New Physical Therapy Board Regulations on Adequate Supervision and Patient Records

The Physical Therapy Board of California (“Board”) has issued new regulations which became effective July 14, 2011. The regulations address and define “adequate supervision” of physical therapist assistants (“PTA”), requirements for use of physical therapy aides (“PT aides”), and new recordkeeping requirements.

Background

In 1983, the Board established a regulation that requires a supervising physical therapist to be on the premises of with the PTA 50% of the work day. In 1993, the Board modified this language eliminating the 50% while emphasizing the physical therapist’s responsibility to ensure the PTA does not function autonomously. As the result of the Board recognizing that the regulation was not clear regarding the responsibility for patient care provided by the PTA, the Board appointed a task force to study the issue. As a result of this task force, the Board launched the rulemaking regulatory process in 2010 which resulted in these changes.

Adequate Supervision Regulation

The Board’s regulations are located at Title 16 of the California Code of Regulations. Section 1398.44 addresses the “adequate supervision” of PTAs. According to the Board’s Initial Statement of Reasons dated May 12, 2010, its purpose in amending section 1398.44 was to “clarify who is the supervising physical therapist of record responsible for the supervision of the [PTA],” and to outline what the PTA is required to do and prohibited from doing.[i]
The new regulation revamped the entire section 1398.44, and defines “adequate supervision” as the physical therapist being responsible for “all physical therapy services” provided by the PTA. The section specifically prohibits the PTA from functioning autonomously and requires the physical therapist to follow the patient’s progress and to maintain responsibility for elements of treatment a PTA may perform.
In addition, the regulations assigns the physical therapist who performs the initial evaluation as the “physical therapist of record” until there is a “reassignment” to another therapist with a “written transfer.” In other words, the medical record must now reflect who is the supervising physical therapist at all times, and the Board will presume the initial evaluator is responsible unless the record reflects a transfer. The PTA must also be able to communicate with the physical therapist of record at all times during the treatment.
Finally, Section 1398.44 now prohibits PTAs from performing physical therapist tasks such as:

• measurement or data collection prior to evaluation of the patient;
• documenting patient evaluations or reevaluations;
• establishing or changing a plan of care
• preparing a discharge summary;
• writing non-chart note summaries to other professionals;
• being the sole physical therapy representative in any meeting with other health care professionals assessing or modifying patient care;
• supervising a PT Aide;
• providing treatment if the PTA has a management position in the physical therapy practice.

 
These restrictions do not prevent the PTA from collecting and documenting data, taking measurements or administering standard tests related to patient status. Further, the PTA is obligated to notify the physical therapist and document in the patient record any change in the patient’s condition that was not within the planned progress or treatment goals.

Physical Therapy Aides

The Board also amended Regulation section 1399 regarding PT Aides to require the physical therapist “to document the aide’s competencies for performing tasks specific to the physical therapy setting” and to clarify the meaning of “under the orders, direction and immediate supervision.”[ii] While the former version of section 1399 defined “patient related tasks” and “non-patient related tasks” regarding PT aides, the new version mandates that the physical therapist must do the following prior to the aide providing patient related care:

• evaluate and document the aide’s competency for providing the patient related task; and
• make the record available to the Board or any physical therapist utilizing that aide upon request.

 
This new section adds a very specific recordkeeping requirement that did not previously exist for physical therapists who use the services of PT aides.
The Board also changed how physical therapists must supervise PT Aides, specifically requiring that the physical therapist must be available to provide “immediate” advice, instruction or “intervention in the care of the patient.”

Medical Records

In the final segment of these amended regulations, the Board moved and amended its “Patient Records” regulation to make more specific the documentation and signature requirements. The Board wanted to strengthen its language to make clear that the physical therapist is responsible to ensure that all assistive personnel comply with record keeping requirements.[iii]
Adding to its general recordkeeping regulation (now section 1398.13), the Board now requires the physical therapist to “sign” the patient record for all treatments by the physical therapist and PT aide in the following areas:

• Examination and re-examination;
• Evaluation and reevaluation;
• Diagnosis;
• Prognosis and intervention;
• Treatment plan and modification of the plan of care;
• Treatments by the physical therapist or PT aide; and
• Discharge summary.

 
The Board also added requirements for PTAs to document in the patient record the date and nature of service provided, the name and title of the service provider (not including “non-patient related tasks” as defined in section 1399).
Finally, the section provides that electronic signatures are sufficient.

Conclusion

The Board’s task force has concluded that there has been confusion regarding the roles and recordkeeping of the different physical therapy service providers and these regulatory amendments are the Board’s solution. These new requirements require physical therapists to increase their documented supervision of PTAs and PT aides when physical therapists use them to provide services.
As a result, when the Board investigates a complaint or audits a physical therapist’s records, the Board’s enforcement personnel will be looking for compliance with these new provisions.  Thus, physical therapists are encouraged to implement these new requirements, provide training to their PTAs, PT aides, and other staff, and to seek legal advice regarding compliance if necessary.