafayette, LA 70507
Phone: 337.262.1043
Fax: 337.262.1054
Intra-State Toll Free: 888.400.9110
lsbpte@laptboard.org
Declaratory Statements - Supervision
04.11.01 Delegation of treatment to technician - Delegation of treatment to technician
1) First the Physical Therapist must have completed and have documented a physical therapy evaluation along with goals and a treatment plan.
2) You must provide responsible, continuous, on-premises observation and supervision of procedures and functions performed by a physical therapy technician.
3) The definition of a technician is a worker not licensed by this Board who functions, in a Physical Therapy Clinic, Department or Business and assists with preparation of the patients for treatment and with limited patient care.
4) The level of responsibility assigned to physical therapy support personnel is at the discretion of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals.
5) Supportive Personnel may perform only those functions for which they have documented training and skills.
6) The prohibitions for physical therapy supportive personnel shall include, but not limited to, interpretation of referrals; performance of evaluations, initiative or adjustment of treatment programs; assumption of responsibility for planning patient care; or any other matters as determined by the Board.
7) The physical therapist shall only delegate portions of the treatment session to a technician, only after the therapist has assessed the patientýs status. If the therapist is following all supervision and documentation requirements as outlined above and in the Louisiana Physical Theray Practice Act and Rules, then the therapist is not prohibited from leaving the technician to complete the patient's treatment session while the therapist goes down the hall to treat another patient.
8) The physical therapy technician may not document in the patient's medical record.
9) The therapist must also consider the facilities policy and procedures as well as Medicare's supervision requirements.
04.10.01 Supervision of technicians/students by physical therapist - Petition: Would a first rotation student be supervised the same as a student on his/her last rotation before graduation? Please provide clarification of line-of-sight vs on-premises.
For the discussion of Continuous Supervision, we will need to separatetrechnicians from students since their training and purpose in the clinic are very different. First, physical therapist technician is defined in 305.A. as
"a worker not licensed by this Board who functions in a physical therapy clinic, department, or business and assists with preparation of a patient for treatment and with limited patient care."
Further, "the level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals" "the physical therapist shall only delegate portions of the treatment session to a technician only after the therapist has assessed the patient's status." "Supportive personnel may perform only those functions for which they have documented training and skills.
The Board does not currently have a requirement for line of site supervision in Rules and Regulations.
Students in a physical therapy clinic, department or business also require continuous supervision by a physical therapist; however, there are differences between students and technicians. Students are present in the clinic for the purpose of education and not as an employee. Students have had formal education and training and their presence in the clinic requires the therapist to teach, observe performance and evaluate and record competence. The therapist would naturally provide closer supervision for a student on a first rotation or in a specialty clinic where the student has not previously observed or worked. Further into a students' clinical period, the therapist may, and usually does allow the student more autonomy and provides less observation and supervision. The clinical instructor must still review the evaluations and treatment performed by the student, thoroughness of documentation by the student and must co-sign all evaluations, progress notes, and discharge summaries.
In both cases, the Board does not require or define line of sight supervision. The therapist is responsible for using good judgment in providing appropriate supervision for each situation. The Board's primary duty is to protect the Safety and Welfare of the public. We will hold therapists responsible for their decision-making in supervision of technicians and students when they are providing patient care.
Aquatic Therapy Supervision - Does the P.T. need to be in the pool at all times with the patient?
Supervision of a patient receiving aquatic therapy requires the same degree of Physical Therapy supervision as in any other setting. According to the Louisiana State Board of Physical Therapy Examiners Practice Act, Section 305, Special Definition; Practice of Physical Therapy,
Physical Therapy Supportive Personnel c. The level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals. Supportive Personnel may perform only those functions for which they have documented skills and training.
Eval by PT permittee in home health setting - 1. Can a physical therapist permittee evaluate a patient in a home health setting? 2. Can the permittee sign said evaluation solely? 3. Is the signature of supervising physical therapist required? 4. Is the identical requirement the same for progress notes? 5. Is on-site supervision by supervising physical therapist required? 6. Can the permittee evaluate a patient in a private office setting? Is the signature of a supervising physical therapist required? Is the identical requirement the same for progress notes?
The physical therapist permittee may evaluate a patient in the home health setting, however, the supervising physical therapist and the physical therapist permittee must comply with the Rules and Regulations. More particularly, the physical therapist permittee must be supervised by the supervising physical therapist two (2) hours per day in all practice settings which would necessitate in a home health setting that the supervising physical therapist be present on the premises when the physical therapist permittee is evaluating or treating the patient.
The physical therapist permittee may solely sign the evaluation. The signature of the supervising physical therapist is not required. These responses are identical for progress notes. Additionally, it is necessary that the supervising physical therapist supervise the physical therapist permittee two (2) hours per day at all practice settings which means on-site supervision by the supervising physical therapist for two hours per day in each practice setting. Each patients home in a home health practice is considered a separate practice setting.
The response to questions listed in number 6 are the same as the responses provided.
Documentation of care provided - Can a technician write daily progress notes documenting patient status, progress, etc.? (i.e. "SOAP" notes?)
No, progress notes may only be written by the physical therapist or physical therapist assistant.
Face to Face Conference - I represent a group of PT's and PTA's working in Home Health. PT/PTA face to face conferences are held each Wednesday in the office to review progress and modify the treatment plan. If the PT who did the Initial Evaluation is unable to attend the meeting, may a different PT cover the face to face meeting to discuss the case with the PTA?
In response, the board determined it inappropriate for a PT who is not treating specific patients to conduct the face to face conference with the PTA. The intent of the rule is for the PT and PTA to discuss the care of patients which they both treat.
Patient care by technician without PT contact - In regards to supervision of technicians, please specify whether or not a technician can treat a patient without any patient contact being made by the Physical Therapist?
No, treatment may not be performed by a P.T. tech without the P.T. first seeing the patient, assessing their status, and delegating a portion of the treatment to the technician.
Physical Therapist initiates therapy sessions - Is the Physical Therapist required to initiate all therapy sessions? Can a technician initiate the Physical Therapy treatment without initial contact being made by the Physical Therapist?
Yes! A Physical Therapist is required to initiate all physical therapy sessions.
No. The physical therapist is required to intitate all physical therapy sessions.
Pre-Sport Physicans - Assessment - Question # 1: Is it permissible for a newly graduated, unlicensed physical therapist to perform orthopedic assessments for pre-sport physicals to include but not limited to manual muscle testing, range of motion, joint stability and scoliosis screenings? Question #2: Is it permissible for a PTA to perform the same screening procedures listed above if under the supervision of a PT? What level of supervision is required? Please list parameters.
Question #1: It is not permissible for a newly graduated, unlicensed PT to perform orthopedic assessments or any other physical therapy service prior to possessing a current, valid temporary permit or license issued by the Board. Furthermore, once the PT who has recently graduated receives a current, valid temporary permit, he must be under periodic supervision as required by Rule 153B as defined in Rule 305. Rule 305 defines periodic supervision as related to temporary permit holders who are graduates of APT A accredited programs to mean (1) daily face to face or phone communication between the supervising physical therapist and permit holders and (2) on premises observation of patient care in each of the permittee's practice settings, a minimum of two (2) hours per day with a minimum total of ten (10) hours per week total.
Once the temporary permit holder successfully passes the National Licensure Examination and is issued a license by the Board, there is no longer the requirement of periodic supervision as required by the Board's Rules and as discussed above.
Question #2: Pursuant to Board Rule 305, physical therapy supportive personnel, such as a PTA, can not perform evaluations which include screening procedures. The Board is of the opinion that a PTA may collect data, but the PT must complete the assessment, and is solely responsible for the interpretation of the data collected, and renders the decision with regards to whether or not a plan of care is required. Furthermore, the Board is of the opinion that during the collection of data by the PTA, the PT must be present.
PT on premises supervision of PT Technician - With respect to a PTs supervision of a PT Technician how do I interpret "on premises, continuous supervision?" Does this mean that a PT Technician can only perform routine tasks when a PT is in the same room/treatment area (direct visual and/or auditory supervision)? A hypothetical question: If a PT was performing an inpatient initial evaluation in hospital room could a PT Technician perform ambulation a patient in room simultaneously if this PT Technician has previously been directly instructed, observed and assessed to be appropriate in performing this task by the supervising PT?
In reading the above inquiry and related information, it must be initially stated that Medicare Rules and requirements are much stricter than the requirements of the Board. It is the Board's understanding that "direct" supervision is required of the technician in order to receive payment pursuant to Medicare guidelines. In further response, "continuous supervision" is defined by Rule 305 promulgated by the Board to mean "responsible, continuous, on the premises observation and supervision by a licensed physical therapist of the procedures, functions and practice rendered by a physical therapy technician." "On the premises" is also defined in Rule 305 as the "supervising physical therapist being personally present in the treating facility and immediately available to the treatment area." The physical therapist must assess the patient before each visit prior to delegating the rendering of any services to the technician. Rule 305 also addresses the level of responsibility which may be assigned to a technician. Rule 305c provides as follows: The level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, 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 prohibitions for physical therapy supportive personnel shall include, but not be limited to, interpretation of referrals; performance of evaluations; initiation or adjustment of treatment program; assumption of the responsibility for planning patient care; or any other matters as determined by the Board. The physical therapist shall only delegate portions of the treatment session to a technician only after the therapist has assessed the patient's status. In summary, the board requires supervision by the physical therapist of unlicensed supportive personnel (technician) as required by Rule 305 set forth above. The Board does not require continuous "visual" supervision of the supportive personnel by the supervising physical therapist. Furthermore, the portions of a treatment plan which may lawfully be delegated to a technician by the supervising physical therapist must comply with rule 305 set forth above.
PT Supervision of CNAs for bathing - Can a PT supervise CNAs for bathing in a home health setting?
Physical therapy is considered a skilled service and the "supervision" is more in the nature of an administrative duty and does not fall within the concept of supervision as defined and required by the Physical Therapy Practice Act and/or the Board's Rules and Regulations.
PT Technician - Question # 1: I would like to describe two similar scenarios and get a formal ruling on the correct interpretation by the Board if these actions of a physical therapy technician are considered physical therapy. Physical therapy treats a patient and places that patient in a chair to sit up after treatment. At a later time, the nursing staff requests that a physical therapy technician return the patient back to bed. The physical therapist is not involved, and the patient is not billed through physical therapy. Question #2: A variation of this question is that the nursing staff requests that a physical therapy technician assist with getting a patient in or out of bed that is not under the care of a physical therapist.
Question # 1: Pursuant to the Physical Therapy Practice Act and the Board's Rules, it is the Board's opinion that if the PT treats the patient and places the patient in a chair, then the PT is responsible for this patient which includes the physical therapy technician returning the patient to bed. As required by the Board's Rules, the physical therapy technician must be under the continuous, on the premises, supervision of the physical therapist. Additionally, as set forth in Rule 305, the technician must have documented training and education to assure competency to perform the task set forth in your scenario.
Question #2: Under the scenario you have presented, the technician is performing such tasks under nursing services. In this situation, the technician will not be required to be supervised by a physical therapist as explained in the Board's Response to Question # 1 above.
PT / PTA Supervision 6th Visit - The discussion was that the PT and not the PTA should see the patient for a re-evaluation upon the patient's final visit, except in certain circumstances. Is it permissible for the PT to do the re-evaluation at the second to last visit instead? I have had patients nearing the end of their script and have done the re-eval on the second to last visit and documented to the effect that the patient would be seen once more to complete the script, but no further PT was recommended. The PTA then completed the last treatment per established treatment plan.
The Board is in agreement that a physical therapist may assess a patient for discharge prior to the last visit, but that this practice must be the exception rather than the rule.
Final visit - What happens if a PTA treats the patient and the patient is unexpectedly discharged?
The Board's intent is that in instances where the patient was discharged unexpectedly and the physical therapist assistant was the last clinician to treat the patient, the physical therapist would review the progress note written by the physical therapist assistant and the physical therapist would write the discharge summary. It is preferable, however, that the physical therapist actually make the final visit and evaluate the patient in order to write the discharge summary.
PTA cannot supervise PT technician - Please explain the rule that states a PTA cannot supervise a PT technician.
The Board received a letter in reference to the prohibition against supervision of physical therapy technicians by physical therapist assistants in matters related to patient care activities. In order to answer your question, please refer to the Rules and Regulations, Section 321 C, which states that 1) the supervising physical therapist shall provide on premises, continuous supervision of the physical therapist technician in all practice settings, and 2) a physical therapist technician shall not be supervised by a physical therapist assistant or physical therapist assistant permittee. On page 18, Section 305, continuous supervision is defined as responsible, continuous, on-premises observation and supervision by a licensed physical therapist of the procedures, functions and practice rendered by a physical therapy technician. It was never the Boards intention to define supervision as it relates to an organizational chart or as to who has responsibility of assessing the technicians overall performance, conduct, merit, etc. The Board expects that during the daily operation of the department the physical therapist assistant will have to give general direction to the technician as it relates to patient care. The Board feels that it is appropriate if the technician assist the physical therapist assistant in maneuvering IV poles, catheters, etc., as long. as there is a licensed physical therapist on the premises. On page 18, Section 305, defines "on premises" as meaning that the supervising physical therapist is personally present in the treating facility and immediately available to the treatment area. If a physical therapist is not on premise the physical therapist assistant can continue to provide patient care as described in the Rules and Regulations in Section 321 on page 21, but the technician can no longer assist the physical therapist assistant in patient care activities.
PTA Facility Supervisor - Recently, the company I work for replaced my immediate supervisor, a speech therapist, with a PTA. She is supervisor for several nursing homes with skills units. Regarding the care of a patient that had been discharged from physical therapy, I was instructed to change the plan of care by placing the patient on restorative nursing care and monitor weekly patient participation. The supervisor, a PTA, was instructing me regarding changing the patient plan of care. As I read the Practice Act for Physical Therapists, evaluations and implementation of plans of care are the responsibility of physical therapists. Regarding the supervision of physical therapy assistants, can anyone other than a physical therapist supervise a physical therapy assistant? I am sure that a PTA can work in a coordinator role that places them in a position dealing with logistics, maintaining statistics, or acting as a liaison, but my question is regarding a PTA's role in assessing a PT's skill in evaluation and establishment of plans of care.
Your understanding of the Practice Act and Rules and Regulations regarding a physical therapist assistant's clinical role is correct. It is not within the role of a PTA to address the change of a plan of care as defined in the Practice Act L.S.R.S. 2410:
(5)(c) A physical therapist assistant's work shall not include the interpretation and implementation of referrals or prescriptions, the performance of evaluations, or the determination or major modification of treatment programs.
Also in Rules and Regulations Section 305(c):
c. The level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, 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 prohibitions for physical therapy supportive personnel shall l include, but not be limited to, physical therapy supportive personnel shall include, but not be limited to, interpretation of referrals; performance of evaluations; initiation or adjustment of treatment programs; assumption of the responsibility for planning patient care; or any other matters as determined by the board. The physical therapist shall only delegate portions of the treatment session to a technician only after the therapist has assessed the patient's status.
PTA Supervision - Intervention - What are the rules/regulations regarding PTA supervision and PTA intervention while the physical therapist is offsite for the entire shift?
A physical therapist always has certain supervisory requirements. Please refer to Section 321.A.2.d which indicates "the supervising physical therapist must be on premises weekly (any seven consecutive days) for at least one-half of the physical therapy tretment hours in which the physical therapist assistant is rendering physical therapy treatment".
PTA Supervision - Outpatient Pediatric - The outpatient pediatric PTA is supervised two days a week by a PT with pediatric experience who is in the same treatment area as the PTA for the PTAs full workday, but is primarily treating adult outpatients. The PT evaluates new pediatric patients on these two days as needed and also performs the sixth visit re-assessment is the patient's treatment schedule dictates. In addition, the PTA is supervised three days a week for the full workday by a PT treating pediatric patients. The question is whether or not the above meets the Rule requirements in Section 321, regarding appropriate supervision of the Licensed Physical Therapist Assistant.
The Board is of the opinion the situation you describe does meet the on premises supervision requirement for the licensed physical therapist assistant, as well as the evaluation and 6th supervision requirements. Our understanding of your described scenario is that a PT is present in the same treatment area as the physical therapist assistant at all times. A physical therapist assistant may treat patients evaluated by various therapists as long as a PT is on premises and all other supervision requirements are met.
PTA Supervision - SNF - We had a conversation regarding PTA supervision in a skilled nursing facility. I heard you to clarify that if a nursing home bed is dually certified (can put either a skilled patient or a non-skilled patient in it) then the supervision still depends on the type of patient in the bed. If skilled, then the PTA needs 50% of their time supervised weekly, and if non-skilled then the lesser supervision of PT treating the patient every 6th visit after the initial plan of care is established. Is this accurate? And can you provide me any documentation to support this?
Your interpretation of the conversation is accurate. When a nursing home is dually certified for nursing home beds and skilled nursing beds, patients are assigned to the bed as either a nursing home resident or as a patient requiring skilled nursing, thusly a skilled nursing patient.
The level of supervision for each environment (nursing home resident or skilled nursing patient) is specified in the Louisiana Physical Therapy Practice Act - Rules and Regulations, specifically, section 321. Supervision Requirements, A. 2-3.
The requirements for supervision of PTAs in a nursing home environment are Initial evaluation, at least every sixth visit for reassessment, monthly assessments, and discharge. Please note that the physical therapist is responsible for determining that the PTA possesses the necessary skills to provide treatment for each patient assigned. If the PTA is not able to provide the level of treatment required, then the physical therapist shall provide the treatment. The level of supervision required for PTAs when treating skilled patients in skilled beds is half the work time per week with the PT and also during the sixth visit for reassessment, monthly assessments, and discharge as outlined in the Rules and Regulations.
PTA Utilization in Screening Process - What is the role of a PTA in the screening process? It is understood the PTA can not make the decision as to whether a screen is positive or negative, however, is the PTA able to obtain supporting information regarding a resident's needs, current/prior level of care, etc. and then present that information to the PT, who makes the decision as to whether a patient is appropriate for PT?
In response, a physical therapist assistant can collect data and present such information to the physical therapist. However, it is the physical therapist's obligation to perform the evaluation and make the appropriate plan of care.
PTA Supervision - Home Health - I would like to know whether or not a physical therapist is permitted to perform any of the supervision for contract physical therapist assistants that are doing home health in addition to the supervision that the physical therapist does for the employees within the hospital?
Pursuant to the Board's Rules, more particularly the supervision requirements set forth in Rule 321, the answer to your question is "no."
PTA Supervision - Related Questions - 1) PTA supervision for skilled nursing patients in a long term nursing facility. Does the physical therapist have to be in the building - the time at the same time as the PTA? Would the Board consider in a rural setting in which staffing has historically been difficult, and the physical therapist and physical therapy assistant are well established in the profession and have close contact by phone, allow the PT and PTA to possibly not always be in the building at the exact same time? The PT would be in the building 1\2 the time and be seeing that patient every 6th visit. Please consider the balance budget act changes on skilled patients have greatly impacted the long term care setting. 2) Can a PT who holds a LA temporary license supervise a PTA with a permanent license? 3) Can a new graduate from an accredited out of state school obtain a temporary license in LA if he has not taken the state board examination? If so, when would the PT be able to obtain a permanent LA PT license?
1) As you are aware, the physical therapist and physical therapist assistant are mandated to follow the specific Rule 321 promulgated by the Board regarding supervision. Pursuant to Rule 321, the type of supervision required at a site is dependent upon the nature of such site. More supervision required at a site is dependent upon the nature of such site. More specifically, the type of supervision required by Rule 321.A (2) and A (3) is determined by how the beds are licensed at the facility. For example, if the patients are in need of acute care and the beds are licensed as acute care facilities or skilled nursing facilities, and then rule 321.A (2) would be applicable for supervising requirements.
On the other hand, if the beds are licensed as a nursing home facility, then the appropriate supervision is required by Rule 321.A (3). Please note that a facility may have different wings with different kinds of patients and different types of licensed beds. Therefore, to determine the exact type or degree of supervision, it is necessary to establish how the beds are licensed; for example, SNF versus nursing home.
In addition, when the Board promulgated Rule 321 regarding supervision, its primary concern was, and continues to be, to protect the public. While the Board is aware of and very sensitive to the Balance Budget Act and other reimbursement issues, the Board is mandated by law to protect the consuming public who receives physical therapy services. Therefore, with regards to supervision requirements, the primary determining factor is the care needed by the patient.
2) Yes.
3) There is a national examination for all physical therapists and physical therapist assistants. However, in response to your specific request, a new graduate from an accredited out of state school may obtain a temporary permit to practice in Louisiana pending meeting other requirements that are set forth in the Board?s Rules.
Question concerning supervision of technician. - In regards to supervision of technicians, can a tech treat a patient without any patient contact being made by the P.T.?
No, treatment may not be performed by a P.T. tech without the P.T. first seeing the patient, assessing their status. The P.T. may not turn over the entire treatment session to the tech, but may delegate tasks or portions of the treatment to the tech. Remember that P.T. is a skilled service which requires the knowledge and judgment of a therapist during the course of treatment with the therapist observing, "feeling", curing, teaching, listening, giving feedback and making constant adjustments in the treatment plan. An 'absentee" P.T. cannot fulfill these skilled functions and cannot legally nor ethically relinquish their responsibilities.
Role of PTA - Supervision - 1) On Premises (defined in the Rules) that the supervising physical therapist is personally present in the treating facility and immediately available to the treatment area. Does this mean if a physical therapist is treating patients on the 4th floor of a hospital, can a physical therapist assistant treat patients on the 9th floor legally under this practice? 2a) If a physical therapist is on the 4th floor doing whirlpool treatments; can a physical therapist assistant and a physical therapy technician treat 2 different patients on 9th floor with the physical therapist assistant initiating both treatments? (PTA is documenting treatment on both patients). 2b) Physical therapist is on 4th floor doing whirlpool treatment, physical therapist assistant is on 9th floor treating a patient and a physical therapy technician is helping treat the same patient. Physical therapist assistant is documenting on this patient. 2c) Outpatient Setting - If a physical therapist and a physical therapist assistant are with 2 or more patients working in the gym, a different patient shows up for the physical therapist assistant, can the physical therapist assistant request for the physical therapist technician to finish patient treatment on a patient the physical therapist assistant initiated?
1) Yes. Also, please refer to Board Rule 305 (Special Definitions) regarding the level of responsibility which may be assigned to supportive personnel, as well as Rule 321 with regards to supervision requirements of physical therapy assistants.
2a) Yes. Also, please refer to the Boards Response to Question #1 above.
2b) Yes. Also, please refer to the Boards Response to Question #1 above. It is further advised that you review Board Rule 323 with regards to documentation standards.
2c) No. The physical therapist assistant cannot delegate treatment to a technician.
Skilled Nursing Facility - PTA Supervision - 1) Is a nursing home with skilled beds considered a skilled nursing facility? 2) If a nursing home with skilled beds is licensed as a skilled nursing facility, what level of supervision is required for the PTA by supervising PT for Part (B) Medicare patients?
1) A nursing home with skilled beds is not considered a skilled nursing home facility except for the skilled beds. For physical therapy supervision purposes, the skilled beds would require the periodic supervision of a physical therapist assistant as set forth in 321.A (2) of the Boards Rule. The non-skilled beds would require the periodic supervision set forth in Rule 321.A (3)
2) With regards to the level of supervision, please refer to the Boards Response to Question #1 above. Again, periodic supervision regarding skilled beds is set forth in 321.A (2). In comparison, the supervision for non-skilled beds is set forth in Rule 321.A (3). Additionally, it is the Boards understanding that skilled facilities do not have Part (B) Medicare as skilled beds.
Skilled Nursing Facility/Parts A & B - I am currently employed with a rehab community contracted with skilled nursing facilities. There has been confusion regarding supervision of PTAs. My understanding is that the PTA is to be supervised for half of the treatment minutes for all patients, Part A and Part B, and that I am to be in the building for those minutes while the treatments are being performed. My regional manager and PTAs disagree with me. They feel the supervision is appropriate when the PT is in the building for half of the treatment time any time throughout the week without the presence of the PTA in the building. They feel it is for Part A billed patients only. Part B is just for the sixth visit only.
The Board has determined that a nursing home with skilled beds is not considered a skilled nursing facility except for the skilled beds. The skilled beds would require the periodic supervision as set forth in Rule 321.A (2). The non-skilled beds would require the periodic supervision set forth in Rule 321.A (3).
Additionally, the supervision required in Rule 321.A (2) regarding skilled beds clearly states that the "supervising physical therapist shall be on premises weekly(any consecutive seven days) for at least one-half of the physical therapy treatment hours in which the physical therapist assistant is rendering physical therapy treatment." Therefore, the regional manager and PTAs are incorrect in their opinion that "the supervision is appropriate when the physical therapist is in the building for half the treatment time anytime through out the day without the presence of the PTA in the building."
Weekend Supervision of PTA and technician - 1) On a weekend, an acute P.T. is scheduled to act as the supervising therapist to a PTA and tech who are assigned to treat rehab patients. The P.T. is on premises?immediately available to the area, but not in direct sight and probably on a different floor. The PTA and tech perform duties as assigned by the weekday rehab therapist per written plan of care as outlined with the tech assisting the PTA. The weekend acute therapist merely serves as proxy and fulfills supervision requirements. Is it sufficient supervision for the PTA and tech to work with patients on the rehab unit while the PT is on a different floor treating in the acute setting and not in direct sight as long as they are following the plan of care as established by the weekday P.T. (The P.T. is on premises and immediately available and the tech is assisting the P.T.A., not working independently)? 2) In the above situation if the tech, in assisting the PTA, ambulates with a patient and/or finishes an exercise regimen with a patient with the PTA physically present is this considered working independently? We have already reviewed rules 305 and 321 but need further interpretation, not a restatement of the rule.
1) With regards to the physical therapist assistant working on Saturday, it is necessary for the physical therapist to supervise one-half (1/2) of the workday which allows the physical therapist assistant to follow the chart for the remainder of that day. With regards to the involvement of a technician, the physical therapist must be familiar with the patient and the physical therapist who is on the premises must asses the patient prior to the provision of any appropriate delegated tasks performed by the technician. Please be advised that pursuant to Rule 305, the level of responsibility assigned to physical therapy supportive personnel, which includes physical therapists assistants and technicians, is the direction of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals. Furthermore, supportive personnel may only perform those functions for which they have documented training and skills. It is strongly recommended that you review Rule 305 in its entirety with regards to the delegation of tasks to supportive personnel.
2) Please refer to the Board's response to Question #1 above. Please understand that the supervising physical therapist who is on the premises must assess each patient prior to the delegation of any tasks to the technician. Again, the physical therapist is ultimately responsible for the acts or omissions of these individuals.
Techs/Charges - Does supervision in the acute care setting or an outpatient setting mean general supervision with the therapist being immediately available on the premises or does this mean direct line of sight? Our physical therapists would like to maintain using technicians where appropriate and also would like to maintain the ability to charge for these services. Currently, our facility is utilizing technicians under the physical therapists general supervision. These technicians are only working with treatments where they have been properly trained and checked off as being competent. The physical therapists are making all initial evaluations and treatment plans and are supervising the work of these technicians, interviewing when changes to the treatment is necessary.
Pursuant to the Physical Therapy Practice Act of Louisiana, more particularly LSA R.S. 37.2401(1)(a), the definition of the practice of physical therapy includes the supervision of physical therapy supportive personnel by a licensed physical therapist. In accordance with its delegated authority, the Board has promulgated Rule 305 which specifically addresses physical therapy personnel as follows:
a. Physical therapy technician refers to a worker not licensed by this Board who functions in a physical therapy clinic, department or business and assists with preparation of the patients for treatment and with limited patient care.
c.) The level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, who is ultimately responsible for the care provided by these individuals. Supportive personnel may perform only those functions for which they have documented training and skills. The prohibitions for physical therapy supportive personnel shall include, but not be limited to, interpretation of referrals; performance of evaluations; initiation or adjustment of treatment programs; assumption of the responsibility for planning patient care; or any other matters as determined by the Board. The physical therapist shall only delegate portions of the treatment session to a technician only after the therapist has assessed the patient's status.
The above cited Rule sets forth the obligations and prohibitions regarding physical therapy supportive personnel as well as the fact that the physical therapist is ultimately responsible for these individuals. It also states that the physical therapist shall only delegate portions of the treatment session to the technician only after the therapist has assessed the patient's status.
Rule 321C promulgated by the Board addresses the supervision requirements of a physical therapy technician by a physical therapist as follows:
1. The level of responsibility assigned to a physical therapy technician is at the discretion of the physical therapist who is ultimately responsible for the care provided by the supervised individual(s). 2. In all practice settings, during the provision of physical therapy services, the supervising physical therapist shall provide continuous, in-person supervision of the physical therapy technician. 3. A physical therapy technician may assist a physical therapist assistant only with those aspects of patient treatment which have been assigned to the physical therapy technician by a physical therapist. 4. To ensure the safety and welfare of a patient during ambulation, transfers, or functional activities, the physical therapist assistant may utilize one or more physical therapy technicians for physical assistance. 5. The supervising physical therapist shall provide continuous, in-person supervision of client preventative services rendered by a physical therapy technician as follows: a. perform and document an initial screening to determine if an individual qualifies for preventative services; b. establish a wellness program, including education and activities, to promote injury prevention, reduction of stress and/or fitness; c. delegate only those functions to a physical therapy technician for which the physical therapist has documented the training and skills of the physical therapy technician; d. be available to the technician for direct and immediate verbal clarification.
In further response, continuous supervision is defined by Rule 305 promulgated by the Board to mean "responsible, continuous, on the premises observation and supervision by a licensed physical therapist of the procedures, functions, and practice rendered by a physical therapy technician." "On the premises" is also defined in Rule 305 as the "supervising physical therapist being personally present in the treating facility and immediately available to the treatment area." The Board does not require continuous "visual" supervision of the physical therapy technician by the supervising physical therapist.
In summary, with regards to the supervision of a physical therapy technician, the supervising physical therapist must be familiar with the patient and assess the patient prior to provision of any appropriate delegated tasks performed by the physical therapy technician, as well as be continuously on the premises during the provision of the service.
Supervising PT of PTA temporary permittee out for illness - Factual Scenario: In hopes of providing a clear picture, I will first describe the setting in which we provide care. Lagniappe Hospital is a long-term acute care hospital. We are licensed for 146 beds with an average census of 100 to 200 inpatients. In addition, outpatients are treated at our facility. We currently employ eight licensed physical therapists and five physical therapist assistants. PTs and PTAs are assigned to a multi-disciplinary team that provides treatment on a specific unit or area within the hospital. We have hired a physical therapist assistant permittee pending examination. Our questions relate to rule and regulation 321 B., supervision of the permittee. As stated in 321B (1), supervision is to be "on premises" and "continuous" by the supervising physical therapist (we are assuming the "supervising physical therapist" is the individual who signed the permitee's application for temporary licensure). 1) May the physical therapy assistant permittee work under the direction of a physical therapist other than the "supervising" therapist all or part of an 8-hour day if the "supervising" physical therapist is on the premises? An example, the permittee works with the "supervising" therapist on I.C.U. in the a.m. then assists another physical therapist in the outpatient area in the p.m. The supervising therapist is immediately available to the treatment area if needed. 2) In the case the "supervising" therapist is not on the premises (secondary to illness or vacation), how is the permittee?s supervision handled?
1) The supervising physical therapist approved by the Board will be held accountable regarding the activities involving the permittee. However, another physical therapist may "supervise" the permittee in the factual scenario presented. Please be advised that the "supervising" physical therapist who is the temporary supervisor in this scenario will also be held accountable for the activities of the permittee. In other words, both the approved supervising physical therapist and the temporary supervising physical therapist will be held accountable for the acts or omissions of the permittee. Additionally, the physical therapist assistant permittee is also bound to comply with the provisions of the Physical Therapy Practice Act and the Board's Rules. He will also be held accountable for his acts or omissions in violation of the law.
2) The board is of the opinion that if the supervising physical therapist of record as approved by the Board is not on the premises (secondary to illness or vacation) for a week or more, then it is necessary for him to send notification to the Board for the approval of a new supervising physical therapist during his period of absence. In the event the supervising physical therapist is not on the premesis (secondary to illness or vacation) for less than one (1) week, a substitute supervising physical therapist may be used with regards to the physical therapist assistant permittee. Under this limited scenario, there is no need to have the second physical therapist approved as a supervisor by the Board. Please refer to Board's response to Question #1 above with regards to the issue of accountability of the supervising physical therapist of record, the temporary supervising physical therapist, as well as the permittee.
MPT Students - Research Projects - In research projects (approved by an Institutional Review Board) in which the subjects are not patients and in which the activities that the subjects are asked to participate in are non-invasive and considered to present low to moderate risks (e.g., stretching, graded exercise tests), is it acceptable for MPT students to conduct the research without direct supervision by a P.T.? IRB regulations state that the principal investigator, who is ultimately responsible for the research project, may designate others to perform research activities under his or her supervision, direct or indirect. Furthermore, it is the responsibility of the principle investigator to ascertain that individuals are qualified to conduct the research activities without direct supervision.
Pursuant to the Physical Therapy Practice Act and its Rules, the Board is of the opinion that since the subjects are not patients and such activity is conducted in the scholastic environment, there is no lawful mandate to have the otherwise required supervision of the students involved in conducting research projects. Please be advised that this response is limited to the facts as set forth.
Supervision LTAC - Is it possible to contract a host hospital to provide supervision for our facilities PTAs?
The Board determined it is acceptable to contract with a host facility providing that the host facility is willing to assign a therapist to be the supervising therapist for your PTA.
Pertinent parts of the Practice Act influencing our decision are reiterated below with some further explanation of our decision.
321.A.2.d The supervising physical therapist must be physically in the LTAC supervising 50% of the time the PTA is treating the patients weekly as it is considered a separate facility from the acute care hospital.
The physical therapist must have a working knowledge of the capabilities and competencies of the PTA working for them. The supervising physical therapist must also have a working knowledge and familiarity with the condition of the patient in order to develop a treatment plan for each specific patient.
Section 321.2.a. The supervising therapist must also evaluate all new patients to your LTAC in order to access patients and establish the written treatment plan prior to delegating anything to your PTA.
321.2. b. The supervising physical therapist must also reassess, treat, and document treatment for every patient on their sixth visit. The board also maintains that BID treatments are to be considered as two visits. This would mean that a patient treated BID would have to be seen and treated by the physical therapist every third day.
321.2.c. The supervising physical therapist must also assess the final treatment and write the discharge summary.
Supervision of Foreign Trained Permittee working weekends - Can a foreign trained P.T. holding a temporary permit work weekends without supervision?
Once the permit holder has passed the P.T. licensing examination and the Board has reduced the supervision requirement to one hour per, day with a minimum of five hours per week, then he shall be eligible to work on a weekend basis without on-premises supervision, provided that: 1) the supervising P.T. is available and accessible by phone, 2) the permittee works a full five day week with supervision as required; 3) the weekend employment is the same employer as listed on the temporary permit 4) the P.T. supervisor has determined the permittee to be competent to provide safe, quality treatment to the patients.
Supervision of PTA - We are a comprehensive outpatient rehabilitation facility. We service patients in our outpatient facility and in assisted living facility. My question to you is should a PTA be supervised treatment time or should it be every 6th visit? Assisted living facilities are apartments with persons living in their homes.
The Board has carefully reviewed your inquiry within the context of the Physical Therapy Practice Act and the Board's rules. Arguably, Rule 321 with regards to supervision applies to both the outpatient facility and the home health environment depending upon where the services are provided. For example, if the patient presents himself to the outpatient facility, Rule 321 which requires supervision one-half (1/2) of the treatment time would be applicable. In contrast, if the patient receives physical therapy services in his home, the home health requirement of every sixth (6th) visit set forth in Rule 321 would apply.
Supervision of PTA in LTAC/rehab facility - The therapist iis employed in a LTAC/rehab facility that is providing outpatient therapy to nursing homes (Part B) and home health patients. The inquiry is whether or not to follow outpatient supervision requirement-PT on premises one-half (1/2) of treatment time weekly, or is it required that you follow nursing home (Non-Skilled) requirements-PT doing every 6th visit.
Rule 321.A(2) or (3) are applicable. Please be advised that pursuant to Rule 321, the site controls the appropriate supervision requirement which is based on the acuity of the patient receiving the service. If you are treating the patient in the nursing home or performing home health, then Rule 321 A(3) would be applicable with regards to periodic supervision and the physical therapist is required to treat and reassess the patient on at least every 6th visit but not less than once per month. In the event the outpatient therapy to a nursing home (Part B) patient is performed at the LTC/rehab facility, then Rule 321.Aa(2) would be applicable which requires the physical therapist to be on the premises weekly one-half (1/2) of the treatment time in which the physical therapist assistant is rendering physical therapy treatment.
Supervision and Ratio Requirements for supportive personnel - What are the supervision and ratio requirements of unlicensed persons once a resident is discharged by the physical therapist in a non-skilled nursing facility?
Since the residents were "discharged" by the physical therapist after residents achieved goals, the Board does not feel the patient is receiving physical therapy services. If the resident is "discharged" by the physical therapist and physical therapy has been completed, the facility would be the entity to supervise the worker. The non-licensed worker is merely carrying out a home program. Additionally, since physical therapy is not being provided after the discharge of the patient, the ratio of physical therapist to supportive personnel is not applicable to the situation.
Supervisory Forms for CNAs - As a physical therapist working with a home health agency, it has been requested that the physical therapist complete the attached aide supervisory form for the CNAs when the physical therapist is the only professional service in the home. Is this within the scope of practice of the physical therapist to complete and sign off on this form under these conditions?
The Board is of the opinion that the physical therapist may complete and sign these forms. The procedure is more in the nature of administrative supervision where an employee is graded on job performance rather than the supervision of physical therapy.
Supervisory Visits Home Care Aides - A question has arisen concerning the role of physical therapists in performing what are termed "supervisory visits" to home care aides. These visits generally consist of questioning the home care recipient or family member about the quality of service provided by the aide. Other questions are asked concerning whether the aide is following any instructions provided by the nursing or therapy discipline. It is required by Medicare that his documentation regarding the aide services be provided every 14 days. Since the onset of the home health prospective payment system, physical therapy is more frequently remaining on a case after nursing has discharged the patient and, due to reimbursement limitations, it would be more reasonable for the physical therapist to perform this task. My question is whether this counts toward the limit of 3 individuals who may be supervised by one PT. My opinion is that it is more of a quality assurance measure rather than the typical supervision issue when a PTA or aide is providing on-going service to a patient under the PT's plan of care. It is also similar to providing instruction to a nursing aide in a nursing home or hospital and then questioning the patient or family member about the follow-through on those instructions.
It is the Board's opinion that the Board's supervision ratio of 3:1 is not applicable to the administrative supervisory relationships which you refer to in your inquiry.
Physical Therapy Technician - 1) Can a technician treat a patient without any patient contact being made by the Physical Therapist? 2) Is the Physical Therapist required to initiate all therapy sessions? Can a technician initiate Physical Therapy treatment without initial contact being made by the Physical Therapist? 3) Can a technician write daily progress notes documenting patient status, progress, etc.? (i.e. SOAP notes)
1) No, according to the Rules and Regulations, Subpart 3, Section 321, the physical therapist must "provide on premises, continuous supervision of the physical therapist technician in all practice settings." "On premises" is further defined in Section 305.A as requiring that the supervising physical therapist is personally present in the treating facility and immediately available to the treatment area. The Board feels that the physical therapist should make contact with every patient during a treatment session. It would be unrealistic to believe that unlicensed support personnel would be capable of making decisions with regard to whether treatment should be provided, withheld, or modified for a particular patient considering all the various changes that might take place in a patient's condition. The physical therapist is ultimately responsible for treatment rendered and should be present and make at least visual, if not physical contact with a patient prior to the provision of treatment by a physical therapist technician.
With regards to having the technicians treat a patient in another hall, or next door room when the therapist is on the premises: Again, the Board feels that a physical therapist should make contact with the patient prior to treatment provision. After the therapist determines that the patient's condition is such that a technician could safely and effectively provide treatment, it would be permissible to allow them to treat in the next room or hallway, with the therapist providing proper direction and supervision as it is necessary for the safety of that particular patient.
2) In response to the first question, Yes. In response to the second question, No. See the above response for further clarification.
3) The Board feels it is inappropriate for a technician to write progress notes of any type. The technician does not have the ability to assess progress and therefore should not document in this manner.
Technicians - Crutch Training - Is it appropriate to use orthopedic technicians (part of hospital therapy services) to provide (only) crutch training without a PTs direct patient evaluation/supervision/initiation of treatment (Crutch training is provided in the emergency room by RNs or nursing aides, but this staff is not part of therapy services department)?
The Board is of the opinion that it is not appropriate to use orthopedic technicians to provide crutch training without a physical therapist's direct patient evaluation/supervision/initiation of treatment as part of physical therapy. Crutch training as provided in the emergency room by RNs or nursing aides is permissible because such service is not part of physical therapy, cannot be referred to as physical therapy and cannot be billed as physical therapy. The board has referred to its Declaratory Statement #3 in the Summer 1997 edition of its newsletter, as well as the Physical Therapy Practice Act and the Board's Rules in making this response.
I will direct your attention to Rule 305 which defines the level of responsibility assigned to supportive personnel which is at the discretion of the physical therapist who is ultimately responsible for the acts or omissions of these individuals. It additionally requires that supportive personnel may perform only those functions for which they have documented training and skills. Rule 305 sets forth certain prohibitions. Furthermore, Rule 305 mandates that 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.
Treatment Session/Plan of Care - This concern addresses the issue of treatment sessions/plans of care. In reference to regulation regarding supervision of PTAs (Section 321), is it necessary for the PT to treat the patient for the entire determined treatment session or can they treat them for the amount of time determined to be sufficient to update the goals and plan of care?
Rule 321.A(2)(b) provides that with regards to the requirement of periodic supervision of physical services rendered by a licensed physical therapist assistant, the supervising physical therapist "shall treat and reassess the patient on at least every sixth (6) visit but not less than once per month." It is the Board's opinion that in order to properly reassess, the physical therapist must be involved in the entire treatment session of the patient. Pursuant to Rule 323.A(4) regarding documentation standards, reassessment is defined to mean the written documentation which includes all elements of a progress note as well as the interpretation of objective findings with a revision of goals and treatment plan as indicated. Therefore, the Board is of the opinion that to reassess only based upon the sixth (6) visit without being involved in the entire treatment session does not comply with the intent and wording of Rule 321.A(2)(b). The Physical Therapy Practice Act and Rules promulgated by the Board have been written, and are enforced, to insure the safety, health and welfare of the public receiving physical therapy services. To that end, the Board must implement the Practice Act and its Rules so as to provide the best standard of care for the patients.
Massage Therapist in PT clinic - Can a licensed massage therapist work under the supervision of a physical therapist in an outpatient/inpatient setting and the physical therapist bill insurance for the therapy done under his supervision?
First, the Board is of the opinion that a massage therapist can perform in the capacity of an unlicensed supportive personnel (physical therapy technician) when working under continuous, on the premises supervision by a licensed physical therapist. Rule 305 promulgated by the Board sets forth that required supervision as well as the parameters of what may be delegated to physical therapy supportive personnel by a physical therapist.
It must also be noted that pursuant to the Physical Therapy Practice Act , R.S. 37:2410A, a physical therapist must have a prescription or referral from a person licensed to practice medicine, surgery, dentistry or podiatry prior to the implementation of physical therapy treatment to a patient. Furthermore, a physical therapist must by law perform an initial evaluation to establish the appropriate physical therapy treatment plan to be implemented regarding each patient. After these requirements are complied with, a physical therapist may delegate appropriate portions of the treatment plan to physical therapy supportive personnel. However, it must be noted that the physical therapist is ultimately responsible for the acts or omissions of these supportive personnel.
With regards to your second question regarding billing insurance for physical therapy services rendered, such services will be billed as the physical therapy treatment plan, but under no circumstances can the delegated physical therapy services performed by a massage therapist be billed as "massage therapy" pursuant to his massage therapist license. According to the Massage Therapy Practice and Establishment Act, the Board is of the opinion that licensed massaged therapists are not healthcare providers and cannot bill as such in the healthcare or rehabilitation area. Furthermore, it would be left to the discretion of the third party payor (or insurance company, Medicare, etc.) to pay for "massage therapy" performed by a massage therapist pursuant to his license when such is rendered to a person outside of the physical therapy treatment plan. Again, it is the Board's opinion that for a massage therapist to bill as such for "massage therapy" in the healthcare or rehabilitation area would be a violation of the Physical Therapy Practice Act as well as the Massage Therapy Practice and Establishment ACT.
