What is patient abandonment, and how do I avoid it?
There are three basic elements that must be present in a situation for it to constitute abandonment:
- You have accepted responsibility for a patient's care, i.e. you are the OT or OTA treating the patient, or the OT supervising the OTA treating the patient, whether an employee or contractor;
- The patient still needs care (i.e., has not been discharged); and
- You stop treatment of the patient (or supervision of that treatment) without sufficient notice to allow a reasonable amount of time to arrange for a new OT or OTA to take your place.
Examples of what is NOT considered abandonment:
- You give sufficient written notice that you are leaving (see below)
- You are too ill to work
- Your employment has been terminated, for any reason
- You are working for a contract company that no longer has the contract to treat the patients you've been seeing
- You refuse to accept responsibility for an assignment for which you believe you are not qualified. (This may be cause for termination, but it is not patient abandonment.)
The above examples are all circumstances that are beyond your control, and the Board considers abandonment to be a choice the licensee makes.
Examples of what IS considered abandonment, if you leave without giving sufficient notice:
- You haven't been paid or the check bounced
- Reimbursement has been denied by a reimbursing entity
- You have an argument or disagreement with your employer, a patient, or a co-worker
- You don't think your employer is dealing with you fairly
- You don't like the patient
- Taking a vacation day (or days) that haven't been approved by your employer when you have patients to treat or OTAs to supervise
The most important consideration is to make sure you give appropriate written notice to your employer (or your patient, if you are self employed). This allows your employer or the patient sufficient time to find a replacement for you, so that patient care is not disrupted. In most cases, 30 days is adequate time for a replacement to be found. The Board does not dictate the actual amount of time as some companies have a stated number of days required in their employment contract. If a complaint of abandonment is made against you, the Board will look at the patient's condition, the circumstances, and the availability of replacement in the area to determine what it considers enough notice. If your employer tells you to leave once you turned in your notice, you are not required to continue working, but you should document for your records that your employer has made that decision.
Document whatever you communicate to your employer or patient about your resignation. Include in your letter the effective date of your resignation, and any other information you believe may be important to establish your plans, your expectations of your employer (or the patient), and your consideration of your patient's needs. Keep a copy of letters you write for your records. If for some reason you delay your resignation and continue working, document the changes to your plans and make sure they are clearly stated to all parties. If you encounter a situation where you feel you must discontinue treatment or leave your job, and you are concerned that your patients or license may suffer, call the Board for direction.
Do I have to renew my certification with NBCOT?
The Board does not require that you maintain your certification however some employers, especially national ones do. The continuing education that you do to maintain your license may be counted for your certification for NBCOT's requirements, so there is no further CE requirements, just the paperwork and payment. If you do maintain the certification you can use the initials OTR or COTA. If you do not, you can use OT or OTA. This is written in OT Rule: Chapter 369, Use of Titles and 362, Definitions.
If I do not maintain my certification what are the consequences?
You will sign your name with OT or OTA. Be aware that some state(s) or employers may have this requirement and you will have to contact NBCOT about restoring your certification should that situation arise.
Can I practice occupational therapy after I pass the certification examination?
You must have a Texas license in hand before you begin to practice. You must also hang your original wall license on the wall at your employer. You cannot hang a copy of your license, if you have a second employer, but they can verify your license online. Refer to Chapter 369, Display of License.
Can I accept a referral from a nurse practitioner?
Yes. The OT can accept a referral from anyone who in their practice act may write script. That includes but is not limited to physicians, chiropractors, dentists, physicians' assistants, optometrists, psychiatrists, podiatrists.
Can an OT or OTA supervise the Restorative Nursing Program?
No. The OT cannot run the restorative nursing program, but can make a recommendation for the patient to participate in the restorative nursing program and/or any specific recommendations for the patient as part of the discharge from skilled services.
Can the occupational therapy practitioner sign off for an Activities Director?
No. The activities director is not providing occupational therapy services. Unless the activities director is working with a client, under the direct, on-site supervision of the OT, and unless that client's activity is part of a prescribed OT plan of care, the OT should not sign off on the activities director's services.
Can the OTA write the discharge?
No. The occupational therapist must review any information from the occupational therapy assistant(s), determine if goals were met or not, complete and sign the discharge documentation and/or make recommendations for any further needs of the patient in another continuum of care. The OT can fill in the narrative about the patient to assign this to anyone to transcribe.
Can OTs apply prescription topical medications, such as those used in iontophoresis?
Since occupational therapy practitioners do not administer medications, the Board recommends that the patients bring the medication, apply the medication during the occupational therapy treatment, and take it home with them.
Do I have to be certified or follow other procedures before I provide a physical agent modality?
The Board does not have specific requirements. You are responsible for any intervention you provide. You should get plenty of CE in any new treatment and become certified if possible.
The Previous OT did not sign the discharge and now I'm faced with the paperwork. What do I do?
You can sign a "late entry" a type of summary note that tells what facts you are aware of according to the patient's file. The patient's last treatment was x date, was discharge on x date and is no longer receiving OT services, then sign the discharge with the date you write the note. The paperwork that you write or sign must be dated when you are writing it, and not backdated. Similarly, if an OT intervention note is lost (?) you write a note and date it when you write it, saying that according to your calendar you provided the intervention on x date and dprovided x services. You can never write a date for the past (backdating) or for the future in anticipation of intervention, only the date you write the note.
Can an OT see a mental health patient such as someone with PTSD or Schizophrenia without a doctor’s referral?
If a patient/client/individual is in the hospital with acute PTSD, then it is a medical condition and it would be necessary to have a script. If seen in the community that says that the individual is stable enough to be in the community and therefore no script is necessary.
Not just PTSD but you can look at a variety of disabilities/diagnoses…Schizophrenia for example. Individuals who suffer from Schizophrenia can be stable and live/work in the community, attend groups in the community, etc.
If the patient deteriorates and symptoms occur, the OT or whoever is running the community based group/facility would contact the doctor, hospital, or the police.
Can I co-treat?
You will have to look at what the payer allows. The Board has no rules on this.
ECI and School
1. Since qualification for OT school-based services depends on educational need, should OT evaluations in the schools be conducted on children that have not had educational exposure (i.e., soon to be 3 year olds who plan to come to school and have an OT evaluation and current services from Easter Seals). Shouldn't these students be in school first with strategies attempted from the staff before an OT evaluation is requested?
IDEA does not address procedural issues - how to handle this kind of situation is exactly the sort of thing the Independent School District(ISD) has to determine itself.
School districts typically develop procedures for guiding staff in the situations you describe, but most allow for discretion on involving the various related services depending on the child's disability. For example, for a 3 year old with Autism entering a PPCD class, the school district may involve the behavior specialist from the start, but want the child to have the opportunity to benefit from the special instruction and structure of the program and see if progress can be made BEFORE considering a referral for OT. On the other hand, for a multiply impaired student with feeding, mobility and visual challenges, the district might want OT, PT, and O & M involved from the beginning to support both child and teacher.
For older children, assessment data and the professional judgment of those involved in the evaluation process (the IEP team) will drive decisions. No district wants to provide services that are not necessary as that becomes an interference with instruction and wastes provider time. My best advice when the team is uncertain is to consider a few hours of services on behalf of the student, such as providing training to staff on strategies for adapting and modifying activities/routines to ensure student participation. If progress is not evident in data collected on the goals 4-6 weeks after this has occurred, the team will want to consider what intervention(s) to move to next. If on-going OT appears necessary, an amendment can be done to the IEP (in person, by phone or online meeting) to add more time.
No, ISD is responsible for services in student's IEPs that are not provided. It is their responsibility to find the needed providers. The professionals who work for the district are not liable.
2. I'm an OT working in the school setting. I have a question regarding prescriptions from an MD. I am aware that non-medical conditions do not require prescriptions for direct services in the school setting. However, I am required to get a script for SHARS billing. When requesting a prescription from the doctor, the doctor returned the prescription specifically stating that the child "does not appear" to need services. As per ARD, OT services were recommended. Are we allowed to see the student (under our OT rules) if a doctor has returned a prescription stating that they do not need services?
Per IDEA, the legal authority for decision-making for educationally needed occupational therapy lies with the ARD committee, not a physician. The OT can move forward with OT services at school.
Obtaining reimbursement from Medicaid through SHARS for IEP-based services, however, will be problematic. Perhaps this student has another physician that will sign the prescription. If not, the district will not be able to obtain reimbursement for IEP-based services from SHARS.
One more suggestion - the student's physician may not know about school-based services and how they may differ from those that are considered "medically necessary." It might be worthwhile for the OT to call or visit with this physician and explain the SHARS program and the educational basis of the IEP. The physician may not realize schools can bill the SHARS Medicaid program for educationally necessary services.
3. Can OTRs write a stand alone goal in a student IEP as a related service or are they suppose to be supporting what the team has come up with?
We have had parents asking OT to write their own goals for "handwriting" and are having a hard time explaining to them that OT looks at more than just handwriting. Do you have any suggestions to help better explain to the parents what OT looks like in the school setting? School districts seem to think that OT is suppose to be teaching handwriting.
There is no law prohibiting "OT goals," but research in OT (as well as other disciplines) supports related service collaboration for positive student outcomes. Team collaboration starts in the IEP meeting with identifying present levels of academic achievement and functional performance (PLAAFP), making decisions regarding what the student needs to accomplish over the next 12 months, writing goals (goals should indicate desired outcomes in measurable terms), then deciding what supports and services are needed to help the student accomplish those goals. If OT is needed in addition to the instructional program, the OT should be added to the goal. There isn't any need or legal requirement for a separate goal. It just needs to be clear in the IEP which goal(s) the OT is supporting.
As for handwriting, this is an instructional issue. OTs are not handwriting teachers. If a regular education student has received instruction but continues to struggle, the OT can be a resource for the teacher by offering general strategies. This will come up if the district has an RtI process and the OT is part of the RtI resource or problem-solving team. Just keep in mind that per TBOTE Rules, OTs cannot provide OT services individualized to a client (student) without have done an evaluation. Restrict your suggestions to those that are generally helpful to children having handwriting problems (try a slanted surface, try a pencil grip, incorporate 10 minutes of practice every day, etc.). It is not appropriate in this scenario to provide direct intervention to the child.
If a special education student has received quality instruction but continues to struggle, an OT referral for evaluation may occur. After it is completed, an IEP can be developed that is supported by both the instructional personnel and the OT. They should work together to support student progress.
In both of these scenarios, all efforts should be made by the educators to ensure quality instruction has taken place before the OT is involved.
4. I am serving on a section 504 committee and we have an upcoming evaluation in which the student has a treating diagnosis of Coordination Disorder from an outside OT. Under the law, we must consider identifying a student under section 504 if the student has an impairment as diagnosed by a certified or licensed health professional. I am struggling with whether or not a "treatment diagnosis" is a "real" diagnosis, and whether "Coordination Disorder" as a treatment diagnosis would constitute impairment. What can you tell me about this?
Developmental coordination disorder is well documented in the literature (search in Google Scholar for research) and should not be dismissed as a legitimate diagnosis.
In deciding whether services are needed under IDEA or Section 504 of the Rehabilitation Act of 1973, a medical diagnosis alone is not a determinant. Rather, the barriers to learning and participation that result from the manifestations of a disability or disorder is what is relevant. In other words, it is not impairment alone that makes the decision, but the activities that are expected of the child and the design of the environments he or she will be in during the school day that should drive the decisions regarding the need for services.
5. I am an OTR working in two special education co-ops. I have recently been told by the special education directors that the way we are writing our minutes down is not acceptable to TEA. We are writing for example "a minimum of 120 minutes 4 times per six weeks" We are now being told that we need to document what will happen each week. I am wondering what is best practice. We of course document when there are holidays and conflicts but I am wondering how you juggle all of this and still try to attend ARDs and still see your students for their weekly time. How should we write it down for ARD documentation?
I am also wondering about doctors’ referrals for OTs. I had read in the past that they are only needed for students that are under medical care. We were also under the interpretation that for Medicaid that they are only needed every three years. Is this correct? We are trying to obtain them on all students that we see if we are able even on the ones not under direct medical care but we are only doing this every three years is this adequate? Of course, if a student goes through a significant medical change we are obtaining a new script even if it is in the middle of the year.
I am also wondering is there a website or conference or something that I can do to keep up on all the most recent rules and regulations for OTs in the school system?
As regards documentation of services: TEA has recently (spring 2011) developed requirements for how time, frequency and duration must be documented in the IEP. This is new in our state and was put in place because parents and other members of the ARD committee were unclear as to exactly what the pattern of visits would be (they could not tell from the way we were documenting services). This decision by our state is not necessarily consistent with best practices, but we must live with it and make it work for our students.
Please refer to the document at the following link for what is required by TEA:
Please note that services do not need to be provided weekly. Nothing has changed about meeting the needs of the individual student, and many students do not require weekly services.
As regards medical referrals: For clarity on TBOTE requirements, please refer to the definitions of medical condition and nonmedical condition in the TBOTE Rules. Medicaid rules and requirements are separate from TBOTE rules. They govern what is required in order to capture reimbursement from Medicaid.
6. The occupational therapists in our school district are being asked to participate in the Response to Intervention process (RTI). This is our question: Is parental consent required to do an observation, and make recommendations for the teacher and/or general education team to use in the classroom.
There is currently no legal requirement to ensure “notice and consent” for general education interventions provided for struggling students. TEA suggests:
1. parents should be informed that there is an RTI process in their school, and
2. parents should be informed when a student in receiving interventions as part of an RTI process.
Again, this is not law, and school districts typically develop their own policies and procedures around this topic.
7. We are being asked to support AT on students that do not receive OT services. I also understand that at times AT is used for "writing" and this is a gray area as to how OT is suppose to support the AT.
Often times we get a parent that is requesting AT for "handwriting". When the OT looks at the child she would not recommend AT as the child has the fine motor skills to be able to write but is not motivated. Often times the team will give the student AT to please the parent and then ask the OT to support for "handwriting". What do we do when we are not seeing a need for OT services but the team gives AT and is asking for OT support? The AT is not needed for the child to be successful in their school environment?
The district can choose to assign their OT folks to the AT team. In that capacity, their role is to follow district procedures for evaluating the child’s need for assistive and/or adaptive technology. Whether serving students for OT or AT, the therapist’s responsibility is to make recommendations, based on current data, regarding the educational need to support OT or AT (whatever is the case). The ARD Committee makes final decisions, and the district is responsible for implementing what is in the IEP.
If this process, which is laid out in IDEA and state law, is followed, the OT has no licensure issues.
8. Can TEA (through its auditing /compliance process) dictate that educationally based occupational therapy services (direct or indirect) be provided on only a daily or weekly basis?
TEA is not dictating the frequency of OT or any other service in its Related Services Guidance – decisions such as this are made by the IEP team, which has full legal authority and responsibility for doing so. No outside entity has authority to tell the IEP team what to decide. Therapists cannot tell the IEP team what to decide, special education administrators cannot tell the IEP team what to decide, TEA cannot tell the IEP team what to decide. Recommendations can be made and discussed by the IEP team, but in accordance with federal law (IDEA), they alone decide.
TEA is, however, requiring that when IEP teams determine that OT (or any other related service) is needed to support a student’s IEP, the time, frequency and duration of the needed service be written so that all stakeholders are clear exactly what the pattern of services will be. Additionally, TEA asks that frequency be expressed in the IEP document in increments of weeks. So, a student who needs services might have in his IEP something that looks like one of these examples:
20 minutes, 1x per week
30 minutes, 2 X per 3 weeks
60 minutes, 1x per 2 weeks
15 minutes, 1 x per 18 weeks (semester).
Another issue that seems to be confusing is the description in the TEA Q & A document regarding direct and indirect services. If you read the Guidance document, you will see that there is nothing in the documents specifying a requirement for documenting time for direct and indirect services.
Understand that 1) TEA monitors working in school districts on compliance matters and 2) some special education directors around the state are making very restrictive interpretations of how services must be documented in the IEP, and this may be the case with Austin ISD. Issues with SHARS documentation and the design of software programs that are used to document IEPs further complicate these matters.
I don’t know where the issues are coming from some ISDs, but it sounds like special education administration is making some decisions about how they want services documented that is more than what TEA requires. The best course of action is to work with the district administration to influence the decisions being made if they restrict the OT’s ability to provide the services the students’ need.
Here is a link to the TEA webpage that can lead you to the official state documents on related services:
9. When providing consult services, does an Occupational Therapist have to have specific OT IEP goals? I have heard different scenarios:
- OT can be checked as an implementer on the teacher's or other's IEP goals and does not have to write their own goals
- OT needs to write specific O.T. goals for consult and direct services
- OT does not have to be attached to any goal to provide consult services
The term "consult" is a term not occurring in federal law, state law, or current OT practice documents. It remains deeply embedded in the culture of school practice, however, including software programs used to document student IEPs.
Any OT services provided to support a student's progress on IEP goals and/or objectives must be in the IEP. Best practices support collaborative IEP goals -- in our role as related service providers, separate "OT" goals/objectives are inappropriate. This is the case whether the services are "provided directly to the child or on behalf of the child" (language from IDEA), or provided using "direct" or "indirect" services (language from TEA).
10. I have a question concerning IEP's for students on consult. I have recently begun supervision of a COTA in a Texas school district. I have always used the practice of writing a goal for "participation" for my kiddos that are on consult. Is this best practice?
Yes writing a goal for participation is best practice. OTs and OTAs can also address any goal in the IEP either on direct or consult basis.
11. I am a Special Education Teacher and one of my students diagnosed with autism was “tested" (and I use the word tested loosely) for sensory issues by our Occupational Therapist using the Sensory Integration Inventory-Revised test. Her, the OT, results indicated that there was insufficient evidence showing any sensory issues and her suggestion was for the student with autism in a life skills classroom not to be placed on a sensory diet. She did not suggest additional testing, which is quite queer to me being the SII-R showed insufficient evidence. In addition, the SII-R is a non-standardized check list that is used when clients cannot participate in standardized test. This student is more than capable to participate in a standardized test. Also the SII-R value depends on interpretive skills of the OT. The OT that works for our district has only practiced for a little over a year and is inexperienced in dealing with sensory issues.
IDEA 2004 requires that all areas of suspected disability be addressed through the data gathering process for the Full and Individual Evaluation (FIE). It is certainly appropriate for members of the IEP team to speak up if they feel there are areas that have not been fully addressed. In my view, the best course of action in the situation described below is for the teacher to meet with the OT and express her concerns regarding the sensory testing. There may very well be sound rationale for the decision the OT made not to pursue further testing. If that is the case, the OT should be able to articulate his or her view so that the rationale is clear to the teacher (and other members of the IEP team). On the other hand, if the OT agrees that additional testing would be beneficial, there are other assessment tools that can assist with the process.
If the teacher continues to have concerns after their discussion, he or she may want to get together with the OT’s supervisor for further discussion.
12. Given that, “The practice of occupational therapy does not include diagnosis or psychological services of the type typically performed by a licensed psychologist.” Does an OT who performs an OT evaluation for the purpose of identifying sensory processing deficits that can then be included in a child’s diagnosis of Autism to establish the proposed revised DSM-V diagnostic criteria that a child exhibit “Hyper-or hypo-reactivity to sensory input” perform an infraction on their Texas OT license?
The OT is not diagnosing in this case. Rather, the OT is providing information from OT evaluation that helps to describe how the child is processing sensory information from the environment. In the medical community, the physician would determine whether or not to make a diagnosis of Autism based on this and other data gathered during a comprehensive diagnostic process. In the case of schools, the ARD Committee decides whether or not the child meets the criteria set by the state as regards the disability of Autism in order for the child to be eligible for special education and related services. Again, this would be based on a comprehensive process of data gathering from many sources, not just the OT evaluation.
13. We have already spoken with TEA and now seek clarification regarding the interpretation of the current OT Rules in relation to stating support of specific goals for school-based OT services: OT services are provided "on behalf" of the student through a collaborative/ integrated approach which may include, but are not limited to the following: direct student contact, consultation with classroom staff, consultation with medical personnel, training of school staff, consult and training of parents.
OT services may be provided with support to specific IEP goals (i.e. handwriting or self-care), but may also be provided "on behalf" of the student to support to the student's IEP through any number of interventions as mentioned above.
A clear statement of how services are provided and how the student's IEP or goals are supported should be written within the IEP document. In our district, this statement can be found in the ARD PLAAFP as well as in our Annual Summary report. This meets the intention of the current OT Rules. In identifying the need for provision of OT services with support of the IEP as a school-based occupational therapist. Two examples of this statement might be:
Occupational therapy services are provided in collaborative/integrative approach through direct and consultative services to support Suzie's IEP. Suzie has made much improvement in her legibility of writing the alphabet. She continues to present difficulty producing diagonal lines and transverse lines that impact her ability to correctly form the letters, though her approximations of these letters are recognizable. Occupational therapy services have been provided for the purpose of enhancing Suzie's ability to manipulate classroom materials and tools and with the development of a handwriting program. See OT Annual Summary for further information.
Occupational and physical therapy services are provided in a collaborative/integrative approach through both direct and consultative services to support John's IEP. Due to John's medical diagnosis, he is unable to sit without full support and he is non-ambulatory. He uses a power wheelchair for all his school seating and mobility needs. The physical and occupational therapists support John's educational program by providing assistance with seating, positioning, access issues and suggestions for IEP strategies, adaptive assistive device and mobility needs at school as well as with training the educational staff in his physical management needs. See OT/PT Annual Summary for further information.
In a nutshell, the IDEA process assumes the student will be educated in the general education classroom (if not, it has to be justified in the IEP document). The sequence of events under IDEA 2004 is as follows (this is a brief overview):
1. The ARD Committee reviews any new evaluation and/or annual data from the collaborative team regarding the student's present levels of academic achievement and functional performance (PLAAFP);
2. The ARD Committee develops a program including goals (and objectives if desired) for the upcoming 12 months based on the PLAAFP and the upcoming grade level curriculum. Academic goals must follow the TEA requirement for Standards Based IEPs. Functional goals are developed for supporting behavior, self-help and social/emotional needs. In all cases goals may be collaborative, as is consistent with best practices.
3. The ARD Committee determines whether related services and supports are needed so that the student can make progress on the goals, and if so, the time, frequency and duration of those services is documented in the IEP as per TEA requirements.
14. I am an OTR working in school-based practice. This upcoming school year my job is going to include RtI for fine motor and handwriting skills in Pre-K and Kindergarten classes in two elementary schools. I am taking the AOTA's CE course for RtI for At Risk Learners and also signed up for the RtI Action Network online. Both of these resources recommend that I check with my state board to understand exactly what I am allowed to do within the OT Practice Act as an OT working in General Education.
I need to know if I am allowed to provide direct one-on-one service during the Tier 3 part of RtI in General Education? What about doing universal screenings for the entire class? And individual screenings....is that permitted for OT in General Education? I feel that it is probably ok to educate the teachers and make general recommendations since that is part of my workload in the schools already.
In regards to how you deliver RtI services within the Texas OT Practice Act and Rules, they are no different than how you provide services for children under IDEA. You can provide screenings, evaluations, direct intervention - 1:1 or by group, and consultation services. You do not require a doctor's referral for any services (evaluation, direct, consultation) unless you believe it necessary "...during the evaluation or treatment process when necessary to insure the safety and welfare of the consumer." - in this case the consumer is the child/student. (§372.1.b(2) Provision of Services) As best practice (but is not specified in the OT Practice Act or Rules), the parents of the children you may provide screening to (either individually or as a group) should be informed by the teacher via a written letter. As long as these RtI services are available to any child, you do not have to seek consent prior to screenings/evals or provision of services. This is different from IDEA - in IDEA, consent must be given because the child is receiving instruction and/or related services that is different from what is available to all children.
15. I’m an OT whose OTA wants to work on handwriting skills over the summer with the some of the kids from our school. The assumption was that handwriting teaching is not OT and the OTA would not be using her license.
Not necessarily. There are issues that must be addressed with this situation. The most important one is this:
Is the OTA going to work in some other capacity, such as the owner or employee of a business that offers handwriting skills instruction but does not characterize what is going on as OT? That could work, but if the children attending are the same children the OTA sees during the school year, the district needs to know about it. They may have concerns that parents might construe what the OTA is doing as supporting the child's IEP, even if the OTA does not say that is what is occurring. The parents could use this as a basis for due process, claiming the OTA's involvement as proof the district wasn't doing enough during the school year (it has happened!). The district may not want the OTA to work in this capacity, and they may very well have board policy in the area of conflict of interest that allows them to approve any outside work their employees want to do. It could be the case that the OTA would have to resign her school district job in order to do what she has in mind.
Additionally, if the OTA is going to work in the summer as owner or employee of a business that offers handwriting skills instruction he/she needs to be certain to have a job title and job description for something other than occupational therapy (handwriting specialist, tutor, etc.), and that does not require an occupational therapist. To clarify the last point, it should be a position that other kinds of folks could qualify for as well, such as teachers, paraprofessionals, etc.
Finally, the OTA should be especially hesitant about going to work for a local private therapy group in the summer to do handwriting (whether it is an OT, PT or speech practice). In that environment, even if the OTA has another job title, it would be very hard to argue that providing support for children with handwriting struggles isn't some form of OT, since that is clearly part of what she does in her school job.
16. In the Early Intervention program that I work for, we have had a hold list for occupational therapy services for several years due to a lack of therapists. Prior to last week, if we evaluated a child we could not see due to having a full schedule, on the IFSP next to our recommendation for services and the time, the early intervention specialist would write "therapis.t" She would then look for services from an outside source and explain to the parent that we could not provide that service as we did not have enough therapists.
As of last week we were told that we could no longer have a "hold list" due to IDEA guidelines and that we were out of compliance. Now on IFSP's, whoever the therapist was, her name would be used as providing the service. Early intervention specialists would still offer alternative solutions or they could wait until the therapist had an opening.
The past three years we have had a hold list. When these children would be seen could be months and months. My case load as a part time OTR would swell and it would appear that I was carrying many more children than I actually am. So there is still a hold list, however, it is not called a hold list. Rather than the institute having the hold list, individuals would have it.
I objected to this practice but was told that "other programs were doing it and it was acceptable practice." That service delivery was not as important as this time but to meet the 28 day guidelines set by EI. This means that a child must be seen within 28 days. After that they could sit with no services until a therapist is available. This would change my case load from somewhere in the high teens to almost double if not more than double even though I was not providing services. I question what happens to these children and the future of ECI as well as if this is legal under my OT license.
To my knowledge, ECI has never sanctioned wait-listing children. It has always been their policy that children are assigned to a provider. Over the years, some programs around the state developed procedures that amounted to wait-listing, and the state has cracked down on that in recent months. Where a therapist is not readily available to serve a child in ECI who has OT in their IFSP, programs in our area typically call on the service coordinator to help the family identify other places in the community that the family might seek services.
The OT who contacted you has legitimate reason to be concerned, but in this case I think the appropriate agency to contact with her concerns is DARS ECI. They would be in the best position to influence the situation.
17. I currently work for an ECI program as a COTA and I was concerned with something we are starting to encounter. We are being asked to deliver a service to a family where on the IFSP it states that the child will receive OT 4x a month for 45 min (for example). However, it is knowledge prior to establishing the frequency that the service will not be delivered as stated due to the therapist schedule being full. We are being asked to fulfill 1 visit for the 28 day deadline and then pick them up according to frequency when our schedule allows. I am seeing this as unethical because we are knowingly establishing what therapy and the frequency would best suit the child’s needs, but are not carrying this out. Is this not considered abandonment or unethical? My supervising OT as well as the other COTA are having a huge ethical issue with this. What are your thoughts or what are the guidelines concerning this?
The IFSP is a legal document identifying the needs of the child and family being served. Programs have a responsibility to serve what is in the IFSP. But sometimes staffing shortages cause delays. There should be full disclosure to the family of what the program can provide during the shortage, with make-up visits planned as soon as possible. If a good faith effort is being made to serve, abandonment and other ethical issues should not be of concern to TBOTE.Program directors in our area have been proactive when this situation has occurred, and sent letters home to families explaining the problem and how they are addressing it.
18. There is a DARS ECI Standards Manual that would be a good place to start. I would use Google to find it. There are also details in the DARS ECI Rules. I believe the Rules can be found in the Texas Administrative code section that deals with Health and Human Services. Having said that, there is great pressure on programs to meet the requirements for starting all services in the IFSP within 28 days after the IFSP meeting is held. I don't know if there are contingencies in the Standards or the Rules for hospitalization of the child.
There is no longer a DARS ECI Standards Manual, so please refer folks to new state policy, effective September 1, 2011, to find the answer to your question:
The new rules haven’t yet been published in the Texas Register – that should happen in the next edition, I believe. That version should be easier to work with for licensees than the TAC.
19. Please explain about OT services and ECI.
In Texas, when special instruction is medically necessary, it is now called developmental service (DS). CMS agreed to reimburse for DS as long as the child receiving the service had a medical necessity for developmental services and personnel on the interdisciplinary team included professionals from a medically related field. Medically related professionals include licensed physicians, registered nurses, licensed physical therapists, licensed occupational therapists, licensed speech/language pathologists, licensed professional counselors, and licensed master social workers-advanced clinical practitioners.
DS is a separate and distinct service. If appropriate, the licensed professional on the team may provide his or her own related professional service at the needed frequency and intensity, or refer to another appropriate medical provider whenever indicated through the IFSP process. A physical therapist may provide consultation and supports to a DS provider or deliver physical therapy directly, or both, depending on what the interdisciplinary team deems appropriate for a child. Depending on need, a child may receive both DS and PT and/or OT. DS does not replace physical or occupational therapy. For AOTAs explanation please click here for PDF document.
20. What is the difference between my role as an OTR in an Early Childhood Intervention (ECI) setting and my role providing Developmental Services (DS)?
In an ECI program, an OT might do one of the following.
- provide occupational therapy services to client families based on an OT assessment
- serve as a case manager (called a Service Coordinator in early intervention program) to program client families (may or many not be the same families served in OT role)
- Serve as a program supervisor, manager or administrator
- provide training to other professionals
- one of seven designated professionals (OT, MD, RN, PT, SLP, LPC, LCSW) who can provide Developmental Services (DS) monitoring or DS services for children participating in Early Childhood Intervention (ECI). The designated professional monitoring DS needs to attend or review any Individualized Family Service Plan (IFSP) for the child receiving DS and assess the child's needs at a minimum of once a year.
Children receive DS services as a result of the IFSP. Once the child's outcomes are developed by the team, which includes the parent(s), the team decides who would be the most appropriate person to assist the family with the outcome/strategies. Besides the Early Intervention Specialist (EIS) anyone of the seven professionals could provide DS services and, as an example, in some ECI programs an occupational therapist may provide 30 minutes of occupational therapy and 30 minutes of DS services. The DS services may be a more generalized fine motor session that would not necessitate an occupational therapist to provide. The EIS has an overview of general early development and training in working with families in the natural environment.
21. Do I need a referral for school practice?
The TBOTE Rules do not require a referral for OT for non-medical conditions. Based on the definition in the Rules, this would include ADHD. Other examples of non-medical conditions would be cerebral palsy, learning disabilities, autism, and spina bifida. This is not an exhaustive list, and in all cases the presumption is that the child with the disability is otherwise healthy. In each of these cases, the disability is static, not acute or progressive. Many folks take medication to help manage symptoms (antihistamines, decongestants, seizure meds, stimulants for ADHS etc.). It is important to know if the child is taking a medication so precautions can be adhered to, but just the fact that someone takes medication does not require the OT to get a referral.
Examples of medical conditions that would require a referral would be for a student with cancer, rheumatoid arthritis, muscular dystrophy (might not be needed during times of stability, but would be needed during times where the student is clearly degenerating and functional or medical status is changing), or when a CP child has a rhizotomy or gets a baclifen pump. The flu or another virus is not cause for a medical referral, but significant change in medical status or functional condition would be. At some facilities they get a medical referral on an annual basis, the but Rules do not specify a frequency.
22. We recently had an ARD (Admission, Review & Dismissal) on a child where the parent disagreed with both the OT time and goals. The student’s former IEP (Individualized Education Program) is expired but the parent wishes for us to continue services. We have revised the IEP, which still does not satisfy the parent though she still wants us to continue with services. How do we proceed?
Sometimes parents disagree with the IEP developed by the ARD Committee (IEP team). They may disagree about instructional issues, placement or related services issues. Sometimes occupational therapy is the issue, either because parents desire the service for their child when the rest of the team does not see the need, or there is disagreement about the amount of time required (parents desiring more time than the team feels necessary). There are several ways the parent may proceed, including the following:
- The parent can agree to disagree, signifying their disagreement by checking "disagree" by their signature on the ARD paperwork, but indicating they do not desire to pursue a remedy (mediation or hearing). In this case, the new IEP takes effect and everyone moves forward with the new plan.
- The district can "table" the meeting -- i.e., hold a 10-day recess, during which time both the district and the parents can gather any further information that may help the IEP team move forward to consensus. At the end of 10 days, the IEP team reconvenes to complete the discussion and come to a final decision. At this juncture, if the parents still disagree, they can decide whether to move forward to mediation, a due process hearing, or do nothing. If they do nothing, the new IEP goes into effect. If they file for mediation or a hearing, there is a "stay put" requirement. That means that the old IEP (with all services provided as specified in that IEP) stays in place until the dispute is resolved through the mediation or hearing process.
In order for occupational therapy or any other related services to be provided, Texas Rules require a written Plan of Care based on a current occupational therapy evaluation. In the case of school practice under IDEA, the Plan of Care is the IEP, specifically the relevant goals and objectives being supported by occupational therapy (collaborative goals and objectives are fine, as long as it is clear in the written document what OT is supporting). So, in answer to your question, there must be an IEP in place in order for OT to be provided. When confusion arises in cases of disagreement, school-based OTs and OTAs should look to the district special education administration for guidance regarding which IEP to follow. If there is no IEP, an ARD meeting must be held to decide which goals and objectives OT will address before any services are provided.
23. I am currently dealing with a parent who is requesting that her child be tested and diagnosed for dysgraphia. It appears that her “outside” OT and/or physician said that the school district OT could test and diagnose this. Can OTs test and diagnose for dysgraphia? If not, who is responsible for this diagnosis? It is my understanding that we cannot diagnose for any condition.
No, OTs do not diagnose in schools (or anywhere else for that matter).
If a parent wants services from their local school district for dysgraphia, they can bring documentation of a medical diagnosis, and then go through the evaluation process so that the IEP team (ARD Committee) can determine if the child has a need for special education and related services (just like any other diagnosis). The personnel involved in the testing might include the OT, but not necessarily. Handwriting is an instructional issue, so it is not automatic that an OT would be involved. Even if a disability that results in dysgraphia is identified, OT may not be required. Best results for writing, as indicated by evidence across research studies over many years, is from explicit instruction and practice, neither of which require an OT.
24. If a student qualifies for Special Education services as a student with Speech Impairment ONLY (goals address language and articulation issues), can OT be a related service for the child for fine motor issues in the classroom setting?
The issue is confusing in our state because Texas has classified speech as an instructional service in our Education Code, rather than as a related service, as it appears in IDEA. On page 9 of the 2004 TEA document, Provision of Related Services, TEA is explicit regarding the action school districts must take regarding related services: “District information reflects that all disability categories are considered for related services.” Along with all official TEA documents, Provision of Related Services can be accessed at:
Finding a way to support speech goals may be difficult (what is OT “relating” to?). The OT should work with the ARD committee to determine if there is an education need for occupational therapy, and if so, to develop goals that support the student’s special education program.
25. I had a director of Special Education ask me about OTs refusing to do sensory integration therapy in the schools. There are more and more demands for SI therapy in the schools, many times by parents, and the director wanted to know what position she should take with her OT. What do you suggest? To me, if the OT does not feel she has the competence to safely serve children using a sensory integration model, then she should not be using the techniques. How would you advise?
Sensory Integration/Sensory Processing is one of the theoretical frames of reference in occupational therapy. ALL occupational therapists working in schools should have a working knowledge of Ayres' original work in this area and also of the current work by Winnie Dunn, Lucy Jane Miller and others that is contributing to the evolution of thought regarding this framework (as with any profession, keeping up with the literature is critical to practice competency).
Through observation of the student in context, and, through use of assessment tools such as the Sensory Profile School Companion and Sensory Processing Measure for Home and School, any occupational therapist should be able to detect atypical sensory processing as part of the OT evaluation, and be able to document whether or not it is contributing to learning and participation difficulties. If a student is identified as having atypical sensory processing that is interfering with his learning and participation, any occupational therapist should be able to provide strategies to the IEP team that can be incorporated into his daily routines at school (including features of a sensory diet, using auditory or visual cues and/or social stories to prepare the student for transitions, consulting with the teachers to ensure sensory motor opportunities are included in his recess time and PE program, etc.).
Under both IDEA 2004, and the No Child Left Behind Act of 2001, providers (teachers & related services personnel) must ensure their practices are evidence-based. The OT should stay abreast of the evidence for all interventions, including sensory-based interventions. At present (2008), there is research occurring to determine whether a "sensory processing disorder" exists separate from diagnoses of anxiety disorder, ADHD or Autism (see http://www.spdnetwork.org/research/index.html), and research comparing aspects of sensory processing to temperament (http://classes.kumc.edu/sah/resources/sensory_processing/summary_research/conceptual_articles.htm). The IEP team (called the ARD Committee in Texas) has the ultimate responsibility for developing the IEP. The OT presents his or her data from assessment to add to the data others have contributed to the Full and Individual Evaluation (FIE). From all the data collected for the FIE, the IEP team decides 1) what the student's goals and objectives should be for the upcoming year, and 2) what supports and services are needed to help the student succeed. IDEA 2004 stipulates that a related service must be provided if needed to assist the child to be involved and progress in general ed curriculum, to advance appropriately toward attaining the annual goals, and/or to participate in extracurricular and other nonacademic activities with other children with and without disabilities. However, the question that IEP teams must answer, as so beautifully expressed by Mary Muhlenhaupt, OTR, is not "Does Johnny need OT at school?," but rather, "Does an OT’s knowledge and expertise provide a needed component of Johnny’s program that will achieve identified outcomes?” If the answer is yes, the OT needs to determine theoretical framework(s) for intervention planning (SI/SP, Motor Learning, Psychosocial, etc.) that offer the greatest opportunity for support in context. This information would not be stipulated in the IEP, as trials of several approaches may be necessary before determining the appropriate approach(es) for an individual student. Data collection on student response to intervention and progress monitoring on IEP goals should be a routine part of all occupational therapy service in schools.
The Occupational Therapy Practice Framework: Domain and Process (2002), available at AOTA, should guide all OT practice, including school practice.
Bundy, A. & Murray,E. (2002). Sensory Integration: Theory and Practice (2nd Edition). Philadelphia: F.A. Davis.
Developing Educationally Relevant IEPs: A Technical Assistance Document for Speech-Language Pathologists. (2000, September). Reston, VA: The Council for Exceptional Children.
Dunn, W., The Sensations of Everyday Life: Empirical, Theoretical, and Pragmatic Considerations (the 2001 Eleanor Clarke Slagle Lecture. The American Journal of Occupational Therapy. 55 (6). 608-620.
Dunn, W., Myles, B.S., & Orr, S. (2002). Sensory Processing Issues Associated with Asperger Syndrome: A Preliminary Investigation. The American Journal of Occupational Therapy. 56 (1). 97–102.
Dunn, W. (1999). Sensory Profile. San Antonio, TX: Psychological Corporation.
Foss, A., Swinth, Y., McGruder, J., & Tomlin, G., (2003, July). Sensory Modulation Dysfunction and the Wilbarger Protocol: An Evidence Review. OT Practice. CE 1-7.
Miller, L. J. (2003, February). Empirical Evidence Related to Therapies for Sensory Processing Impairments. NASP (National Association of School Psychologists) Communique, www.nasponline.org/publications/cq312si.html.
Miller, L. J. (2008, April 12). Physiological Measurement of Sensory Modulation Disorders. Presentation at AOTA Conference. Long Beach, CA.
Muhlenhaupt, M. (1998, December). Does Johnny Need OT in School? OT Practice. 26-28.
Muhlenhaupt, M. (2000, December). OT Services Under IDEA 97. OT Practice. 10–13.
Mulligan, S. (2003, March). Examination of the evidence for occupational therapy using a sensory integration framework with children: Part one.
Sensory Integration Special Interest Section Quarterly, 26, 1-4. Mulligan, S. (2003, June). Examination of the evidence for occupational therapy using a sensory integration framework with children: Part two.
Sensory Integration Special Interest Section Quarterly, 26, 1-5. )
Swinth, Y., & Mailloux, Z. (January 28, 2002). Addressing Sensory Processing in the Schools. OT Practice. 8 – 13.
Vargas, S. & Gregory Camilli (1999). A Meta-Analysis of Research on Sensory Integration Treatment. The American Journal of Occupational Therapy. 53 (2). 189 – 198.
What kind of supervision do I need to provide someone with a temporary license?
§373.2, Supervision of a Temporary Licensee says that the temporary licensee cannot work alone. Rather a licensee with a regular license must be in the building, or in case of home health, with the licensee. The OT temporary licensee needs another OT with a regular license in the building, while the OTA with a temporary license may have an OT or an OTA with a regular license in the building.
Do I need to send in my OTA supervision log?
No. However the OT or facility may ask for a copy and the board can audit the log.
Do I need to keep two logs for each of my two jobs?
Yes. Each shows that you have received the required supervision for each job. §373.3 states, “All the occupational therapist(s) whether working full time, PRN or part-time, who delegate to the occupational therapy assistant, must be participating in the supervision time, whether on a rotational or shared basis.” The OTs can discuss whether they each want to provide supervision time on a shared basis, such as ½ hour each every month; or if they want to each provide the supervision time with each one covering a month at a time, i.e. Julie covers for October, Marty covers for November and Sally covers for December.
Whose name do I write in my notes?
You should write the name of the OT who is available to you on that given day. It does not have to be the OT who wrote the Plan of Care, or the OT who is the head of the department, but one of the OTs who you can contact immediately to ask a question. If there is no OT in your building do you have a contact number to reach the OT with your question? If not, you cannot provide occupational therapy services.
What about student supervision?
§454.005 of the OT Practice Act exempts students from the OT Practice Act and the Board Rules. Rather you should look to the AOTA Fieldwork Supervision Guidelines, available through the students' schools or directly through AOTA.
Student Supervision in a SNF: