PTs are watching PTAs--
but just how closely depends
on where they're practicing
Should physical therapist assistants be directly supervised at all times by licensed physical therapists?
The consensus among state physical therapy associations appears to be "no." But while the majority of state practice acts across the nation allow PTAs to work independently in settings like home care (provided they maintain regular contact with supervising PTs), other states are more restrictive, requiring direct on-site supervision by PTs.
Proponents of direct on-site supervision argue that it's the best safeguard for high quality health care. Others counter that manpower changes due to downsizing and an increasing number of patients discharged early to home health care have created a growing need for PTAs to provide services off premises--and away from direct supervision.
Professional organizations like the American Physical Therapy Association (APTA) and the Federation of State Boards of Physical Therapy (FSBPT), meanwhile, have continued to allow states flexibility in defining PTA supervision.
On-Site, But Indirect
"Rarely does any state require direct visual supervision," said Blair Packard, PT, chairperson of the FSBPT's legislative committee. "Where states choose to retain the on-site supervision requirement, we recommend using the simple term 'on-site,' which usually means on the premises, and not necessary direct visual supervision. In fact, in Arizona the on-site requirement was recently expanded by also adding 'on the campus' to include a long-term care or rehab facility adjacent to a hospital."
In the FSBPT's model practice act, language for supervisory requirements was based both on APTA position statements and existing practice acts in states across the country, said Packard. The model practice act suggests that PTAs should be under the supervision of licensed physical therapists at all times, not only for the "health, welfare and safety" of the patient, but also because of potential liability of the licensed physical therapist.
The APTA position also stresses that the physical therapist is responsible for the performance of the PTA under all circumstances. "Regardless of the setting in which service is given, the following responsibilities must be borne solely by the physical therapist," states the policy. Those responsibilities are interpreting the referral; initial evaluation, diagnosis and development of the treatment plan; delegating and instructing the PTA or other support personnel; reviewing treatment documentation; re-evaluating the patient and revising the plan when indicated; and establishing the discharge plan.
APTA's Off-Site Rules
If a state allows off-site supervision, APTA policy requires the physical therapist be accessible at all times by phone. The physical therapist is also expected to make the first visit for evaluation, to regularly schedule and document conferences with the PTA, to make supervisory visits at least once a month, and to re-evaluate the patient when modification is needed or prior to discharge.
Maryland has allowed off-site PTA supervision for the past 20 years, explained Ann Tyminski, executive director of the Maryland Board of Physical Therapy Examiners.
"The physical therapist must first see the patient, evaluate him and write the treatment plan," she said. "The PTA may do up to 10 treatments. Then there is a joint on-site visit with the physical therapist supervising the PTA during treatment and making any change, if necessary." The PTA must also be in phone contact with the physical therapist, she added.
Has the state considered making the policy more strict? "From time to time, there are people who feel we need to have it tightened," she said. "[But] we haven't had [too] many complaints." According to Tyminski, the most common problem is with physical therapists who allow the follow-up visit to "slide."
"But we make sure the physical therapist understands that he or she has ultimate responsibility for that patient," she said.
On- and Off-Site in NY
In New York, direct on-site supervision is required for PTAs working in a facility. But PTAs employed by a home health care agency (except for early intervention with children through age 3) or working with school-aged children in a school setting may practice independently under off-site supervision.
Furthermore, a physical therapist may supervise no more than four PTAs within a facility, said Patrick Vanbeveren, PT, president of the New York chapter of the APTA.
In the home health care setting, a licensed supervising PT must accompany the PTA to each patient's initial evaluation and must participate in a joint visit once every 30 days or six visits. In home health, the PT may supervise no more than two PTAs.
In a school setting, the PTA must have been supervised directly by a physical therapist for two years prior to undertaking independent care. The physical therapist must also perform the initial and discharge evaluations, while participating in a joint visit once every 12 visits.
Phoning Home in Indiana
Indiana used to have stricter supervision standards--until it confronted the issue of home health care.
Five years ago, Indiana's definition of "direct supervision" required a face-to-face meeting every day between the PT and the PTA to review patient treatment, explained William Rosenbaum, attorney for the Indiana APTA. "But it was causing problems in home care because PTAs were out and about, and it was difficult for PTAs to get together with PTs every day," he said. So the state home health care association contacted the Indiana APTA and made a request.
"We were encouraged to amend our definition of direct supervision," remembered Rosenbaum. "We worked with them over several months and came up with a definition that met their needs." Now direct supervision in Indiana allows the daily PT-PTA meetings to occur by telephone.
Adopted in 1993, the current code further stipulates that the physical therapist, or physician, be available at all times for consultation with the PTA. The supervising physical therapist or physician must also examine patients in hospitals or rehab centers once every 14 days; patients in facilities for the mentally retarded, in facilities for the developmentally disabled, or in school systems once every 90 days or six visits; and for all other patients once every 30 days or 15 visits.
On-Premise in PA and AZ
Like Arizona, Pennsylvania has adopted a more stringent policy that requires direct, on-premise supervision of PTAs by licensed physical therapists. According to the act, "the term 'direct on-premises supervision' shall mean the physical presence of a licensed physical therapist on the premises who is immediately available to exercise supervision, direction and control."
Packard, a physical therapist in private practice in Arizona, said he personally prefers on-site supervision at all times to ensure quality of care. "I believe in this day and age, with managed care and the acuity of patients [discharged early]...it requires more consistent involvement of the physical therapist," said Packard.
When Arizona's state practice act was updated in August, there was no reason to change the on-site policy, said Larry Autrey, member and treasurer of the Arizona Board of Physical Therapy Examiners. "It's been historic in the state, and the consensus in development...was that quality of care issues were better assured with on-site supervision," he said. "My understanding was that the legislature and the people involved, as well as the state physical therapy chapter, felt with on-site supervision, the public is better protected."
Could PTs Make the Call?
Direct on-site supervision might be appropriate for new PTA graduates with little experience, but it can also seem excessively restrictive to PTAs with experience, explained Paul Groseclose, PTA, president of the National Assembly of Physical Therapist Assistants of the APTA.
Rather than imposing a statewide rule on the level of PTA supervision, Groseclose said practice acts should allow supervising physical therapists to make the determination. "It's their license. They have to feel comfortable with what they delegate and what level of supervision [they give the PTA]," he said. After all, "The individual PT knows the PTA he or she is working with."
As to whether on-site supervision really ensures greater quality of care, Groseclose said there's no set guarantee. "It really depends on the individual," he reflected. "I know PTAs who are very professional in demeanor, who only care about the patient's best interest, and who would provide wonderful care if supervised or not." Then there's the other side of the coin--which often goes unconsidered. "You're presuming every PT has the ability to supervise, [but] there's an art to supervision," Groseclose pointed out. "What we really have to look at is what's best for our patients." *
Marlene Prost is a free-lance writer from Audubon, PA, and a frequent contributor to ADVANCE.
There's state law, and then there's "HCFA law."
Physical therapy practices must follow the first to stay out of trouble. Medicare-certified practices must also follow the second to get paid.
Effective Jan. 1, Medicare will require PTAs and aides working in private practice (specifically defined, with a number of exceptions) to be personally supervised by a licensed physical therapist from the practice, who is required to be "in the room" with them while they treat. Hospitals, skilled nursing facilities, CORFs, rehab agencies and home health agencies are not affected. The Health Care Financing Association (HCFA) put forth the requirement for private practices receiving Medicare reimbursement in its final ruling in the Nov. 2 Federal Register.
An issue under hot debate is whether the "personal supervision" requirement is a new one. In the recent Federal Register, HCFA maintains that personal supervision has been the "current requirement" for PTAs and aides working in private practices, and that the federal agency doesn't "have the authority to modify" it.
Not so, argues the American Physical Therapy Association. "A search of the Code of Federal Regulations does not reveal that personal supervision is currently required for PTAs and aides. In fact, in the 'conditions for payment' section, physical therapy is paid if provided under direct--not personal--supervision of a physical therapist, without specific mention of assistants and aides," said Michael B. Arnall, MBA, MS, PT, chairman of the Payer Relations Committee of the APTA's Private Practice Section.
In the Code of Federal Regulations, "direct supervision" is defined as "on the premises." As to why HCFA took "on the premises" and whittled it down to the more restrictive "in the room," Arnall said the APTA is trying to find out. "All of this requires further discussion and clarification and some rationale forthcoming from HCFA," he said.
According to Arnall, the APTA initially addressed personal supervision when it was proposed in HCFA's interim rule back in June. Saying that supervision for PTAs and aides should remain direct, the organization submitted its comments to HCFA formally in the time allotted for feedback; but "there was no indication in the discussion that was published along with the Nov. 2 final rule that the considerations we put forward were even noticed," said Arnall.
The Nov. 2 policy changes the current regulation that requires physical therapists in independent practices to be on the premises during all treatment of Medicare beneficiaries, even when the treatment is being provided by other licensed physical therapists. *
--By Jolynn Tumolo