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Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment

Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment
Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
December 20, 2016

I think this is such a valuable topic, and as I put this course together, more and more things kept coming up with situations, scenarios, and questions. I think some of the scenarios, which are very real, will be quite an eye-opener for all of us. So with that, let's review our objectives.

Learning Objectives:

  • The participant will be able to define at least two of the following terminology including direct supervision and general supervision.
  • The participant will be able to describe at least three Medicare guidelines for supervision and billing related to students and therapy aides.
  • The participant will be able to define at least three best practice initiatives from APTA and AOTA related to supervision of assistants in practice.
  • The participant will be able to list at least three key concepts from state practice acts that relate to supervision and ethics.
  • The participant will be able to outline at least three best practice guidelines to common ethical dilemmas.


The Role of the Physical Therapist


The American Physical Therapy Association and the American Occupational Therapy Association are in complete agreement regarding the most prudent ways to exercise supervision in our sites, whether that is for students, for assistants, or for our rehab aides or rehab techs if we have them.

A Collaborative Effort

Within the scope of practice for OT or PT, supervision is a process aimed at ensuring the safe and effective delivery of therapy services. It’s also about fostering professional competence. I recently read about how supervision just isn't signing off on that document or making sure that somebody did their documentation; it's about helping the people who are working with you to improve their clinical competence, meaning that supervision is collaborative. It's a two-way street between the therapist and the assistant.  It is a joint effort to maintain and evaluate that level of competence and that level of performance. It's a mutual understanding between the supervisor and the supervisee about each other's experience, their education, and their credentials. Hopefully, it fosters growth, promotes effective utilization of our resources in our clinics, it encourages creativity and innovation, and it provides education. 


Regardless of the setting the PT is providing services in, the following responsibilities are solely and completely for the physical therapist.

  • Interpretation of referrals when those referrals are available.
  • Initial examination, evaluation, diagnosis, and prognosis: An assistant may perform a standardized assessment but cannot interpret the results.
  • Development or modification of a plan of care including goals.
  • Expertise and decision-making. Determination of when the capability of the physical therapist requires the physical therapist to personally render physical therapy interventions and when it may be appropriate to utilize the physical therapist assistant.
  • Reexamination of the patient/client in light of their goals and revision of the plan of care.
  • Establishment of the discharge plan and documentation of discharge summary/status.
  • Oversight of all documentation for services rendered to each patient/client.

The physical therapist assistant and OT assistant can certainly contribute to the evaluation process but cannot complete the true initial examination. The assistant may complete standardized assessments and provide verbal and or written observations of what the client is doing in the therapy program. Now again, the assistant can perform a standardized assessment, but keep in mind that the assistant cannot technically interpret the results. So what does that mean? While an assistant may complete a Berg balance assessment, a Tinetti, and/or a dynamic gait index, what the assistant cannot do is utilize the data to develop a goal, or to utilize it to develop interventions for that patient. The assistant should give the measurement back to the therapist who will then use that measurement in developing the plan of care.

Now the therapist is also responsible for developing or modifying the plan of care, which is based on that initial evaluation or a re-examination when that occurs.  That would also include the outcomes and the goals. If a goal needs to be added to a plan of care, again, that needs to be done by the physical therapist. That is not something the physical therapy assistant is able to do. Depending on the practice setting, the therapist may be offsite providing general supervision and there may be collaboration via phone. The assistant would document in the documentation that the collaboration or that conversation occurred, and the therapist recommended x, y, and z.   The therapist would come in later at some point and back up that documentation. So there is some of that collaboration, but without collaboration with the therapist, the assistant is not permitted to modify the goals, add modalities, or change that plan of care.

Additional responsibilities of the therapist include determining when the expertise and decision-making of the physical therapist requires that therapist to personally render the physical therapy interventions and when it might be appropriate to use the PTA.  It’s the PT who's going to determine the most appropriate utilization of the assistant that provides therapy delivery that is safe, that is effective, and that is efficient. This is critical.  

An example scenario related to supervision is a PT who did not want to provide the treatment to a client and delegated it to the assistant. The treatment was a lymphedema treatment, and the assistant had no expertise there and no idea what to do. The assistant was trying to read from a manual to provide the care. We need to make sure that both individuals are competent to do something that is delegated to him or her, and that it's okay to say, “I don't know about that,” or “I'm not sure how to do that.” “ I saw it in school but haven't done it since. “ If a patient is so complex or the technique is complex, then this should be done by the therapist and not the assistant.

Medicare and Insurance Carriers. State by state differs but some payers such as Medicare Administrative Contractors and other insurance carriers will determine that the therapist can only do specific tasks and not the assistant.

kathleen d weissberg

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS

In her 30+ years of practice, Dr. Kathleen Weissberg has worked in rehabilitation and long-term care as an executive, researcher, and educator.  She has established numerous programs in nursing facilities; authored peer-reviewed publications on topics such as low vision, dementia quality care, and wellness; and has spoken at national and international conferences. She provides continuing education support to over 40,000 individuals nationwide as National Director of Education for Select Rehabilitation. She is a Certified Dementia Care Practitioner, a Certified Montessori Dementia Care Practitioner, and a Certified Fall Prevention Specialist.  She serves as the Region 1 Director for the American Occupational Therapy Association Political Action Committee and adjunct professor at Gannon University in Erie, PA. 

Related Courses

Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
Recorded Webinar
Course: #4377Level: Intermediate2 Hours
This presentation reviews the definitions of supervision as well as APTA guidance related to supervising assistants, students, and aides in various healthcare environments. Documentation guidelines for Medicare are reviewed as these relate to what an assistant can complete versus a therapist. The use of students and rehab aides in long-term care is reviewed in accordance with Medicare guidelines. Real examples of common supervisory ethical dilemmas from the field, including the appropriate action steps to take in each one, are highlighted. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA

Supporting the LGBTQ Senior in Healthcare
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
Recorded Webinar
Course: #4096Level: Intermediate2 Hours
This training describes the required elements for responding to the emerging needs of long term care communities to provide sensitive and respectful services to LGBT elders. The training reviews definitions related to sexual orientation and gender identity challenges experienced by LGBT older adults, and strategies for communication and policies that honor residents' rights. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Bullying Among Older Adults: Not Just a Playground Problem
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
Recorded Webinar
Course: #4692Level: Introductory1 Hour
In this session, participants learn the definition and incidence of bullying in adult living communities and day centers, including what older adult bullying looks like in this population. Characteristics of older adult bullies, as well as their targets and gender differences, are explored. The reasons why bullying occurs, as well as the five different types of bullies, are defined. Interventions for the organization, the bully, and the target are reviewed to help communities minimize (and prevent, where possible) bullying and mitigate the effects on the target. Addressing bullying behavior among older adults is critically important for enhancing the quality of life and promoting emotional well-being; strategies to create caring and empathic communities for all residents and staff members are reviewed.

Ethics: A Clinical Perspective for Therapists
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
Recorded Webinar
Course: #4693Level: Intermediate3 Hours
This seminar provides practical information about ethics from a clinical perspective. Basic principles of ethics as they relate to healthcare and physical therapy are reviewed. Behaviors that are considered unethical by most credentialing bodies are considered, as well as health care/therapy codes of ethics. The CELIBATE and RIPS methods for analyzing ethical dilemmas are reviewed with case studies to demonstrate use.

Medicare Part B Coding and Billing: Compliance is Key!
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS
Live WebinarFri, May 31, 2024 at 10:00 am EDT
Course: #4964Level: Intermediate2 Hours
This seminar offers an in-depth review of Medicare Part B coding and billing. It covers CPT coding, unit-to-minute conversion, appropriate use of evaluation codes, and caregiver education codes. The seminar reviews the most commonly billed codes. Using multiple examples, clinicians learn how to comply with coding, maintain thorough documentation to support skilled interventions, and avoid common errors. The seminar also discusses elements known to trigger medical reviews, including coding and documentation to support the plan of care. It explores tips and strategies for successfully managing medical reviews.

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