PNI

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Musculoskeletal Science and Practice

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Systematic Review

Diagnostic accuracy of upper limb neurodynamic tests for the assessment of peripheral neuropathic pain: A systematic review Konstantinos Koulidisa, Yannis Veremisa, Christina Andersona, Nicola R. Heneghanb,∗

a School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK b Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

A R T I C L E I N F O

Keywords: Entrapment neuropathies Carpal tunnel syndrome Cervical radiculopathy Upper limb neurodynamics Validity

A B S T R A C T

Background: Upper limb neurodynamic tests (ULNTs) are used to identify a neuropathic pain component in patients' presenting with arm and/or neck pain. Clinical tests with established diagnostic accuracy are required to not only to inform clinical management but also minimise costs associated with expensive medical in- vestigations. Objective: To evaluate the role of ULNTs in assessment of peripheral neuropathic pain and to inform their value in clinical practice when assessing patients with arm and/or neck symptoms. Design: Systematic review was undertaken according to published guidelines, and reported in line with PRISMA- DTA. Method: Key databases were searched up to 21/11/2017. Inclusion criteria: Patient population experiencing arm and/or neck symptoms with suspected peripheral neuropathic involvement, studies that compared ULNT to a reference standard, any study design using primary diagnostic accuracy data. Two reviewers independently assessed risk of bias (ROB) using QUADAS-2. The overall quality of evidence was evaluated using GRADE. Results: Of eight included studies (n = 579), four were assessed as low ROB, although all had concerns regarding applicability. For carpal tunnel syndrome, ULNT1 sensitivity values ranged 0.4–0.93, specificity 0.13–0.93, positive likelihood ratio 0.86–3.67 and negative likelihood ratio 0.5–1.9. For cervical radiculopathy ULNT1 and the combined use of four ULNTs had sensitivity of 0.97 (95%CI 0.85–1.00) whereas the ULNT3 was the most specific (0.87, 95%CI 0.62–0.98). Positive likelihood ratio ranged 0.58–5.68 and negative likelihood ratio 0.12–1.62. Conclusion: Based on the available evidence ULNTs cannot be utilised as a stand-alone test for the diagnosis of CTS. Limited evidence suggests that ULNTs may be clinically relevant for the diagnosis of CR, but only as a “ruling out” strategy. However, the overall quality of the body of evidence after applying the GRADE approach was low to very low across studies. Further higher quality research is needed to establish firm conclusions.

1. Introduction

Peripheral neuropathic pain (PNP) is a term used to describe pain that results from a lesion or disease affecting the somatosensory ner- vous system (Finnerup et al., 2016). PNP can arise when a peripheral nerve trunk or a nerve root has been subject to injury, compression, inflammation or ischemia resulting in reduced physical capabilities of the nervous system (Nee and Butler, 2006). Symptoms and signs in neuropathies can be classified as positive (gain of function) or negative (loss of function). Positive symptoms include pain, paresthesia, dys- esthesia, hyperalgesia and allodynia and indicate abnormal excitability in the nervous system, whereas negative symptoms, such as

hypoesthesia or anesthesia and weakness reflect reduced impulse con- duction (Woolf, 2004).

The most common conditions affecting the peripheral nervous system are entrapment neuropathies (EN), with carpal tunnel syndrome (CTS), cubital tunnel syndrome and cervical radiculopathy (CR) being examples which contribute considerably to the socioeconomic burden of occupational related musculoskeletal complaints and the associated costs. Individually EN have been associated with severe pain, depres- sion and functional limitations (Fernández-de-las-Peñas et al., 2015). CTS is often observed in activities involving repetitive manual tasks, forceful wrist movements or with direct pressure on the wrist, estimated to affect 2–15% of workers (Atroshi et al., 1999) and costing more than

https://doi.org/10.1016/j.msksp.2019.01.001 Received 16 May 2018; Received in revised form 18 December 2018; Accepted 2 January 2019

∗ Corresponding author. E-mail addresses: [email protected] (K. Koulidis), [email protected] (Y. Veremis), [email protected] (C. Anderson),

[email protected] (N.R. Heneghan).

Musculoskeletal Science and Practice 40 (2019) 21–33

2468-7812/ Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.

T

2 billion dollars each year in the USA (work absenteeism, medical evaluation, treatment) (Saint-Lary et al., 2015). In the case of CR, the data regarding the prevalence and the epidemiology of the condition are very limited. The reported annual incident of CR is 83.2 per 100.000 persons (107.3 for men and 63.5 for women) with a peak in- cidence in the fifth and sixth decade for both genders (Radhakrishnan et al., 1994).

The diagnosis of EN is based on information received during the subjective (history taking) and physical examination, which is then confirmed via diagnostic imaging or electrophysiological studies. Clinical examination of EN encompasses a variety of tests (sensation, muscle strength and reflexes) assessing the integrity and ability of the nervous system to conduct afferent or efferent impulses (loss of func- tion) (Baselgia et al., 2017). In addition, a thorough examination in- cludes evaluation of increased mechanical sensitivity of the nervous system, since PNP can be present without or with minimal loss of nerve conduction (Schmid et al., 2009). Diagnostic imaging and electro- physiological studies are most commonly used to establish a diagnosis of EN (Wainner et al., 2003). For most clinicians, these methods are accessible but given the waiting time for patients and the high cost for the society it would be useful to establish accurate clinical examination tests for the diagnosis of EN.

Neurodynamic tests are used by musculoskeletal physiotherapists in order to identify changes of mechanosensitivity in the nervous system, thus assessing gain of function (Baselgia et al., 2017). Due to the in- terdependence of the mechanical, electrical and chemical properties of the nervous system, changes in one of these features may affect the others (Butler, 2008). Impairments in the surrounding musculoskeletal structures could apply mechanical or chemical stimuli to a nerve, re- sulting in venous congestion, impaired axoplasmic flow, inflammation and development of mechanosensitive abnormal impulse generating sites (Nee and Butler, 2006).

For disorders affecting the upper limbs four different neurodynamic tests have been proposed to assess mechanosensitivity of the brachial plexus, medial, radial and ulnar nerve (Elvey, 1980) (Table 1). Where symptoms are not related to central pain mechanisms (broader dis- tribution of symptoms due to central sensitization e.g. in case of per- sistent pain) a positive test response could be associated with neural or non-neural tissue sensitivity. A neurodynamic test is considered posi- tive if it can reproduce the patient's own symptoms and if those symptoms can be altered through structural differentiation (Butler, 2000). Schmid et al. (2009) assessed the reliability of ULNTs and found that those tests have moderate reliability. Wainner et al. (2003, 2005) reported substantial to almost perfect reliability for the interpretation of theULNT1 (median) and ULNT2b (radial).

Although used by clinicians the diagnostic accuracy of upper limb neurodynamic tests (ULNTs) has not yet been fully established and is important to optimise patient care. A recent systematic review has summarised the evidence on diagnostic performance of tests (including ULNTs) which are utilised for the identification of CR and concluded that when consistent with patient history, a combined result of four negative ULNTs (high sensitivity) and a negative Arm Squeeze test

could be used to rule out the disorder (Thoomes et al., 2017). Likewise an earlier systematic review, concluded that a positive Spurling's, traction/neck distraction, and Valsalva's test might be indicative of CR, while a negative ULNT1 might be used to rule it out (high sensitivity) (Rubinstein et al., 2007). Of the eight included studies in this systematic review only two had assessed the diagnostic accuracy of ULNTs. Finally in a previous clinical commentary the authors attempted to summarise the available evidence in regard to the diagnostic usefulness of neuro- dynamic tests (Nee et al., 2012). The authors, based on biomechanical and experimental studies, concluded that ULNTs can potentially dis- tinguish pain related to neural mechanosensitivity from pain arising from other tissues, and therefore could detect PNP. In the view of the growing body of evidence, a systematic review is required to evaluate the quality and synthesis the available current evidence of the diag- nostic accuracy of ULNTs and to inform clinical practice. The aim therefore of this study was to examine the intended role of ULNTs in assessment of PNP, by answering the following research question: What is the diagnostic accuracy of ULNTs when compared to diagnostic imaging or electrophysiologic studies, and how results from ULNTs can be interpreted when assessing patients with arm and/or neck symp- toms?

2. Design and methods

This systematic review was conducted according to a pre-defined protocol based on the Cochrane Handbook for Diagnostic Test Accuracy studies (Deeks et al., 2013) and the Center for Reviews and Dis- semination (CRD, 2009). In addition, the study is reported according to Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) (McInnes et al., 2018). (Appendix 1)

2.1. Search strategy

Informed by subject (NH, KK, YV) and methodological experts (NH, CA) key bibliographic databases were searched independently by two reviewers (KK, YV). The search employed sensitive topic-based strate- gies designed for each database from inception to 21st November 2017. Databases of interest were: PEDro, MEDLINE (through PubMed), AMED, CINAHL, Cochrane Library, and EMBASE. The search strategy, informed by scoping search included MeSH terms and text words, as well as a combination of both for a comprehensive search. The fol- lowing keywords and combination of them were used: upper limb neurodynamic test, neural provocation test, upper limb tension test, diagnosis, peripheral neuropathic pain, peripheral entrapment neuro- pathy, radicular pain, cervical radiculopathy, brachial plexus, carpal tunnel syndrome, cubital tunnel syndrome, accuracy, specificity, sen- sitivity, validity.

The search was augmented using reference lists of included studies, as well as searching the grey literature. Box 1 details the MEDLINE search strategy.

Table 1 ULNT procedure.

Order of movements ULNT1 (median) ULNT2a (median) ULNT2b (radial) ULNT3 (ulnar)

1 Shoulder depression Shoulder depression Shoulder depression Shoulder depression 2 Shoulder abduction 110° Elbow extension Elbow extension Shoulder abduction 100° 3 Wrist and fingers extension Lateral rotation of the arm Medial rotation arm Lateral rotation arm 4 Forearm supination Wrist and finger extension Wrist and fingers flexion Forearm pronation 5 Shoulder lateral rotation Shoulder abduction 10° Shoulder abduction Elbow flexion 6 Elbow extension Contralateral lateral flexion of the

cervical spine Contralateral lateral flexion of the cervical spine

Wrist and fingers extension

7 Contralateral lateral flexion of the cervical spine

Contralateral lateral flexion of the cervical spine

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2.2. Eligibility criteria

Eligibility criteria were established following the recommendations of The Cochrane Handbook for Diagnostic Test Accuracy studies (Leeflang et al., 2008) and informed using the SPIDER search concept (Cooke et al., 2012). Titles and abstract of the identified studies were screened by two independent reviewers (KK, YV) for eligibility using pre-specified inclusion criteria.

Inclusion criteria (based on SPIDER) included that the sample (S) comprised populations aged > 18 years with arm and/or neck symp- toms with suspected peripheral neuropathic involvement (signs and symptoms suggesting excitability in the nervous system such as pain, paresthesia, dysesthesia, spasm or reduced impulse conduction such as hypoesthesia or anesthesia and weakness) (Nee and Butler, 2006); the phenomenon of interest (PI) was the diagnostic accuracy of ULNTs; investigated using a diagnostic accuracy study design (D); with com- parison of the index test (ULNTs) to a reference standard, such as, electrophysiologic examination (electromyography and nerve conduc- tion studies) or advanced imaging (e.g. Magnetic Resonance Imaging (MRI), CT, myelography) (E). Although not perfect, these tests are considered to be the most accurate diagnostic tests available (Wainner et al., 2003; Jablecki et al., 1993, 2002; Kuijper et al., 2009).

Exclusion criteria: case series, case reports, surgical or cadaveric studies; publications for which full text not available.

2.3. Quality assessment

Two reviewers (KK, YV) independently conducted the risk of bias (ROB) assessment using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) – tool, a development of the original tool (Whiting et al., 2011). It consists of four key domains: patient selection, index test, reference standard and, flow and timing. All key areas are assessed for ROB, whereas the first three are also assessed in terms of applicability to the review question. Each domain is judged as “high risk”, “low risk” or “unclear risk” based on signaling questions aiming to assist judgment (Whiting et al., 2011). Overall, a study can be judged

as having “low risk of bias” if every domain has been ranked as “low risk”. Assessment of applicability is based on the first three domains and whether they are in line with the review question. The study is judged as having “no concerns” regarding applicability if these domains are in line with the review question and “with concerns” if deviates from the review objective. The QUADAS-2 has been used in recent systematic reviews (Grodahl et al., 2016; Hegedus et al., 2012) and is re- commended by the Cochrane Collaboration and the U.K National In- stitute for Health and Clinical Excellence (Reitsma et al., 2009).

2.4. Data extraction

Diagnostic accuracy data and study characteristics were extracted by one reviewer (KK) using a pre-designed data extraction sheet which covered five areas. The data were audited by a second reviewer (YV) for accuracy. The following data were extracted: authors and publication details, studies' methods (aim of study, study design, method of re- cruitment, eligibility criteria, and ethical approval), participant details, diagnostic test data (sensitivity, specificity, predictive values, like- lihood ratios and other). Finally, the fifth section was 2 × 2 con- tingency tables for the diagnostic tests.

2.5. Summary measures

Sensitivity, specificity, likelihood ratios (LR) and predictive values (PV) were the outcomes for which data were sought. True positive, false positive, true negative and false negative values were summarised. In cases where only incomplete or raw data were presented, a 2 × 2 contingency table was used to re-estimate these values. Sensitivity and specificity were graded as low (< 0.50), low/moderate (0.51–0.64), moderate (0.65–0.74), moderate/high (0.75–0.84) and high (> 0.85) in line with previous systematic reviews of diagnostic accuracy studies (Grodahl et al., 2016; Schneiders et al., 2012). Clinical interpretation of likelihood ratios was based on Jaeschke et al. (1994a,b) as follows: conclusive evidence (LR+ > 10 and LR- < 0.1), strong diagnostic evi- dence (LR+ 5 to 10 and LR- 0.1 to 0.2), weak diagnostic evidence (LR

Box 1 MEDLINE search strategy

1. peripheral neuropathic pain.mp or exp Neuralgia/ 2. radicular pain.mp or exp Hereditary Sensory and Autonomic Neuropathies/ 3. peripheral entrapment neuropathy.mp 4. cervical radiculopathy.mp or exp Radiculopathy/ 5. carpal tunnel syndrome.mp or exp Carpal tunnel syndrome/ 6. cubital tunnel syndrome.mp or exp Cubital tunnel syndrome/ 7. brachial plexus neuropathies.mp or exp Brachial plexus neuropathies/ 8. exp Nerve compression syndromes/ 9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8

10. upper limb neurodynamic test.mp 11. upper limb tension test.mp 12. neural provocation test.mp 13. exp Diagnosis/ 14. exp Pain measurements/ 15. exp Neurologic examination/ 16. exp Physical examination/ 17. 10 or 11 or 12 or 13 or 14 or 15 or 16 18. diagnostic accuracy.mp 19. sensitivity and specificity.mp or exp Sensitivity and specificity/ 20. validity.mp 21. exp Reproducibility of results/ 22. exp Predictive value of tests/ 23. 18 or 19 or 20 or 21 or 22 24. 9 and 17 and 23

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+2 to 5 and LR- 0.2 to 0.5) and negligible evidence (LR+ 1 to 2 and LR- 0.5 to 1).

2.6. Data analysis

Homogeneity among studies was explored to evaluate if the studies were suitable for combining in a meta-analysis. Areas of exploration were: study designs, patient population, comparable reference tests and diagnostic data, no differences in diagnostic thresholds (Burgess et al., 2011). In addition, quality assessment of the included studies was conducted, since studies with high ROB often over-estimate the per- formance of a test (Lijmer et al., 2002). Given the heterogeneity of the included studies a narrative synthesis was undertaken.

2.7. Quality of evidence across studies

Quality of evidence, including risk of bias across studies was eval- uated using GRADE (Schünemann et al., 2008) for individual tests. Quality of overall body of evidence is influenced by amongst other factors, study design, patient populations, precision, consistency, di- rectness and as such each outcome was evaluated by both reviewers independently (Schünemann et al., 2008).

3. Results

3.1. Study identification

The searches identified 1802 studies with screening of title and abstract resulting in 15 studies that were retrieved for full-text eva- luation and 8 studies (n = 579) meeting the eligibility requirements for inclusion. (Fig. 1). There was 100% of agreement between the re- viewers on selecting studies.

3.2. Study description

Table 2 summarises the specific characteristics of all eight studies. Three studies investigated the diagnostic accuracy of ULNTs in in- dividuals with suspected CR (Wainner et al., 2003; Apelby-Albrecht et al., 2013; Ghasemi et al., 2013). Two of the studies used electro- physiologic procedures as the reference standard (Wainner et al., 2003; Ghasemi et al., 2013). One study used MRI, clinical examination and history as a reference standard (Apelby-Albrecht et al., 2013). Five studies investigated the diagnostic accuracy of ULNTs in individuals with suspected CTS with nerve conduction studies as the reference standard (Wainner et al., 2005; Vanti et al., 2011; 2012; Bueno-Gracia et al., 2016; Trillos et al., 2018).

3.3. Risk of bias assessment

Agreement of risk of bias following discussion was excellent (100%). Four studies were assessed as “low risk of bias” (ROB) (Wainner et al., 2003, 2005; Vanti et al., 2012; Trillos et al., 2018), but all of them had concerns with regards to applicability (Table 3). Patient selection procedures and poor reporting of flow and timing were the main areas of ROB. Only two studies were assessed as no concerns for applicability (Fig. 2) (Apelby-Albrecht et al., 2013; Bueno-Gracia et al., 2016). Interpretation of the index test was the main reason for concern regarding applicability since it was not in agreement with our review question. In our study an ULNT is considered positive only when it reproduces the patient's clinical symptoms and those symptoms are modified with structural differentiation (Nee et al., 2012; Butler, 2000; Coppieters et al., 2002).

3.4. Synthesis of results

The main limitations for performing a meta-analysis were the

heterogeneity in terms of the reference standard utilised, as well as in the interpretation of the index test and the methodological quality of the included studies. Since a meta-analysis was not possible, diagnostic accuracy data (sensitivity, specificity, predictive values and likelihood ratios) are presented using a narrative approach. The overall body of the evidence in terms of ROB, inconsistency, indirectness, imprecision, and the presence of potential reported bias after applying the GRADE approach was low to very low across studies and across outcomes. Diagnostic accuracy for all clinical indicators is summarised in Tables 4 and 5 and outcome of GRADE evaluation in Tables 6 and 7.

3.5. Diagnostic accuracy of upper limb neurodynamic tests

3.5.1. Carpal tunnel syndrome Five studies examined the diagnostic accuracy of ULNTs in patients

with suspected CTS (Wainner et al., 2005; Vanti et al., 2011; 2012; Bueno-Gracia et al., 2016; Trillos et al., 2018). From these studies two were at ROB (Vanti et al., 2011; Bueno-Gracia et al., 2016) and four had concerns regarding applicability (Wainner et al., 2005; Vanti et al., 2011; 2012; Trillos et al., 2018). Those at ROB had limitations related to patient selection and flow and timing. The study of Vanti et al. (2011) was at ROB because the number of patients enrolled in the study was different from the number of patients that were included in the analysis (Whiting et al., 2011), whereas in the study by Bueno-Gracia et al. (2016) the authors provided limited information in regards to the methods used for the enrollment of the sample (consecutive or random sample). The studies that had concerns regarding applicability used a definition for a positive ULNT that differs from that being used in this review.

Three studies assessed the validity of ULNT1 (median) considering the test positive in the presence of only one of the following criteria: 1) reproduction of patient's symptoms; 2) side to side differences (> 10°) in elbow extension; 3) contralateral neck side-flexion increased symp- toms or ipsilateral side-flexion decreased symptoms (Wainner et al., 2005; Vanti et al., 2011; Trillos et al., 2018). Sensitivity was moderate/ high 0.75 (95%CI 0.58–0.92) (Wainner et al., 2005) to high 0.91 (95%CI 0.74–0.98) (Vanti et al., 2011) and 0.93 (95%CI 0.88–0.96) (Trillos et al., 2011). Specificity was low in all 3 studies: 0.13 (95%CI 0.04–0.22) (Wainner et al., 2005), 0.15 (95%CI 0.05–0.36) (Vanti et al., 2011) and 0.06 (95%CI 0.0–0.33) (Trillos et al., 2018). In the study by Vanti et al. (2011) the authors conducted a second analysis in which “reproduction of patient's symptoms” changed to “reproduction of symptoms in the first, second or third digit”, but again only one of the three criteria was required for a positive ULNT1. The second analysis revealed low to moderate sensitivity (0.54, 95%CI 0.35–0.72) and moderate specificity (0.70, 95%CI 0.48–0.85). Overall, none of the in- terpretations of ULNT1 was capable of ruling in or ruling out a diag- nosis of CTS because LRs were between 0.5 and 2.0.

Two studies examined the diagnostic accuracy of ULNT1 using a different interpretation for a positive test. In these studies the test was considered positive if it was able to reproduce patient's symptoms and these symptoms were altered with structural differentiation (Vanti et al., 2012; Bueno-Gracia et al., 2016). Sensitivity ranged from low 0.05 (95%CI 0.02–0.19) (Vanti et al., 2012) to low/moderate 0.58 (95%CI 0.45–0.71) (Bueno-Gracia et al., 2016). Specificity ranged from moderate/high 0.84 (95%CI 0.72–0.96) (Bueno-Gracia et al., 2016) to high 0.93 (95%CI 0.82–0.98) (Vanti et al., 2012). Bueno-Gracia and colleagues (2016) suggested that the ULNT1 may be clinically useful to determine patients with CTS due to high +LR (3.67). However the high number of false negatives results challenges this notion (Table 4).

3.5.2. Cervical radiculopathy Three studies investigated the concordance of ULNT1 with a re-

ference standard in patients with suspected CR (Wainner et al., 2003; Apelby-Albrecht et al., 2013; Ghasemi et al., 2013). The reference standard in two of these studies was NCS and needle electromyography

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(Wainner et al., 2003; Ghasemi et al., 2013), whereas in the third study the authors used the combination of patient history, clinical examina- tion and MRI findings as the reference standard (Apelby-Albrecht et al., 2013). In two of these studies ULNT1 showed moderate to high (0.83, 95%CI 0.66–0.93) and high sensitivity (0.97, 95%CI 0.90–1.0) (Apelby- Albrecht et al., 2013; Wainner et al., 2003) whereas in the third study the sensitivity was low 0.35 for chronic CR and low/moderate 0.6 for acute CR (Ghasemi et al., 2013). Specificity ranged from low 0.22 (95%CI 0.12–0.33) (Wainner et al., 2003) and 0.4 (Ghasemi et al., 2013) to moderate/high 0.75 (95%CI 0.48–0.93) (Apelby-Albrecht et al., 2013). Moreover, in the study of Wainner et al. (2003) the ULNT1 demonstrated negative likelihood ratio (LR) of 0.12, meaning that a negative ULNT1 could rule out CR. This study had low ROB, but had

concerns regarding applicability related to the different interpretation of the index test from the authors compared with the review question (Whiting et al., 2011). In addition, due to wide 95% CI the results of this study should be interpreted cautiously. Wide CIs reduce the strength of evidence by influencing the precision of the pooled esti- mates.

The validity of ULNT2b (radial) was assessed by two studies (Wainner et al., 2003; Apelby-Albrecht et al., 2013). Sensitivity was moderate in both studies: 0.66 (95%CI 0.48–0.81) (Apelby-Albrecht et al., 2013) and 0.72 (95%CI 0.52–0.93) (Wainner et al., 2003). Spe- cificity ranged from low 0.33 (95%CI 0.21–0.45) (Wainner et al., 2003) to moderate/high 0.75 (95%CI 0.48–0.93) (Apelby-Albrecht et al., 2013).

Fig. 1. PRISMA flow diagram for systematic reviews.

K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

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w ri

sk

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ra ci

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al .

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6) Sp

ai n

Pr os

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rp al

tu nn

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m e

N ot

re po

rt ed

In cl

us io

n: pa

tie nt

s w

ith ha

nd ,w

ri st

or fo

re ar

m sy

m pt

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Ex cl

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n: an

y RO

M lim

ita tio

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th e

up pe

r lim

b, in

ab ili

ty to

lie su

pi ne

,a ny

ph ys

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th er

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pr es

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of an

y co

gn iti

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co m

m un

ic at

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de fic

its

N =

58 W

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= 16

M ea

n ag

e: 54

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14 .5

ye ar

s

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ri sk

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al .(

20 18

) Co

lo m

bi a

Pr os

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e 18

–8 6,

re fe

rr ed

w ith

a cl

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ag no

si s

of CT

S Ex

cl us

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up pe

r lim

b jo

in ta

nd ce

rv ic

al sp

in e

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ie s,

pa tie

nt s

w ith

hi st

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of rh

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nt er

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ld er

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, Ra

yn au

d' s

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ea st

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es ,

pa tie

nt s

w ith

ce rv

ic al

sp in

al st

en os

is ,o

r co

gn iti

ve de

fic its

N =

11 8

W om

en n

= 98

M en

n =

20 M

ea n

ag e:

50 .5

1 ±

11 .1

ye ar

s

U LN

T 1

(m ed

ia n)

N CS

Lo w

ri sk

Va nt

ie t

al .(

20 11

) Ita

ly Pr

os pe

ct iv

e co

ho rt

Ca rp

al tu

nn el

sy nd

ro m

e Cl

in ic

of O

cc up

at io

na lM

ed ic

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e U

ni ve

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lo gn

a (I

ta ly

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cl us

io n:

in di

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al s

w ith

su sp

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d CT

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up pe

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R, co

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M ea

n ag

e: 46

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ye ar

s

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T 1

(m ed

ia n)

N CS

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ri sk

Va nt

ie t

al .(

20 12

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ly Pr

os pe

ct iv

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Ca rp

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cc up

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sp ec

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fic its

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n =

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en n

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n ag

e: 45

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T 1

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Lo w

ri sk

Lo w

ri sk

(c on tin ue d on

ne xt pa ge

)

K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

26

Apelby-Albrecht et al. (2013) also examined the diagnostic accuracy of ULNT2a (median), ULNT3 (ulnar) and ULNTs combined as a single test. This study was assessed as at ROB due to the time lapse between the MRI and the neurodynamic testing (up to six months) (Whiting et al., 2011); however, no concerns regarding applicability were iden- tified. Combined ULNTs showed high sensitivity (0.97, 95%CI 0.85–1.00) and moderate specificity (0.69, 95%CI 0.41–0.89) whereas the ULNT3 (ulnar) was the most specific (0.87, 95%CI 0.62–0.98) (Apelby-Albrecht et al., 2013) (Table 5).

4. Discussion

The purpose of this study was to evaluate the role of ULNTs in the assessment of PNP and to reflect on their value in clinical practice in the assessment and diagnosis of patients with arm and/or neck symptoms. Current research suggests that ULNTs cannot be used in isolation for the diagnosis of PNP. Specifically, ULNTs cannot be utilised as a stand- alone test in the clinical setting for the diagnosis of CTS. Limited evi- dence suggests that ULNTs demonstrate better diagnostic accuracy and may be clinically relevant for the diagnosis of CR, but only as a “ruling out” strategy. However, the overall body of the evidence after applying the GRADE approach was low to very low for all outcomes, therefore any interpretation of these findings should be made cautiously.

4.1. Carpal tunnel syndrome

Overall, the five studies that examined the validity of ULNT1 are characterised by diversity in the interpretation of the index test. From these studies only the interpretation by Bueno-Gracia et al. (2016) is in agreement with the review question, that is, the ULNT1 is considered positive only when it reproduces the patient's clinical symptoms and those symptoms are modified with structural differentiation. This cri- terion is supported by several authors, who suggest that structural differentiation is necessary in order to distinguish between neuropathic pain and pain that arises from other somatic sources (Nee et al., 2012; Butler, 2000, Coppieters et al., 2002). Using the above definition for a positive test Bueno-Gracia et al. (2016) found that the ULNT1 may has strong ability to identify patients who do not have CTS (high specifi- city).

Using a different definition of a positive test Wainner et al. (2005), Vanti et al. (2011) and Trillos et al. (2018) found that the ULNT1 had moderate/high to high sensitivity. However, the low specificities and LRs that have been obtained in these studies decrease the diagnostic accuracy of ULNT1 and suggest that they cannot be considered ade- quate for the diagnosis of CTS.

4.2. Cervical radiculopathy

The diagnostic accuracy of ULNTs seems more promising for the diagnosis of CR. Apelby-Albrecht et al. (2013) investigated the validity of ULNTs combined and individually, using the same definition for a positive test as this review. Individually, ULNT1 and ULNT3 were the most valid tests for detecting CR. Combining the tests increased the diagnostic accuracy of ULNTs further, giving an accurate diagnosis in 88.2% of patients.

Whilst findings by Wainner et al. (2003) are in agreement with the study by Apelby-Albrecht et al. (2013) the authors used a more liberal definition of a positive test. In their study, the ULNT1 was highly sen- sitive and had LR-of 0.12 meaning that when the test is negative, CR can be ruled out. In these studies the vast majority of patients with CR presented with nerve root compression at C6-C7 level, therefore the diagnostic properties of ULNTs may be different when the C5 or C8 root level is involved.

Overall, following analysis of the available evidence, ULNTs seem to have no diagnostic accuracy to inform clinical practice in patients with suspected CTS. In contrast, ULNTs may be more useful for the diagnosisTa

bl e

2 (c on tin ue d)

A ut

ho r.

(y ea

r) ,

co un

tr y

Ty pe

of st

ud y

Pa th

ol og

y Se

tt in

g In

cl us

io n/

Ex cl

us io

n cr

ite ri

a Po

pu la

tio n

(N um

be r,

ge nd

er ,a

ge )

O ut

co m

e m

ea su

re s

Re fe

re nc

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an da

rd RO

B

W ai

nn er

et al

. (2

00 5)

Pr os

pe ct

iv e

co ho

rt Ca

rp al

tu nn

el sy

nd ro

m e

M ul

tic en

te r

m ed

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ce nt

er an

d co

m m

un ity

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ita l

In cl

us io

n: si

gn s

an d

sy m

pt om

s co

m pa

tib le

w ith

CR or

CT S

Ex cl

us io

n: sy

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ic di

se as

e, pr

im ar

y re

po rt

of bi

la te

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ad ia

tin g

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oc ed

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fo r

pa th

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ie s

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S, di

sc on

tin ua

tio n

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> 6

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EM G

an d

N CS

te st

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th e

sy m

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at ic

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fo r

CR ,C

TS ,o

r bo

th

N =

82 W

om en

n =

41 M

en n

= 41

M ea

n ag

e: 45

± 12

ye ar

s

U LN

T 1

(m ed

ia n)

U LN

T 2b

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ia l)

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K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

27

of CR, but only as a “ruling out” strategy. Nonetheless, these findings should be interpreted cautiously due to the small number of studies investigating the diagnostic accuracy of ULNTs and the differences between them in regards to the interpretation of a positive test.

There are a number of concerns that may explain some of the results obtained in these studies. Firstly, electrodiagnostic testing provides information in regards to conduction loss in large myelinated motor neurons and Aβ fibres (Schmid et al., 2013). Increased mechan- osensitivity, however, is related to increased excitability of small-dia- meter afferents and sensitization of nociceptors in the nervi nervorum and sinuvertebral nerves (Baron et al., 2010). Moreover, recent evi- dence suggests that damage of small axons is more common in en- trapment neuropathies than previously believed (Chien et al., 2008; Schmid et al., 2012) and may occur even before any dysfunction of large axons (Tamburin et al., 2011). Thus, it becomes apparent that the inability of the criterion standard to identify neuropathies related to small axons damage may have led to false-negative results in cases where NCS classified a patient as not having the condition whereas the ULNTs were positive.

Secondly, in a recent study Baselgia et al. (2017) found that > 54% of patients with CTS had negative ULNT1 despite a clear dysfunction in the median nerve, as proven with NCS. The authors advocated that the non-reproduction of symptoms during neurodynamic testing can be a sign of a more severe neural dysfunction of the unmyelinated fibres (Baselgia et al., 2017). These findings, could explain some of the false- negative results that have been obtained in the included studies in cases where the NCS confirmed a diagnosis but the neurodynamic testing was negative.

4.3. Future direction

A reference standard should be comprehensive enough to accurately inform clinicians in regards to the diagnostic accuracy of an index test. Given the insufficiency of electrodiagnostic tests to provide information about the integrity of small-diameter nerve fibres (Schmid et al., 2013), it becomes apparent that diagnostic accuracy studies need a supple- mentary test that will increase the criterion validity of the reference standard. Quantitative Sensory Testing (QST) provides information for both loss and gain of function, in large myelinated (Aβ) and thinly myelinated (Aδ) or unmyelinated fibres (C-fibres) (Rolke et al., 2006). QST protocols include tests that investigate thermal, mechanical and pain thresholds, and based on the results clinicians could be informed in regards to which type of nerve fibres might be involved. Incorporating QST in protocols, may enhance their ability to correctly classify patients with PNP. Additionally future diagnostic accuracy studies aiming to investigate the validity of ULNTs in patients with CTS could adopt the principle of “neurodynamic sequencing” and alter the order of joint movement. Various studies have shown that the range of motion and the symptoms can be modified by altering the testing sequence during straight leg raise (Boland and Adams, 2000), slump test (Johnson and Chiarello, 1997) and ULNT1 (Coppieters et al., 2001). Moving the wrist to extension first during ULNT1 testing may increase the likelihood of a positive neurodynamic test (Baselgia et al., 2017). Moreover, consensus as to what defines a positive test would be useful. Standardisation of the performance and the interpretation of ULNTs are essential to draw safe inferences for the true diagnostic accuracy of the tests (Nee et al., 2012). Finally, future diagnostic accuracy studies should evaluate the

Table 3 Risk of bias assessment of included studies.

Study RISK OF BIAS Summary APPLICABILITY CONCERNS Summary

PATIENT SELECTION

INDEX TEST

REFERENCE STANDARD

FLOW AND TIMING

PATIENT SELECTION

INDEX TEST

REFERENCE STANDARD

Apelby-Albrecht et al. (2013)

☺ ☺ ☺ ☹ At risk ☺ ☺ ☺ No concern

Bueno-Gracia et al. (2016)

☹ ☺ ☺ ☺ At risk ☺ ☺ ☺ No concern

Ghasemi et al. (2013) ☹ ? ? ? At risk ☺ ☹ ☺ With concern Trillos et al. (2018) ☺ ☺ ☺ ☺ Low risk ☺ ☹ ☺ With concern Vanti et al. (2011) ☺ ☺ ☺ ☹ At risk ☺ ☹ ☺ With concern Vanti et al. (2012) ☺ ☺ ☺ ☺ Low risk ☺ ☹ ☺ With concern Wainner et al. (2003) ☺ ☺ ☺ ☺ Low risk ☺ ☹ ☺ With concern Wainner et al. (2005) ☺ ☺ ☺ ☺ Low risk ☺ ☹ ☺ With concern

Fig. 2. Proportion of studies assessed as low, high or unclear ROB and/or applicability.

K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

28

Ta bl

e 4

D ia

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K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

29

Ta bl

e 5

D ia

gn os

tic U

LN Ts

ac cu

ra cy

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fo r

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K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

30

diagnostic utility of ULNTs for ulnar nerve EN, since currently there are limited evidence regarding to the validity of ULNTs in pathologies such cubital syndrome.

4.4. Strengths and limitations

The strengths of this review are that provides clear recommenda- tions for future studies and emphasises the importance of precisely reported methodologically robust studies. Among the limitations of this systematic review is that it includes studies only written in English which may have introduced bias (Song et al., 2002). Whilst we have adopted the grading of sensitivity and specificity using parameters based on existing reviews we acknowledge interpretation is context specific; further research is required to validate these categories.

5. Conclusion

Based on the available evidence, ULNTs have no diagnostic accu- racy to identify patients with CTS when used in isolation. Limited evidence suggests that ULNTs demonstrate better diagnostic accuracy and may be clinically relevant for the diagnosis of CR, but only in a “ruling out” strategy. However, the overall quality of the body of evi- dence after applying the GRADE approach was low to very low across studies. Further higher quality research is needed to establish firm

conclusions regarding to the value of ULNTs in the assessment and diagnosis of patients with arm and/or neck symptoms.

Conflict of interest

None declared.

Ethical approval

None required.

Funding

None.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

None required.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.msksp.2019.01.001.

Appendix 1

Section/topic # PRISMA-DTA Checklist Item Reported on page #

TITLE/ABSTRACT Title 1 Identify the report as a systematic review (+/− meta-analysis) of diagnostic test accuracy (DTA) studies. 1 Abstract 2 Abstract: See PRISMA-DTA for abstracts. 1

Table 6 GRADE assessment of evidence (CR).

No of studies (No of patients) Accuracy measures

RoB Indirectness Inconsistency Imprecision Publication bias Quality of evince

ULNT1 3 studies (n = 230) (Apelby-Albrecht et al., 2013; Ghasemi et al., 2013; Wainner et al., 2003)

Sensitivity Serious Serious Serious Serious Undetected Very low Specificity Serious Serious Very serious Very serious Undetected Very low

ULNT2a 1 study (n = 51) (Apelby-Albrecht et al., 2013)

Sensitivity Serious No No Very serious Undetected Very low Specificity Serious No No Very serious Undetected Very low

ULNT2b 2 studies (n = 133) (Apelby-Albrecht et al., 2013; Wainner et al., 2003)

Sensitivity Serious Serious Very serious Very serious Undetected Very low Specificity Serious Serious Very serious Serious Undetected Very low

ULNT3 1 study (n = 51) (Apelby-Albrecht et al., 2013)

Sensitivity Serious No No Very serious Undetected Very low Specificity Serious No No Very serious Undetected Very low

ULNT (combined) 1 study (n = 51) (Apelby-Albrecht et al., 2013)

Sensitivity Serious No No Serious Undetected Low Specificity Serious No No Very serious Undetected Very low

ULNT: upper limb neurodynamic test, RoB: risk of bias, CR: cervical radiculopathy.

Table 7 GRADE assessment of evidence (CTS).

No of studies (No of patients) Accuracy measures

RoB Indirectness Inconsistency Imprecision Publication bias Quality of evince

ULNT1 5 studies (n = 349) Wainner et al. (2005); Vanti et al. (2011, 2012); Bueno- Gracia et al. (2016); Trillos et al. (2018)

Sensitivity Serious Serious Serious Very serious Undetected Very low Specificity Serious Serious Very serious Very serious Undetected Very low

ULNT2b 1 study (n = 82) (Wainner et al., 2005)

Sensitivity No Serious Serious Very serious Undetected Very low Specificity No Serious Serious Very serious Undetected Very low

ULNT: upper limb neurodynamic test, RoB: risk of bias, CTS: carpal tunnel syndrome.

K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

31

INTRODUCTION Rationale 3 Describe the rationale for the review in the context of what is already known. 2–4 Clinical role of index

test D1 State the scientific and clinical background, including the intended use and clinical role of the index test, and if applicable, the

rationale for minimally acceptable test accuracy (or minimum difference in accuracy for comparative design). 2–4

Objectives 4 Provide an explicit statement of question(s) being addressed in terms of participants, index test(s), and target condition(s). 4 METHODS Protocol and registra-

tion 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration

information including registration number. N/A

Eligibility criteria 6 Specify study characteristics (participants, setting, index test(s), reference standard(s), target condition(s), and study design) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

5–6

Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

4–5

Search 8 Present full search strategies for all electronic databases and other sources searched, including any limits used, such that they could be repeated.

5

Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

7–8

Data collection pro- cess

10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

6–7

Definitions for data extraction

11 Provide definitions used in data extraction and classifications of target condition(s), index test(s), reference standard(s) and other characteristics (e.g. study design, clinical setting).

6–7

Risk of bias and ap- plicability

12 Describe methods used for assessing risk of bias in individual studies and concerns regarding the applicability to the review question. 6

Diagnostic accuracy measures

13 State the principal diagnostic accuracy measure(s) reported (e.g. sensitivity, specificity) and state the unit of assessment (e.g. per- patient, per-lesion).

7

Synthesis of results 14 Describe methods of handling data, combining results of studies and describing variability between studies. This could include, but is not limited to: a) handling of multiple definitions of target condition. b) handling of multiple thresholds of test positivity, c) handling multiple index test readers, d) handling of indeterminate test results, e) grouping and comparing tests, f) handling of different reference standards

14

Meta-analysis D2 Report the statistical methods used for meta-analyses, if performed. N/A Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-

specified. N/A

RESULTS Study selection 17 Provide numbers of studies screened, assessed for eligibility, included in the review (and included in meta-analysis, if applicable) with

reasons for exclusions at each stage, ideally with a flow diagram. 7–8

Study characteristics 18 For each included study provide citations and present key characteristics including: a) participant characteristics (presentation, prior testing), b) clinical setting, c) study design, d) target condition definition, e) index test, f) reference standard, g) sample size, h) funding sources

8–12

Risk of bias and ap- plicability

19 Present evaluation of risk of bias and concerns regarding applicability for each study. 13–14

Results of individual studies

20 For each analysis in each study (e.g. unique combination of index test, reference standard, and positivity threshold) report 2 × 2 data (TP, FP, FN, TN) with estimates of diagnostic accuracy and confidence intervals, ideally with a forest or receiver operator characteristic (ROC) plot.

?

Synthesis of results 21 Describe test accuracy, including variability; if meta-analysis was done, include results and confidence intervals. 14–18 Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression; analysis of index test: failure rates,

proportion of inconclusive results, adverse events). N/A

DISCUSSION Summary of evidence 24 Summarise the main findings including the strength of evidence. 21–22 Limitations 25 Discuss limitations from included studies (e.g. risk of bias and concerns regarding applicability) and from the review process (e.g.

incomplete retrieval of identified research). 23

Conclusions 26 Provide a general interpretation of the results in the context of other evidence. Discuss implications for future research and clinical practice (e.g. the intended use and clinical role of the index test).

24

FUNDING Funding 27 For the systematic review, describe the sources of funding and other support and the role of the funders. 24

Adapted From: McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, The PRISMA-DTA Group (2018). Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies: The PRISMA-DTA Statement. JAMA. 2018 Jan 23; 319(4):388–396. https://doi.org/10.1001/jama.2017. 19163. For more information, visit: www.prisma-statement.org.

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Wainner, R.S., Fritz, J.M., Irrgang, J.J., et al., 2005. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch. Phys. Med. Rehabil. 86 (4), 609–618.

Whiting, P.F., Rutjes, A.W., Westwood, M.E., et al., 2011. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann. Intern. Med. 155 (8), 529–536.

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K. Koulidis et al. Musculoskeletal Science and Practice 40 (2019) 21–33

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The Model Practice Act for Physical Therapy

A Tool for Public Protection and Legislative Change

Seventh Edition

Revised 2022(Original Printing 1997)

Federation of State Boards of Physical Therapy

124 West Street South, 3rd floor · Alexandria, VA 22314 Telephone: 800.881.1430 · 703.299.3100

Fax: 800.981.3031 · 703.299.3110 www.fsbpt.org

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_______________________Preface

he Model Practice Act for Physical Therapy: A Tool for Public Protection and Legislative Change (MPA) is the preeminent standard and most effective tool available for revising and modernizing physical therapy practice acts. The continuing movement to update physical therapy practice

acts helps ensure that they provide the legal authority to fully protect the public while allowing for the effective regulation of the profession. This is the Seventh Edition of the Model Practice Act. Differences from the Sixth Edition can be compared in Appendix A. The structure of the Model Practice Act has remained consistent and is a model worthy of use in all jurisdiction practice acts. The statute language has remained clear and understandable throughout each edition and will continue to influence greater uniformity in practice acts now and in the future. Delegate Assembly motion DEL-02-07 encouraged each jurisdiction to review, improve and strengthen practice acts and to use the latest edition of the Model Practice Act as a resource in that task. Even where sections of existing jurisdiction law may differ from the Model Practice Act, there is much that can be learned from MPA model statute language and the commentary that can be applied to many regulatory situations or questions. The Federation of State Boards of Physical Therapy welcomes recommendations relative to any aspect of The Model Practice Act for Physical Therapy: A Tool for Public Protection and Legislative Change. Recommendations may be sent to the Federation for consideration in later revisions that will be initiated by the Ethics and Legislation Committee. The committee remains a continuing resource for any jurisdiction contemplating practice act changes. The Federation invites your use of this Model Practice Act for Physical Therapy and pledges its resources for your ongoing support. Copyright 2011. Federation of State Boards of Physical Therapy. All rights reserved. Unauthorized reproduction or use of this document is punishable under federal law. Limited permission to reproduce sections of this document is granted to state/jurisdiction physical therapy regulatory boards and associations for the purpose of writing legislation for their respective jurisdictions. For all other use, permission may be requested by writing to FSBPT, 124 West Street S, Third Floor, Alexandria, VA 22314.

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________________Acknowledgements

The Model Practice Act Task Force of the Federation of State Boards of Physical Therapy served from November 1994 until the completion of their task in March 1997. Acknowledgement and appreciation are extended to them, to Federation staff and to many others who reviewed an contributed comments on early drafts and on the field review. Acknowledgement and appreciation are also extended to the Ethics and Legislation Committee, which continues the work of the original task force by periodically updating and revising the Model Practice Act as needed. The Federation is also grateful to the many jurisdiction licensing boards and APTA chapters that have already used this tool to effectively modernize jurisdiction practice acts. “Original Developers” Model Practice Act Task Force, 1994-1997 J. Kent Culley, Esq., Federation Counsel Pennsylvania Ann Giffin, PT Tennessee Anne H. Harrison Petty, PT Nebraska Deborah Tharp Hatherill, PT Kentucky Ron J. Hruska, PT Nebraska Mark Lane, PT Virginia Christine A. Larson, PT Wisconsin Blair J. Packard, PT Arizona Mary Hass Sheid, PT, OCS Missouri

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_____________________Introduction

he Federation of State Boards of Physical Therapy was organized in 1986. Soon thereafter, discussion began about the feasibility of developing model language for physical therapy practice acts. It wasn’t until 1994 that the FSBPT Board of Directors appointed an eight-member task force, and their work was completed in 1997 with the publication of The Model Practice Act for Physical Therapy: A Tool for Public

Protection and Legislative Change. Over decades the various physical therapy practice acts have contained functional and useful regulatory language but also some problematic language. Most jurisdictional practice acts had their origins in the 1950s and early 1960s, and amendments have turned some practice acts into cobbled-together collections of regulatory language that are very diverse in their approach to the basic board responsibility of protecting the public and regulating the profession. The task force originally envisioned a model act that could be used cafeteria style to allow states to change a specific section of a practice act as needed. While the Model Practice Act can be used effectively this way, those who study this document will find a tightly constructed and integrated model for the regulation of physical therapy. The component sections of this model fit together well and complement other sections. Certain areas of this model act are indispensable from others and changes in one of these areas will require additional modification of a jurisdiction’s practice act in other areas. The commentary sections of this Model Practice Act will identify important cross-links in statute language. Since 1997 many states have enacted large portions and, in some instances, nearly the entire Model Practice Act as their jurisdiction statute. As regulatory changes are made in jurisdiction practice acts, the Federation suggests the use of terms and statute language as recommended in this model act. This underscores the importance of a “model” act and will help avoid further confusion of terminology and regulation from jurisdiction to jurisdiction and occasionally within the same practice act.

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_________________________Contents

Model Practice Act Language ………………………………………………………………………………………………….. 1

Physical Therapy Practice Act ………………………………………………………………………………………………….. 1 Article 1: General Provisions ……………………………………………………………………………………………………………… 1

1.01 Legislative Intent ………………………………………………………………………………………………………………………………… 1 1.02 Definitions …………………………………………………………………………………………………………………………………………… 1

Article 2: Board of Physical Therapy ………………………………………………………………………………………………….. 3 2.01 Board of Physical Therapy …………………………………………………………………………………………………………………. 3 2.02 Powers and Duties of the Board ……………………………………………………………………………………………………….. 4 2.03 Disposition of Funds …………………………………………………………………………………………………………………………… 5

Article 3: Examination and Licensure ………………………………………………………………………………………………… 5 3.01 National Examination …………………………………………………………………………………………………………………………. 5 3.02 Qualifications for Licensure [and Certification] ………………………………………………………………………………. 6 3.03 Licensure [and Certification] by Endorsement ……………………………………………………………………………….. 8 3.04 Exemptions from Licensure [or Certification] …………………………………………………………………………………. 8 3.05 License [or Certificate] Renewal ……………………………………………………………………………………………………….. 9 3.06 Changes of Name, Address or Telephone Number ………………………………………………………………………… 9 3.07 Reinstatement of License [or Certificate] ………………………………………………………………………………………… 9

Article 4: Regulation of Physical Therapy ……………………………………………………………………………………….. 10 4.01 Ethics in the Physical Therapy Profession ……………………………………………………………………………………… 10 4.02 Use of Titles and Terms; Restrictions; Classification of Violation ……………………………………………….. 10 4.03 Patient/Client Care Management …………………………………………………………………………………………………… 11 4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action ………………………………………. 12 4.05 Investigative Powers; Emergency Action; Hearing Officers ………………………………………………………… 13 4.06 Hearings ……………………………………………………………………………………………………………………………………………… 14 4.07 Disciplinary Actions; Penalties ………………………………………………………………………………………………………… 14 4.08 Procedural Due Process …………………………………………………………………………………………………………………… 14 4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief …………………………………………….. 14 4.10 Reporting Violations; Immunity ………………………………………………………………………………………………………. 15 4.11 Substance Abuse Recovery Program ……………………………………………………………………………………………… 15 4.12 Rights of Consumers …………………………………………………………………………………………………………………………. 15

Model Practice Act with Commentary …………………………………………………………………………………….. 1 Introductory Notes …………………………………………………………………………………………………………………………….. 1 Physical Therapy Practice Act ……………………………………………………………………………………………………………. 1 Article 1: General Provisions ……………………………………………………………………………………………………………… 1

1.01 Legislative Intent …………………………………………………………………………………………………………………………… 1 1.02 Definitions …………………………………………………………………………………………………………………………………………… 1

Article 2: Board of Physical Therapy ……………………………………………………………………………………………….. 10 2.01 Board of Physical Therapy ……………………………………………………………………………………………………………….. 10 2.02 Powers and Duties of the Board ……………………………………………………………………………………………………… 12 Commentary ………………………………………………………………………………………………………………………………………………. 19 2.03 Disposition of Funds …………………………………………………………………………………………………………………………. 19

Article 3: Examination and Licensure ……………………………………………………………………………………………… 19 3.01 National ExaminationF3.01 ……………………………………………………………………………………………………………… 19

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3.02 Qualifications for Licensure [and Certification] …………………………………………………………………………….. 20 3.03 Licensure [and Certification] by Endorsement ……………………………………………………………………………… 24 3.04 Exemptions from Licensure [or Certification] ……………………………………………………………………………….. 25 3.05 License [or Certificate] Renewal ……………………………………………………………………………………………………… 28 3.06 Changes of Name, Address or Telephone Number ………………………………………………………………………. 28 3.07 Reinstatement of License [or Certificate] ………………………………………………………………………………………. 29 [3.08 Fees] ………………………………………………………………………………………………………………………………………………….. 30

Article 4: Regulation of Physical Therapy ……………………………………………………………………………………….. 31 4.01 Ethics in the Physical Therapy Profession ……………………………………………………………………………………… 31 4.02 Use of Titles and Terms; Restrictions; Classification of Violation ……………………………………………….. 31 4.03 Patient/Client Care Management …………………………………………………………………………………………………… 34 4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action ………………………………………. 37 4.05 Investigative Powers; Emergency Action; Hearing Officers ………………………………………………………… 44 4.06 Hearings ……………………………………………………………………………………………………………………………………………… 47 4.07 Disciplinary Actions; Penalties ………………………………………………………………………………………………………… 48 4.08 Procedural Due Process …………………………………………………………………………………………………………………… 49 4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief …………………………………………….. 50 4.10. Reporting Violations; Immunity …………………………………………………………………………………………………….. 51 4.11. Substance Abuse Recovery Program …………………………………………………………………………………………….. 52 4.12. Rights of Consumers ……………………………………………………………………………………………………………………….. 53

Guidelines for Rules ………………………………………………………………………………………………………………… 2 Introduction ………………………………………………………………………………………………………………………………………. 2

Appendix A: Model Statute Language Changes ………………………………………………………………………. 1

Physical Therapy Practice Act ………………………………………………………………………………………………….. 1 Article 1: General Provisions ……………………………………………………………………………………………………………… 1

1.01 Legislative Intent ………………………………………………………………………………………………………………………………… 1 1.02 Definitions …………………………………………………………………………………………………………………………………………… 1

Article 2: Board of Physical Therapy ………………………………………………………………………………………………….. 3 2.01 Board of Physical Therapy …………………………………………………………………………………………………………………. 3 2.02 Powers and Duties of the Board ……………………………………………………………………………………………………….. 4 2.03 Disposition of Funds …………………………………………………………………………………………………………………………… 5

Article 3: Examination and Licensure ………………………………………………………………………………………………… 5 3.01 National Examination …………………………………………………………………………………………………………………………. 5 3.02 Qualifications for Licensure [and Certification] ………………………………………………………………………………. 6 3.03 Licensure [and Certification] by Endorsement ……………………………………………………………………………….. 8 3.04 Exemptions from Licensure [or Certification] …………………………………………………………………………………. 8 3.05 License [or Certificate] Renewal ……………………………………………………………………………………………………….. 9 3.06 Changes of Name, Address or Telephone Number ………………………………………………………………………… 9 3.07 Reinstatement of License [or Certificate] ………………………………………………………………………………………… 9 [3.08 Fees] ………………………………………………………………………………………………………………………………………………….. 10

Article 4: Regulation of Physical Therapy ……………………………………………………………………………………….. 10 4.01 Ethics in the Physical Therapy Profession ……………………………………………………………………………………… 10 4.02 Use of Titles and Terms; Restrictions; Classification of Violation ……………………………………………….. 10 4.03 Patient/Client Care Management …………………………………………………………………………………………………… 11 4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action ………………………………………. 12 4.05 Investigative Powers; Emergency Action; Hearing Officers ………………………………………………………… 13

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4.06 Hearings ……………………………………………………………………………………………………………………………………………… 14 4.07 Disciplinary Actions; Penalties ………………………………………………………………………………………………………… 14 4.08 Procedural Due Process …………………………………………………………………………………………………………………… 14 4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief …………………………………………….. 14 4.10 Reporting Violations; Immunity ………………………………………………………………………………………………………. 15 4.11 Substance Abuse Recovery Program ……………………………………………………………………………………………… 15 4.12 Rights of Consumers …………………………………………………………………………………………………………………………. 15

Appendix B: Code of Ethics for the Physical Therapist and Guide for Professional Conduct …… 1

Appendix C: Standards of Ethical Conduct for the Physical Therapist Assistant & Guide for Conduct …………………………………………………………………………………………………………………………………… 1

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Model Practice Act Language

Introductory Notes

• This is the Federation of State Boards of Physical Therapy’s model physical therapy practice act.

• The numerical references used with each paragraph are only for organizational purposes within this model act. Each jurisdiction should use a numbering system that conforms to its own statutory classification system.

• Bracketed areas throughout the Model Practice Act indicate optional language each jurisdiction should adapt to its own needs. For example, the use of [act] in this model is a drafting option for statutory references such as “chapter,” “act,” “section” or “law” used commonly in practice acts. Each jurisdiction should use the term applicable to its statutes. The optional [certificate] and [certificate holder] apply if physical therapist assistants are certified by a jurisdiction. However, if physical therapist assistants are licensed by a jurisdiction this particular bracket option would not apply. Other bracketed options are explained in the context of the paragraphs where they appear or in commentary.

• For jurisdictions that are members of the Physical Therapy Compact, additional language to this act may be considered. These recommendations are found in the commentary of this document. However, jurisdictions should be assured that the Physical Therapy Compact legislation grants the authority to the jurisdiction to be a fully participating member of the Compact.

• Several other documents are referenced throughout the Model Practice Act. A few of these are included in the Appendix. Others may be referenced on websites of the Federation of State Boards of Physical Therapy or the American Physical Therapy Association.

Physical Therapy Practice Act

[Include proper numerical statute reference, e.g., Chapter # and/or Title #]

Article 1: General Provisions 1.01 Legislative Intent This [act] is enacted for the purpose of protecting the public health, safety, and welfare, and provides for jurisdiction administrative control, supervision, licensure, and regulation of the practice of physical therapy. It is the legislature’s intent that only individuals who meet and maintain prescribed standards of competence and conduct may engage in the practice of physical therapy as authorized by this [act]. This [act] shall be liberally construed to promote the public interest and to accomplish the purpose stated herein.

1.02 Definitions

As specifically used in this [act], the following terms have the meanings set forth below, unless the context requires otherwise.

1. “Board” means the [specify the jurisdiction] board of physical therapy.

2. “Competence” is the application of knowledge, skills, and behaviors required to function effectively, safely, ethically and legally within the context of the patient/client’s role and environment.

3. “Consultation” means a physical therapist seeking assistance from, or rendering professional or expert

opinion or advice to, another physical therapist or professional healthcare provider via electronic communications, telehealth, or in-person.

4. “Continuing competence” is the lifelong process of maintaining and documenting competence through

ongoing self-assessment, development, and implementation of a personal learning plan, and subsequent reassessment.

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5. “Electronic Communications” means the science and technology of communication (the process of exchanging information) over any distance by electronic transmission of impulses including activities that involve using electronic communications to store, organize, send, retrieve, and/or convey information.

6. “Examination” means a national examination approved by the board for the licensure of a physical therapist or the [certification/licensure] of a physical therapist assistant.

7. “Jurisdiction of the United States” means any state, the District of Columbia, the Commonwealth of

Puerto Rico, or any American territory.

8. “Nexus to practice” means the criminal act of the applicant or licensee [certificant] posing a risk to the public’s welfare and safety relative to the practice of physical therapy.

9. “Onsite supervision” means supervision provided by a physical therapist who is continuously onsite and

present in the department or facility where services are provided. The supervising therapist is immediately available to the person being supervised and maintains continued involvement in the necessary aspects of patient/client care.

10. “Patient/client” means any individual receiving physical therapy from a licensee [or certificate holder]

under this Act.

11. “Physical therapist assistant” means a person who is [certified/licensed] pursuant to this [act] and who assists the physical therapist in selected components of the physical therapy treatment intervention.

12. “Physical therapist assistant-patient/client relationship” means the formal or inferred relationship

entered into by mutual consent between a licensed [certified] physical therapist assistant and a patient/client or their legally authorized representative established once the physical therapist assistant assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged or treatment is formally transferred to another practitioner or as further defined by rule.

13. “Physical therapist” means a person who is a licensed healthcare practitioner pursuant to this [act] to

practice physical therapy. The terms “physiotherapist” or “physio” shall be synonymous with “physical therapist” pursuant to this [act].

14. “Physical therapist-patient/client relationship” means the formal or inferred relationship entered into by

mutual consent between a licensed physical therapist and a patient/client or their legally authorized representative established once the physical therapist assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged, or treatment is formally transferred to another healthcare practitioner or as further defined by rule.

15. “Physical therapy aide” means a person trained by or under the direction of a physical therapist who

performs designated and supervised routine tasks related to physical therapy services.

16. “Physical therapy” means the care and services provided in-person or via telehealth by or under the direction and supervision of a physical therapist who is licensed pursuant to this [act]. The term “physiotherapy” shall be synonymous with “physical therapy” pursuant to this [act].

17. “Practice of physical therapy” means:

a. Examining, evaluating, and testing patients/clients with mechanical, physiological and developmental impairments, functional limitations, and disabilities or other health and movement-related conditions in order to determine a diagnosis, prognosis and plan of treatment intervention, and to assess the ongoing effects of intervention.

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b. Alleviating impairments, functional limitations and disabilities; promoting health; and preventing disease by designing, implementing and modifying treatment interventions that may include, but not limited to: therapeutic exercise; needle insertion; patient-related instruction; therapeutic massage; airway clearance techniques; integumentary protection and repair techniques; debridement and wound care; physical agents or modalities; mechanical and electrotherapeutic modalities; manual therapy including soft tissue and joint mobilization/manipulation; functional training in self-care and in home, community or work integration or reintegration; as well as prescription application and, as appropriate, fabrication of assistive, adaptive, orthotic, prosthetic, protective and supportive devices and equipment. c. Reducing the risk of injury, impairment, functional limitation, and disability, including performance of participation-focused physical examinations and the promotion and maintenance of fitness, health, and wellness in populations of all ages. d. Referring a patient/client to healthcare providers and facilities for services and testing to inform the physical therapist plan of care. e. Engaging in administration, consultation, education, and research.

18. “Restricted [certificate/license]” for a physical therapist assistant means a [certificate/license] on which the board has placed any restrictions and/or condition as to scope of work, place of work, duration of certified or licensed status, or type or condition of patient/client to whom the certificate holder or licensee may provide services.

19. “Restricted license” for a physical therapist means a license on which the board has placed any restrictions and/or conditions as to scope of practice, place of practice, supervision of practice, duration of licensed status, or type or condition of individual to whom the licensee may provide services.

20. “Supervision” means the process by which a physical therapist oversees and directs safe and effective

delivery of patient care through appropriate verbal, written, or electronic communication. This may be accomplished with the physical therapist located onsite or remotely as deemed appropriate based on the patient/client needs.

21. “Telehealth” is the use of electronic communications to provide and deliver a host of health-related

information and healthcare services, including, but not limited to physical therapy related information and services, over large and small distances. Telehealth encompasses a variety of healthcare and health promotion activities, including, but not limited to, education, advice, reminders, interventions, and monitoring of interventions.

22. “Testing” means standard methods and techniques used to gather data about the patient/client, including

but not limited to imaging, electrodiagnostic and electrophysiologic tests and measures.

Article 2: Board of Physical Therapy The Board shall have all of the duties, powers, and authority specifically granted by or necessary for the enforcement of this Act, as well as such other duties, powers, and authority as it may be granted from time to time by applicable law.

2.01 Board of Physical Therapy

A. The board of physical therapy shall consist of [seven] members appointed by the Governor. [Four] members

shall be physical therapists who are residents of this jurisdiction, possess unrestricted licenses to practice physical therapy in this jurisdiction and have been practicing in this jurisdiction for no less than five years before their appointments. [One] member shall be a physical therapist assistant who is a resident of this jurisdiction and possesses an unrestricted [certificate/license]. The Governor shall also appoint [two] public members who shall be residents of this jurisdiction and who are not affiliated with, nor have a financial interest

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in, any healthcare profession and who have an interest in consumer rights. The Governor shall, to the greatest extent possible, appoint individuals to achieve diversity on the board.

B. Board members shall serve staggered four-year terms. Board members shall serve no more than two successive

four-year terms or for more than ten consecutive years. By approval of the majority of the board, the service of a member may be extended at the completion of a four-year term until a new member is appointed or the current member is reappointed.

C. The board may request the Governor remove any member of the board for misconduct, incompetence, or

neglect of duty. D. Board members are eligible for [compensation and/or] reimbursement of necessary expenses pursuant to [cite

applicable statute relating to [compensation and/or] reimbursement] for attending each board meeting or representing the board in an official board-approved activity.

E. A board member who acts within the scope of board duties, without malice and in the reasonable belief that the

member’s action is warranted by law, is immune from civil liability. 2.02 Powers and Duties of the Board

The board shall:

1. Evaluate the qualifications of applicants for licensure [and certification].

2. Provide for the examination of physical therapists and physical therapist assistants.

3. Issue licenses [or certificates] to persons who meet the qualifications of this [act].

4. Regulate the practice of physical therapy by interpreting and enforcing this [act].

5. Have the authority to establish committees, advisory panels, and task forces to further the work of the board.

6. Adopt and revise rules consistent with this [act]. Such rules, when lawfully adopted, shall have the effect of law.

7. Meet at least once each quarter in compliance with the open meeting requirements of [cite applicable statute]. A majority of filled board member positions shall constitute a quorum for the transaction of business. The board shall keep an official record of its meetings.

8. Establish mechanisms for assessing the continuing competence of physical therapists to practice physical therapy.

9. Establish mechanisms for assessing the continuing competence of physical therapist assistants to work in the profession of physical therapy.

10. Establish and collect fees for sustaining the necessary operation and expenses of the board.

11. Elect officers from its members necessary for the operations and obligations of the board. Terms of office shall be one year.

12. Provide for the timely orientation and training of new professional and public appointees to the board regarding board licensing and disciplinary procedures, this [act], and board rules, policies and procedures.

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13. Maintain a current list of all persons regulated under this [act]. This information includes the person’s name, current business and residential address, email address, telephone numbers, and license [or certificate] number.

14. Provide information to the public regarding the complaint process. 15. Employ necessary personnel to carry out the administrative work of the board. Board personnel are

eligible to receive compensation pursuant to [cite specific statute].

16. Enter into contracts for services necessary for enforcement of this [act].

17. Report final disciplinary action taken against a licensee [or certificate holder] to a national disciplinary database recognized by the board or as required by law.

18. Report information of alleged unlawful conduct by licensees [or certificate holders], unlicensed individuals, other healthcare providers, and entities to the appropriate county, jurisdiction, or federal authority.

19. Publish, at least annually, final adverse action taken against a licensee [or certificate holder].

20. Publish at least annually, board rulings, opinions, and interpretations of statutes or rules in order to guide persons regulated pursuant to this [act].

21. Participate in or conduct performance audits.

22. Have the authority to fully participate in a national Exam, Licensure, and Disciplinary Database as defined by rule.

23. Have the authority to obtain biometric-based information from every physical therapist or physical therapist assistant applicant for licensure[certification] and submit this information to the Federal Bureau of Investigation for a criminal background check.

24. Have the authority to determine and collect, at the time of new licensure [or certification] and licensure [or certification] renewal, a core set of data elements deemed necessary for the purpose of workforce assessment and planning. The data elements shall be used to create and maintain a healthcare workforce database. The Board may enter into agreements with a private or public entity to establish and maintain the database, perform data analysis, and/or prepare reports concerning the physical therapy workforce. The Board shall promulgate rules to perform duties pursuant to this [act].

25. Have the authority to require a licensee [certificate holder] to complete educational activities.

2.03 Disposition of Funds (No model language is offered under this section heading. See Commentary for further information.)

Article 3: Examination and Licensure 3.01 National Examination

A. The board shall provide for a national examination within the jurisdiction. B. To be eligible to sit for the national examination, the candidate must meet nationally recognized requirements

that support the integrity of the examination and are further defined by rule. 1. The physical therapist examination is a national examination that tests entry-level competence related to

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physical therapy theory, examination and evaluation, diagnosis, prognosis, treatment intervention, prevention and consultation. 2. The physical therapist assistant examination is a national examination that tests for requisite knowledge and skills in the technical application of physical therapy services.

C. Candidates must agree to abide by security and copyright provisions related to the national licensure

examination. If the board determines that an applicant has violated any of these provisions or engaged in or attempted to engage in any other conduct that subverts or undermines the integrity of the examination process or validity of examination results, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time.

D. Any violation of security and copyright provisions related to the national licensure examination, subversion or

attempts to subvert the national examination shall be reported by the board to the Federation of State Boards of Physical Therapy.

E. If the board determines that an applicant has engaged or has attempted to engage in conduct that subverts or

undermines the integrity of the examination process, including a violation of security and copyright provisions related to the national licensure examination, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time.

3.02 Qualifications for Licensure [and Certification]

A. An applicant for a license as a physical therapist shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a professional physical therapy education program accredited by a

national accreditation agency approved by the board. 3. Pass a national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. B. An applicant for a license as a physical therapist who has been educated at a school that has not been

accredited by an agency approved by the board shall: 1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of

physical therapists educated in an accredited entry-level program as determined by the board. Graduation outside the United States from a professional education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated at a school that has not been accredited by an agency approved by the board shall have: a. Graduated from a physical therapist education program that prepares the applicant to engage without restriction in the practice of physical therapy; b. Provided written proof that the applicant’s school of physical therapy is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

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3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass a national examination approved by the board. 5. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 6. Submit to a criminal records check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed under this [Act].

C. An applicant for a [certificate/license] as a physical therapist assistant shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a physical therapist assistant education program accredited by a national

accreditation agency approved by the board. 3. Pass a national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. D. An applicant for a [certificate/license] as a physical therapist assistant who has been educated at a school that

has not been accredited by an agency approved by the board shall: 1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of

physical therapist assistants educated in an accredited entry-level program as determined by the board. Graduation outside the United States from an education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated at a school that has not been accredited by an agency approved by the board shall have: a. Graduated from a physical therapist assistant educational program that prepares the applicant to work as a physical therapist assistant; b. Provided written proof that the applicant’s physical therapist assistant school is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass a national examination approved by the board. 5. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 6. Submit to a criminal records check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act].

E. . An applicant for a [certificate/license] as a physical therapist assistant who has completed a United States

Armed Services program of training not accredited by a national accreditation agency approved by the board shall:

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1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of

physical therapist assistants educated in an accredited entry-level program as determined by the board. Successful completion of a United States Armed Services program of training accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure who has completed a United States Armed Services program of training shall have: a. Completed a physical therapist assistant training program that prepares the applicant to work as a physical therapist assistant; b. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and c. Completed any additional education as required by the board.

3. Pass a national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act].

3.03 Licensure [and Certification] by Endorsement

A. The board shall issue a license to a physical therapist who has a current unrestricted license from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant’s initial licensure. B. The board shall issue a license [certificate] to a physical therapist assistant who has a current unrestricted license [certificate] from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant’s initial licensure.

3.04 Exemptions from Licensure [or Certification]

A. This [act] does not restrict a person licensed or certified under any other law of this jurisdiction from engaging in the profession or practice for which that person is licensed if that person does not represent, imply or claim that he/she is a physical therapist, physical therapist assistant, or a provider of physical therapy as defined in Article 1, 1.02.

B. The following persons are exempt from the licensure [certification] requirements of this [act] when engaged in

the following activities: 1. A person in an entry-level professional education program approved by the board who is satisfying

supervised clinical education requirements related to the person’s physical therapist education while under onsite supervision of a physical therapist.

2. A person satisfying a clinical education experience under the onsite supervision of a physical therapist as required by the board.

3. A physical therapist who is practicing in the United States Armed Services, United States Public Health Service or Veterans Administration pursuant to federal regulations for jurisdiction licensure of healthcare providers. If such person, while federally employed as a physical therapist, shall engage in the practice of physical therapy outside the course and scope of such federal employment, he/she shall then be required to obtain a license in accordance with this [act].

4. A physical therapist who is licensed in another jurisdiction of the United States or credentialed to practice physical therapy in another country if that person is teaching, demonstrating or providing physical therapy services in connection with teaching or participating in an educational seminar of no more than 60 days in a calendar year.

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5. A physical therapist who is licensed in another jurisdiction of the United States if that person is rendering advice or professional or expert to a licensed healthcare practitioner in this jurisdiction.

6. A physical therapist who is licensed in a jurisdiction of the United States or credentialed in another country, if that person by contract or employment is providing physical therapy to patients/clients affiliated with or employed by established athletic teams, athletic organizations or performing arts companies temporarily practicing, competing, or performing in the jurisdiction for no more than 60 days in a calendar year.

7. A physical therapist who is licensed in a jurisdiction of the United States and who enters this jurisdiction to provide physical therapy during a declared local, jurisdictional or national disaster or emergency. This exemption applies for no longer than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

8. A physical therapist licensed in a jurisdiction of the United States who is forced to leave his/her residence or place of employment due to a declared local, jurisdictional or national disaster or emergency and due to such displacement seeks to practice physical therapy. This exemption applies for no more than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

C. A physical therapist assistant who is [certified/licensed] in a jurisdiction of the United States and is assisting a

physical therapist engaged specifically in activities related to [subparagraphs (B) 2, 3, 5, 6 and 7 of this section] is exempt from the requirement of [certification/licensure] under this [act].

3.05 License [or Certificate] Renewal

A. A physical therapist applying for renewal of the license shall: 1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed under this [Act].

B. A physical therapist assistant applying for renewal of the license [certificate] shall:

1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. 3.06 Changes of Name, Address or Telephone Number

Each licensee [and certificate holder] is responsible for reporting a name change and changes in business and home address, email address and telephone numbers to the board within 30 days.

3.07 Reinstatement of License [or Certificate]

A. The board may reinstate a lapsed license [or certificate] upon completion of a reinstatement application including payment of fees, as defined by rule.

B. If a physical therapist’s license has lapsed for a specified time period, as defined by rule, that person shall fulfill

all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to practice physical therapy by one or more of the following as determined by the board: 1. Complete supervised clinical practice as defined by rule with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during lapsed

licensure period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed practice in another jurisdiction.

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C. If a physical therapist assistant’s [certificate/ license] has lapsed for a specified time period, as defined by rule, that person shall fulfill all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to work as a physical therapist assistant by one or more of the following as determined by the board: 1. Complete supervised clinical practice as defined by rules with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during lapsed

licensure [certification] period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed [certified] work as a physical therapist assistant in another jurisdiction.

D. The board may reinstate a suspended or revoked physical therapist’s license upon completion of the

requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of competence to practice physical therapy through the following activities: 1. Complete supervised clinical practice, as defined by rule, with a restricted license. 2. Demonstrate or complete continued competence requirements, defined by rule, required during the

suspended or revoked licensure period. 3. Successfully complete assessment tool(s) and/or pass examination(s) approved by the board.

E. The board may reinstate a suspended or revoked physical therapist assistant’s [certificate/license] upon

completion of the requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of the physical therapist assistant’s competence to work in the profession of physical therapy through the following activities. 1. Complete supervised clinical practice with a restricted license under a qualified and approved supervisor. 2. Demonstrate or complete continued competence requirements, defined by rule, required during the

suspended or revoked licensure period. 3. Successfully complete assessment tool(s) and/or pass examination(s) approved by the board.

[3.08 Fees] (This is optional statute language for states requiring maximum fee ceilings within their statutes.) A. The board shall establish and collect fees not to exceed:

1. ________ dollars for an application for an original license [or certificate]. This fee is nonrefundable. 2. ________ dollars for a certificate of renewal of a license [or certificate]. 3. ________ dollars for an application for reinstatement of a license [or certificate]. 4. ________ dollars for each duplicate license [or certificate]. 5. ________ dollars for other administrative fees [e.g., criminal records report, pass through or processing

fees] Article 4: Regulation of Physical Therapy 4.01 Ethics in the Physical Therapy Profession A. A physical therapist shall adhere to the recognized standards of ethics of the physical therapy profession as

established by rule. B. A physical therapist assistant shall adhere to the recognized standards of ethics of the physical therapy

profession as established by rule. 4.02 Use of Titles and Terms; Restrictions; Classification of Violation A. A physical therapist shall use the letters “PT” or the term “physical therapist” immediately following their name

to designate licensure as a healthcare practitioner under this [act]. B. A person or business entity, its employees, agents or representatives shall not use in connection with that

person’s name or the name or activity of the business, the words “physical therapy,” “physical therapist,” “physiotherapy,” “physiotherapist,” “physio,” “registered physical therapist,” “doctor of physical therapy,” the letters “PT,” “DPT,” “LPT,” “RPT,” or any other words, abbreviations or insignia indicating or implying directly

7th Edition MPA, version 7.0 11

or indirectly that physical therapy is provided or supplied, unless such services are provided by or under the direction of a physical therapist licensed pursuant to this [act]. A person or business entity shall not advertise or otherwise promote another person as being a “physical therapist” or “physiotherapist” unless the individual so advertised or promoted is licensed as a physical therapist under this act. A person or business entity that offers, provides, or bills any other person for services shall not characterize those services as “physical therapy” or “physiotherapy” unless the individual performing those services is a person licensed as a physical therapist under this [act].

C. Physical therapists who have graduated from a DPT program may use the title Doctor of Physical Therapy. A

physical therapist holding a DPT or other doctoral degree shall not use the title Doctor without also clearly informing the public of his or her profession as a physical therapist. Use of the title shall be in accordance with jurisdictional law.

D. A physical therapist assistant shall use the letters “PTA” immediately following his or her name to designate

[certification/licensure] under this [act]. E. A person shall not use the title “physical therapist assistant,” the letters “PTA,” or any other words,

abbreviations, or insignia in connection with that person’s name to indicate or imply, directly or indirectly, that the person is a physical therapist assistant unless that person is [certified/licensed] as a physical therapist assistant pursuant to this [act].

F. A person or business entity that violates paragraphs (B) or (E) of this section is guilty of a [cite specific legal

sanction]. The board shall have authority to impose a civil penalty, in an amount not to exceed [specify number of dollars] per violation, against any person or business entity that violates paragraphs (B) or (E). In addition, the board shall seek an injunction against conduct in violation of paragraphs (B) or (E) in any court of competent jurisdiction. For purposes of this [act], the board, in seeking an injunction, need only show that the defendant violated paragraphs (B) and (E) of this section to establish irreparable injury or a likelihood of a continuation of the violation.

4.03 Patient/Client Care Management A. A physical therapist is fully responsible for managing all aspects of the physical therapy care of each

patient/client. A physical therapist shall provide: 1. The initial evaluation, determination of diagnosis, prognosis, and plan of treatment intervention and

documentation of each encounter with each patient/client; 2. Periodic reevaluation and documentation of each patient/client; 3. The documented discharge of the patient/client, including the patient’s/client’s response to treatment

intervention at the time of discharge.

B. A physical therapist shall assure the qualifications of all physical therapist assistants and physical therapy aides under their direction and supervision.

C. For each patient/client on each date of service, a physical therapist shall provide all the treatment intervention

that requires the education, skills, and knowledge of a physical therapist and shall determine the use of physical therapist assistants or physical therapy aides to ensure that the delivery of care that is safe, effective, and efficient. 1. A physical therapist assistant shall work under a physical therapist’s supervision. A physical therapist

assistant shall document the care they provide. 2. A physical therapist may use physical therapy aides for designated routine tasks. A physical therapy aide

shall work under the supervision of a physical therapist.

D. The physical therapist shall communicate the plan of care with, and obtain informed consent from, the patient/client or their legally authorized representative.

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E. A physical therapist’s responsibility shall include accurate documentation and billing of the services provided. F. A physical therapist assistant’s responsibility shall include accurate documentation and billing of the services

provided. G. Nothing in this [Act] shall prohibit a licensee[certificate holder] from providing physical therapy to animals for

which the licensee[certificate holder] has completed the education and training as further established by rule.

4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action

A. The following are grounds for denial of a license [and certificate] or disciplinary action: 1. Violating any provision of this [act], board rules or a written order of the board. 2. Obtaining or attempting to obtain a license [or certificate] by fraud or misrepresentation. 3. Attempting to engage in conduct that subverts or undermines the integrity of the examination or the

examination process including, but not limited to, a violation of security and copyright provisions related to the national licensure exam, utilizing in any manner recalled or memorized examination questions from or with any person or entity, failing to comply with all test center security procedures, communicating or attempting to communicate with other examinees during the test, or copying or sharing examination questions or portions of questions.

4. Practicing or offering to practice beyond the scope of the practice of physical therapy. 5. Acting in a manner inconsistent with generally accepted standards of physical therapy practice, regardless

of whether actual injury to the patient/client is established. 6. Failing to adhere to the recognized standards of ethics of the physical therapy profession as established

by rule. 7. Failing to complete continuing competence requirements as established by rule. 8. Failing to maintain adequate patient/client records. For the purposes of this paragraph, “adequate

patient/client records” means legible records that contain at minimum sufficient information to identify the patient/client, an evaluation of objective findings, a diagnosis, a plan of care, a treatment record and a discharge plan.

9. Failing to supervise physical therapist assistants, physical therapy aides, a person in an entry-level professional education program approved by the board who is satisfying supervised clinical education requirements related to the person’s education, or a person satisfying a supervised clinical practice in accordance with this [act] and board rules.

10. Failing to report to the board, where there is direct knowledge, any unprofessional, incompetent, or illegal acts that appear to be in violation of this [act] or any rules established by the board.

11. Engaging in sexual misconduct. For the purpose of this paragraph, sexual misconduct includes: a. Engaging in or soliciting romantic or sexual relationships, whether consensual or non-consensual,

while a physical therapist or physical therapist assistant-patient/client relationship exists. b. Making advances, requesting favors, or expressing thoughts, feelings, or making gestures that

are sexual in nature, or that reasonably may be construed by a patient/client as sexual in nature, by any means including verbal or physical contact, or via electronic communications.

c. Intentionally viewing a completely or partially disrobed patient/client in the course of treatment if the viewing is not related to patient/client diagnosis or treatment under current practice standards.

12. Sexual contact between a physical therapist and patient/client after termination of the physical therapist- patient/client relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

13. Sexual contact between a physical therapist assistant and patient/client after termination of the physical therapist assistant-patient/client relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

14. Abusing the physical therapist-patient/client relationship to exert undue influence or exploiting persons over whom the licensee has supervisory, evaluative, or other authority.

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15. Abusing the physical therapist assistant-patient/client relationship to exert undue influence or exploiting persons over whom the licensee [certificate holder] has supervisory or other authority.

16. Having had a license [or certificate] revoked or suspended, other disciplinary action taken, or an application for licensure [or certification] refused, revoked or suspended by the proper authorities of another jurisdiction, territory, or country.

17. Having been convicted of or pled guilty to a felony with a nexus to the practice of a physical therapist or work of a physical therapist assistant in the courts of this jurisdiction or any other jurisdiction, territory or country. Conviction, as used in this paragraph, shall include a deferred conviction, deferred prosecution, deferred sentence, finding or verdict of guilt, an admission of guilt, an Alfred plea, or a plea of nolo contendere.

18. Aiding and abetting the unlicensed practice of physical therapy. 19. Directly or indirectly requesting, receiving, or participating in the dividing, transferring, assigning, rebating

or refunding of an unearned fee, or profiting by means of a credit or other valuable consideration such as an unearned commission, discount or gratuity in connection with the furnishing of physical therapy services. This does not prohibit the members of any regularly and properly organized business entity recognized by law and comprising physical therapists from dividing fees received for professional services among themselves as they determine necessary.

20. Promoting any unnecessary device, treatment intervention, or service resulting in the financial gain of the practitioner or of a third party.

21. Providing treatment intervention unwarranted by the condition of the patient/client or continuing treatment beyond the point of reasonable benefit.

22. Participating in underutilization or overutilization of physical therapy services for personal or institutional financial gain.

23. Charging fraudulent fees for services performed or not performed. 24. Making misleading, deceptive, untrue or fraudulent representations in violation of this [act] or in the

practice of the profession. 25. Practicing as a physical therapist or working as a physical therapist assistant when physical or mental

abilities are impaired by the use of controlled substances or other habit-forming drugs, chemicals or alcohol, or by other causes.

26. Practicing physical therapy with a mental or physical condition that impairs the ability of the licensee to practice with skill and safety.

27. Practicing after having been adjudged mentally incompetent by a court of competent jurisdiction. 28. Interfering with an investigation or disciplinary proceeding by failure to cooperate, by misrepresentation

of facts, or by the use of threats or harassment against any patient/client or witness to prevent that patient/client or witness from providing evidence in a disciplinary proceeding or any legal action.

29. Failing to maintain patient/client confidentiality without documented authorization of the patient/client or unless otherwise required by law. All records used or resulting from a consultation by telehealth, as defined in [Definitions, Article 1.02], are part of a patient’s/client’s records and are subject to applicable confidentiality requirements.

4.05 Investigative Powers; Emergency Action; Hearing Officers

A. To enforce this [act], the board is authorized to: 1. Receive complaints filed against licensees [or certificate holders] and conduct a timely investigation. 2. File complaints against licensees [or certificate holders] or individuals engaging in the unlawful or

unlicensed practice of physical therapy and conduct timely investigations. 3. Conduct an investigation at any time and on its own initiative without receipt of a written complaint if the

board has reason to believe that there may be a violation of this [act]. 4. Issue subpoenas to compel the attendance of any witness or the production of any documentation

relative to a case. 5. Take emergency action ordering the summary suspension of a license [or certificate] or the restriction of a

physical therapist’s practice or a physical therapist assistant’s work pending proceedings by the board.

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6. Appoint hearing officers authorized to conduct hearings. Hearing officers shall prepare and submit to the board findings of fact, conclusions of law and a recommendation for board action that shall be reviewed and voted on by the board.

7. Require a physical therapist to be examined in order to determine his or her mental or physical ability to practice physical therapy.

8. Require a physical therapist assistant to be examined in order to determine his or her mental or physical ability to work in the profession of physical therapy.

B. If the board finds that the information received in a complaint or an investigation does not merit disciplinary action against a licensee [or certificate holder] it may take one of the following actions:

1. Dismiss the complaint. 2. Issue an advisory letter to the licensee [or certificate holder]. An advisory letter is non-disciplinary and

notifies a licensee [or certificate holder] that, while there is no evidence to merit disciplinary action, the board believes that the licensee [or certificate holder] should become educated about the requirements of this [act] and board rules.

4.06 Hearings (No model statute language is offered under this section heading. See Commentary for additional information.)

4.07 Disciplinary Actions; Penalties Upon proof that any grounds prescribed in section [Grounds for Denial of License [and Certificate]; Disciplinary Action, Article 4.04], have been violated, the board may take the following disciplinary actions singly or in combination.

1. Issue a censure. 2. Restrict a license [or certificate]. The board may require a licensee [or certificate holder] to report

regularly to the board on matters related to the grounds for the restricted license [or certificate]. 3. Suspend a license [or certificate] for a period prescribed by the board. 4. Revoke a license [or certificate]. 5. Refuse to issue or renew a license [or certificate]. 6. Impose a civil penalty of at least ____________ but not more than ____________. (Include minimum and

maximum dollar amounts of civil penalties.) 7. Accept a voluntary surrendering of a license [or certificate] based on an order of consent from the board.

4.08 Procedural Due Process

Actions of the board shall be taken subject to the right of notice, opportunity to be heard, and the right of appeal in accordance with [specify the jurisdiction] law relating to administrative law and procedure.

4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief A. It is unlawful for any person or business entity, its employees, agents, or representatives not licensed as a

physical therapist under this [act] to engage in the practice of physical therapy. Any person who violates this paragraph [(A) or Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02], is guilty of [cite specific criminal sanction, e.g., class 1 misdemeanor] and subject to any other remedies specified in this [act].

B. The board shall investigate any person or business entity to the extent necessary to determine whether the

person or business entity is engaged in the unlawful practice of physical therapy. If an investigation indicates that a person or business entity is practicing physical therapy unlawfully, the board shall inform the person or the business entity of the alleged violation. The board may refer the matter for prosecution regardless of whether the person or business entity ceases the unlawful practice of physical therapy.

C. The board shall apply to any court of competent jurisdiction for an order enjoining any person or business

entity from committing any violation of this [act]. Injunction proceedings under this paragraph shall be in addition to, and not in lieu of, all penalties and other remedies prescribed in this [act].

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D. If a person or business entity knowingly violates this [act] or board rules, fraudulently uses or permits the use

of a license [or certificate] number, or knowingly aids or requires another person to violate this [act] or board rules, the board may impose upon such person a civil penalty of not more than [dollar amount of penalty] for the first violation and not more than [dollar amount of penalty] for each subsequent violation.

[Optional Statute] E. The board shall transmit all monies it collects from civil penalties pursuant to this [act] to the [specify the

disposition of these funds if different from other funds]. 4.10 Reporting Violations; Immunity

A. A person, including but not limited to a licensee [or certificate holder], corporation, insurance company, healthcare organization or healthcare facility and jurisdiction or local governmental agencies, shall report to the board any conviction or determination by an agency or court that a licensee [or certificate holder] has committed an act that constitutes a violation of [Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04].

B. A person is immune from civil liability, whether direct or derivative, for reporting such facts as set forth in "A"

above to the board in good faith and participating in the board’s investigation and subsequent disciplinary process, if applicable.

C. The board shall not disclose the identity of a person who provides information unless such information is

essential to proceedings conducted pursuant to [Investigative Powers; Emergency Action; Hearing Officers and Hearings, Articles 4.05 and 4.06], or unless required by a court of law.

4.11 Substance Abuse Recovery Program A. The board may permit a licensee [or certificate holder] to actively participate in a board-approved substance

abuse recovery program if: 1. The board has evidence that the licensee [or certificate holder] is impaired. 2. The licensee [or certificate holder] enters into a written agreement with the board for a restricted license

[or certificate] and complies with all the terms of the agreement, including making satisfactory progress in the program and adhering to any limitations on his or her practice or employment imposed by the board to protect the public. Failure to enter into such an agreement shall activate an immediate investigation and disciplinary proceeding by the board.

3. As part of the agreement established between the licensee [or certificate holder] and the board, the licensee [or certificate holder] signs a waiver allowing the substance abuse program to release information to the board if the licensee [or certificate holder] does not comply with the requirements of this section or is unable to practice or work with reasonable skill or safety.

4.12 Rights of Consumers A. The public shall have access to the following information:

1. A list of licensees [and certificate holders] that includes license [or certificate] number, date of license [or certificate] expiration, status of license [or certificate], and employment information.

2. A list of final adverse actions taken by the board. 3. The address, website, email and phone number of the board.

B. Each licensee [and certificate holder] shall display a copy of his or her license [or certificate] in a location

accessible to public view or produce a copy immediately upon request. C. Each licensee [and certificate holder] shall provide the public with information on how to file a complaint with

the board against a licensee [or certificate holder].

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D. Any person may submit a complaint regarding any licensee, [certificate holder] or any other person potentially in violation of this [act]. Confidentiality shall be maintained subject to law.

E. The home address, email address and home telephone numbers of physical therapists and physical therapist

assistants are not public records and shall be kept confidential by the board unless they are the only addresses and telephone numbers of record.

F. A patient/client has freedom of choice in selection of services and products. G. Information relating to the physical therapist-patient/client relationship is confidential and shall not be

communicated to a third party who is not involved in that patient’s/client’s care without the written authorization of the patient/client. The physical therapist-patient/client privilege does not extend to cases in which the physical therapist has a duty to report or disclose information as required by law.

H. Information relating to the physical therapist assistant-patient/client relationship is confidential and shall not be

communicated to a third party who is not involved in that patient’s/client’s care without the written authorization of the patient/client. The physical therapist assistant-patient/client privilege does not extend to cases in which the physical therapist assistant has a duty to report or disclose information as required by law.

I. The board shall keep all information relating to the receipt and investigation of complaints filed against licensees

[or certificate holders] confidential until the information is disclosed in the course of the investigation or any subsequent proceeding or until disclosure is required by law. Patient/client records, including clinical records, files, any other report or oral statement relating to diagnostic findings or treatment of patients/clients, any information from which a patient/client or their family might be identified, or information received and records or reports kept by the board as a result of an investigation made pursuant to this [act] shall not be available to the public and shall be kept confidential by the board.

7th Edition MPA Commentary 1

Model Practice Act with Commentary Introductory Notes

This section of the Model Practice Act is divided into two distinct areas for easy reference:

• The Model Language (in bold text) for each statutory section

• The Commentary that clarifies the intent or adds other information about the suggested model language

Physical Therapy Practice Act

[Include proper numerical statute reference, e.g., Chapter # and/or Title #] Article 1: General Provisions 1.01 Legislative Intent

This [act] is enacted for the purpose of protecting the public health, safety and welfare, and provides for jurisdiction administrative control, supervision, licensure and regulation of the practice of physical therapy. It is the legislature’s intent that only individuals who meet and maintain prescribed standards of competence and conduct shall engage in the practice of physical therapy as authorized by this [act]. This [act] shall be liberally construed to promote the public interest and to accomplish the purpose stated herein. Commentary A statement of legislative intent makes explicit the desire of the legislature to place public interest first and foremost in the law that governs physical therapy. There is an inherent benefit to society and to individuals when public health, safety and welfare are protected through licensure. Licensing boards are obligated to ensure that the public actually realizes these benefits from the law. Licensure is inherently restrictive for the licensee and exclusive to the particular profession. Only those who “meet and maintain prescribed standards” established by the board will, for the protection and benefit of the public, be allowed to profess their qualifications and provide their services to the public. The public is dependent upon the jurisdiction to evaluate and affirm the qualifications for licensure of physical therapists and licensure [certification] of physical therapist assistants. The use of “maintain” in the model statute refers to the licensee’s ongoing commitment to maintain minimal standards of practice throughout a career, also known as continuing competence. The Model Practice Act addresses continuing competence and provides the regulatory authority for this responsibility in the additional paragraphs: Powers and Duties of the Board, Article 2.02.8 and 2.02.26 License [or Certificate] Renewal, Article 3.05.A.2 and B.2, Reinstatement of License [or Certificate], Articles 3.07.B and C. The last sentence of the model statute mandates that all interpretations of the practice act and associated rules be “construed liberally”; Liberal construction is a legal concept instructing all parties interpreting a statute to give an expansive meaning to terms and provisions within the statute. This applies to the drafting and interpretation of rules, as well as instruction to the courts for how the statutes and rules combined should be interpreted, and that interpretation shall not only be based on the actual words and phrases used herein, but also by taking into account the legislative intent of promoting the public interest and accomplishing the purposes stated.

1.02 Definitions

As specifically used in this [act], the following terms have the meanings set forth below, unless the context requires otherwise. Commentary More exact language in the law produces more consistent understanding of the law by the public, the profession and the regulatory agencies created to enforce the law. Clear and concise laws require fewer modifications and less legal interpretation by attorneys, courts or by the office of the state attorney general.

7th Edition MPA Commentary 2

Practice acts achieve clarity of intent and internal consistency by including definitions of the terms and phrases used within the act. Some of these are operational definitions that have more significance in a specific practice act because of the language used in that jurisdiction’s laws. Other terms have overall significance in all practice acts because they define to whom and what is being regulated. The definitional terms listed below are the minimum recommended for inclusion in all practice acts, because they define whom and what is being regulated.

1. “Board” means the [specify the jurisdiction] board of physical therapy. Commentary This model language indicates a preference for an autonomous physical therapy licensing board structure. Some jurisdictions have autonomous boards, but some jurisdictions have physical therapy boards as part of jurisdiction medical boards or combined with other professions. There are also a few “super boards” where all regulatory activities are subordinate to one board, with distinct committees or commissions for the various professions. (See additional discussion in Board of Physical Therapy, Article 2.01).

2. “Competence” is the application of knowledge, skills, and behaviors required to function effectively, safely, ethically and legally within the context of the patient/client’s’s role and environment.

3. “Consultation” means a physical therapist seeking assistance from or rendering advice or professional or expert opinion to, another physical therapist or professional healthcare provider via electronic communications, telehealth, or in-person. Commentary For the purposes of the Model Practice Act, per the definition of professional employee from the National Labor Relations Act , physical therapist assistants would be exempt from the status of “professional employee.” “(15) “professional employee” means—

(A) an employee engaged in the performance of work— (i) requiring knowledge of an advanced type in a field of science or learning customarily acquired by a prolonged course of specialized intellectual instruction and study in an institution of higher learning or a hospital (as distinguished from knowledge acquired by a general academic education, or from an apprenticeship, or from training in the performance of routine mental, manual, mechanical, or physical activities); (ii) requiring the consistent exercise of discretion and judgment in its performance; (iii) which is predominantly intellectual and varied in character (as distinguished from routine mental, manual, mechanical, or physical work); and (iv) which is of such character that the output produced or the result accomplished by such work cannot be standardized in relation to a given period of time; or

(B) an employee who has completed the courses of specialized intellectual instruction and study described in subparagraph (A)(i) of this paragraph and is performing related work under appropriate direction or guidance to qualify the employee as a professional employee described in subparagraph (A) of this paragraph;”

Consultation refers to a physical therapist rendering professional expert opinion or seeking professional expert opinion from another health care practitioner. The health care practitioner being consulted may possess highly specialized knowledge and skills to make recommendations, identify problems or solutions. In some cases, the physical therapist will find it necessary to seek the expertise of another healthcare practitioner to benefit the patient/client.

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Consultations via electronic communications are intended to improve access to specialty expertise for patients/clients and practitioners without the need for an in-person visit.

4. “Continuing competence” is the lifelong process of maintaining and documenting competence through ongoing self-assessment, development, and implementation of a personal learning plan, and subsequent reassessment.

5. “Examination” means a national examination approved by the board for the licensure of a physical therapist or the [certification/licensure] of a physical therapist assistant. Commentary This definition for examination clarifies that each jurisdiction’s practice act requires a national examination approved by the Board for licensure or certification. It also allows for the term “examination” to be used consistently throughout the act. The name of the examination shall be specified in rules, as many jurisdictions now specify the National Physical Therapy Examination of the Federation of State Boards of Physical Therapy.

6. “Electronic Communications” means the science and technology of communication (the process of exchanging information) over any distance by electronic transmission of impulses including activities that involve using electronic communications to store, organize, send, retrieve, and/or convey information. Commentary Electronic communications more accurately reflects the rapid change in technology and possible means of communications rather than the term telecommunications.

7. “Jurisdiction of the United States” means any state, the District of Columbia, the Commonwealth of Puerto Rico, or any American territory. Commentary This necessary clarifying definition specifies the range of possible licensing jurisdictions within the United States.

8. “Nexus to practice” means the criminal act of the applicant or licensee [certificant] posing a risk to the public’s welfare and safety relative to the practice of physical therapy. Commentary A “nexus” is a connection or series of connections linking two or more things. “Nexus” is a concept commonly used in the criminal law system, and generally evaluates if the act has a relationship in timing, causation, or logic to the practice of physical therapy. When evaluating nexus to practice, a jurisdiction looking at how the criminal action may affect or have a connection with their ability to safely practice physical therapy. At the same time, the nexus to practice requirement means that a jurisdiction cannot deny an applicant solely on the basis on the existence of a criminal act. The nexus to practice requirement means the jurisdiction must be able to document a direct relationship between the criminal act and the specific responsibilities and practice setting considerations of the license or certificate the for which the applicant is applying. A nexus to practice requirement is considered best practice and many jurisdictions have been passing legislation addressing the requirement. According to the Council of State Governments Justice Center, nearly one in four jobs in the U.S. require a government-issued license. However, many people with a criminal record are prohibited from receiving occupational licenses or discouraged from seeking jobs in licensed fields even when no nexus is present.

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Furthermore, according to research compiled by the Council of State Legislatures, people of color and those from lower socio-economic status are far more likely to enter the nation’s justice system than the general population. For licensing boards, this can mean that disqualification from licensure based on the existence of criminal history without demonstration of nexus can have an unintended discriminatory impact.

9. “Onsite supervision” means supervision by a physical therapist who is continuously onsite and present in the department or facility where services are provided. The supervising therapist is immediately available to the person being supervised and maintains continued involvement in the necessary aspects of patient/client care. Commentary “Onsite supervision” is an important inclusion in the definitions section. Some practice acts have very specific definitions where, for example, “onsite” is further defined as meaning direct visual contact, or defining “immediately available” within a time parameter of so many seconds or minutes. Such definitions are overly restrictive. The supervising physical therapist remains professionally and legally responsible for care rendered under the physical therapist’s license, as discussed under the previous definition for “Supervision”. . When onsite supervision is appropriate, the Model Practice Act language recommends that the supervisor should be within close proximity—in the department or facility—and immediately available. “Immediately available” is a term frequently used in healthcare statutes and in Medicare rules. It denotes a sense of urgency in delivery of care, not a sense, necessarily, of standing next to the person being supervised at all times. The phrase, “maintains continued involvement in the necessary aspects of patient care,” is emphasized and underscores that supervising physical therapists are responsible for provided physical therapy interventions. Supervising physical therapists should remain actively involved with those persons who are under their care and supervision. The definition has been broadened to be inclusive of various types of onsite supervision and may include but not limited to the supervision of physical therapy assistants, physical therapy aides as well as supervision of personnel under restrictive licensure.

10. “Patient/client” means any individual receiving physical therapy from a licensee [or certificate holder] under this Act. Commentary The term “patient” has been replaced throughout this document by the term “patient/client” to reflect that licensees [certificate holders] work in a variety of different settings and that, in some of these settings (e.g. health clubs, wellness centers), the term “client” is more representative of the person the licensee [certificate holder] is treating.

11. “Physical therapist assistant” means a person who is [certified/licensed] pursuant to this [act] and who assists the physical therapist in selected components of physical therapy treatment intervention. Commentary Several jurisdictions continue to use language that designates that the “assistant” assists in practice (physical therapy assistant), rather than language that defines the “assistant” as one who assists the physical therapist (physical therapist assistant). Language that equates physical therapy assistant with physical therapist assistant is best handled in Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02. The requirement that a physical therapist assistant “has met the conditions of this [act]” refers to applicant qualifications and requirements addressed in Examination and Licensure, Article 3. Educational requirements, such as being a graduate of an accredited physical therapist assistant education program, are best addressed in other areas of the practice act, not in definitions.

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Other role delineation or restrictions a board shall wish to include should be specified in rules. The Model Practice Act includes language for both certification and licensure. A jurisdiction shall select its preferred form of regulation for PTAs and apply the appropriate term throughout the practice act. Optional for PT Compact Members 11. “Physical therapist assistant” means a person who is [certified/licensed] pursuant to this [act] or holds a compact privilege and who assists the physical therapist in selected components of physical therapy treatment intervention.

12.“Physical therapist assistant-patient/client relationship” means the formal or inferred relationship entered into by mutual consent between a licensed [certified] physical therapist assistant and a patient/client or their legally authorized representative established once the physical therapist assistant assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged or treatment is formally transferred to another practitioner or as further defined by rule.

Commentary

Clearly defining the physical therapist assistant-patient/client relationship is important to clarify the professional boundary that must exist for objectivity in care. It is important to understand the inherent power dynamic in a clinician-patient relationship—regardless of gender or patient condition, this dynamic is real and powerful. The power differential between the physical therapist assistant and patient/client exists because the physical therapist assistant has knowledge and skills needed by the patient/client, access to personal medical information, and the patient/client's reliance on them for establishing boundaries in care. That power differential may continue after the end of formal treatment sessions, and boards should develop appropriate standards to protect the public even when the relationship may appear to be mutually consensual. Physical therapist assistants cannot have a relationship with someone who may still be vulnerable to the power imbalance. Additionally, discharging a patient only to have a relationship with them would also not be acceptable and is noted in some administrative codes.

13. “Physical therapist” means a person who is a licensed healthcare practitioner pursuant to this [act] to practice physical therapy. The term “physiotherapist” or “physio” shall be synonymous with “physical therapist” pursuant to this [act]. Commentary Only a licensed physical therapist shall use the professional designation of “physical therapist.” Physiotherapist is included in the definition as synonymous with physical therapist to strengthen use of that title only by physical therapists. (See additional discussion under Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02.) The term “healthcare practitioner” is defined in the Guidebook for the National Practitioner Data Bank as the “individual who is licensed or otherwise authorized by a state to provide healthcare services.” The term “health care provider” has a broader context. At this time, as related to this act, healthcare practitioner refers to a physical therapist, while healthcare provider is more appropriate for the physical therapist assistant. Several jurisdictions have used the definition of “physical therapist” to introduce other concepts that are better addressed in other areas of a practice act. Language concerning supervision, educational preparation, exclusive use of titles and practice restrictions (no X-rays, surgery, etc.) are sometimes included in this definition in older practice acts but are more appropriately addressed elsewhere in the law. Outside of the United States, the term “physiotherapist” and the abbreviation “physio” are more commonly used titles than physical therapist.

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Optional for PT Compact Members 13. “Physical therapist” means a person who is a licensed health care practitioner pursuant to this [act] or holds a compact privilege to practice physical therapy. The term “physiotherapist” or “physio” shall be synonymous with “physical therapist” pursuant to this [act].

14. “Physical therapist-patient/client relationship” means the formal or inferred relationship entered into by mutual consent between a licensed physical therapist and a patient/client or their legally authorized representative established once the physical therapist assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged or treatment is formally transferred to another healthcare practitioner or as further defined by rule.

Commentary

Clearly defining the physical therapist-patient/client relationship is important to clarify the professional boundary that must exist for objectivity in care. It is important to understand the inherent power dynamic in a clinician- patient relationship—regardless of gender or patient condition, this dynamic is real and powerful. The power differential between the physical therapist and patient/client exists because the physical therapist has knowledge and skills needed by the patient/client, access to personal medical information, and the patient/client's reliance on them for establishing boundaries in care. That power differential may continue after the end of formal treatment sessions, and boards should develop appropriate standards to protect the public even when the relationship may appear to be mutually consensual. Physical therapists cannot have a relationship with someone who may still be vulnerable to the power imbalance. Additionally, discharging a patient only to have a relationship with them would also not be acceptable and is noted in some administrative codes.

15. “Physical therapy aide” means a person trained by or under the direction of a physical therapist who performs designated and supervised components of care related to physical therapy services. Commentary Physical therapy aides are generally trained on the job. Physical therapy aides are also known as, but not limited to: technicians (techs), rehabilitation(rehab) aides, or rehabilitation technicians (rehab techs). This does not preclude vocational or technical training that shall exist for physical therapy aides or “techs.” However, such training does not relieve the supervising physical therapist of responsibility for further on-the-job training. What this training is, and the documentation of the training, should be specifically addressed in rules. Regulation beyond this definition is not recommended for aides. Massage therapists, exercise physiologists, athletic trainers or other persons who have technical or professional education or training, and who assist the physical therapist, should be considered physical therapy aides and be represented as such. The only exception to this is if such persons are providing consultative services and their particular service is not represented or billed as physical therapy.

16. “Physical therapy” means the care and services provided in-person or via telehealth by or under the

direction and supervision of a physical therapist who is licensed pursuant to this [act]. The term “physiotherapy” shall be synonymous with “physical therapy” pursuant to this [act].

Commentary ”Physical therapy" and “physiotherapy” are not generic terms. The combined language of the three definitions, “physical therapy,” “physical therapist” and the “practice of physical therapy,” is crucial to curtail frequent misrepresentation in the use of these terms and thus strengthen physical therapy practice acts. When changes to

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any of these definitions are made they should be examined and changed in concert. It is equally important that the exclusive use of titles and terms be included whenever changes in definitions are made. (See National Examination, Article 3.01, Use of Titles and Terms, Restrictions; Classification of Violation, Article 4.02, and Unlawful Practice; Classification; Civil Penalties; Injunctive Relief,Article 4.09.) The public expects the jurisdiction to ensure that practitioners of every profession practice competently within their scope. Jurisdiction regulation includes restrictions on how licensees represent themselves and the use of titles and/or letters and representations that do not mislead the public. For example, a medical or osteopathic physician practices and represents to the public that he or she practices medicine but not dentistry. When practitioners other than physical therapists represent that they are providing “physical therapy” or “physiotherapy,” they are violating the very spirit and core of licensure laws by misrepresenting themselves to the public. “Physiotherapy” is included in the definition as synonymous with “physical therapy.” This strengthens the protection of the term “physiotherapy,” a historically significant term and current international title, and one that is often used as a generic term and misrepresented by other disciplines. In the past the practice of physical therapy was defined by listing various physical agents and modalities such as heat, ice, ultrasound, etc. This perpetuated the false concept that physical therapy was a generic term since these physical agents and modalities have not been the exclusive domain of physical therapy. The solution to strengthening practice acts is to clearly define “physical therapy” as “the care and services provided or under the direction and supervision by (and only by) a physical therapist.” Additional strengthening comes from a more modernized definition of the “Practice of physical therapy” that describes current scope of practice and from language in Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02 that protects the public from misrepresentation by others. Removing the term individuals provides opportunity for boards to allow the practice of animal physical therapy for those boards who wish to address animal physical therapy. Considering the growth of the delivery of physical therapy via telehealth, specifying both modes of delivery in the definition makes clear that the practice of physical therapy is not defined by the mode of delivery.

17. “Practice of physical therapy” means:

a. Examining, evaluating and testing patients/clients with mechanical, physiological and developmental impairments, functional limitations, and disabilities or other health and movement-related conditions in order to determine a diagnosis, prognosis and plan of treatment intervention, and to assess the ongoing effects of intervention. b. Alleviating impairments, functional limitations and disabilities; promoting health; and preventing disease by designing, implementing and modifying treatment interventions that may include, but are not limited to: therapeutic exercise;, needle insertion; patient-related instruction; therapeutic massage; airway clearance techniques; integumentary protection and repair techniques; debridement and wound care; physical agents or modalities; mechanical and electrotherapeutic modalities; manual therapy including soft tissue and joint mobilization/manipulation; functional training in self-care and in home, community or work integration or reintegration; as well as prescription, application and, as appropriate, fabrication of assistive, adaptive, orthotic, prosthetic, protective and supportive devices and equipment. c. Reducing the risk of injury, impairment, functional limitation, and disability, including performance of participation-focused physical examinations and the promotion and maintenance of fitness, health, and wellness in populations of all ages. d. Referring a patient/client to healthcare providers and facilities for services and testing to inform the physical therapist plan of care. e. Engaging in administration, consultation, education, and research.

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Commentary This language represents the “statutory” definition of the scope of physical therapist practice by identifying the main elements included within the scope. It also supports the two preceding definitions of the profession (physical therapy) and the professional (physical therapist). The component elements of a profession’s “scope of practice” include three determinants: 1) an established history of inclusion in education and training; 2) an established history of inclusion in clinical practice; and 3) specific statutory authority. When the first two determinants are well established, then specific statutory authority may also be substituted by the “absence of statutory prohibition.” For example, where a practice act is silent on the issue of needle insertion EMG, the fact that there is a long history of educational inclusion and an established history of clinical practice in physical therapy substantiates this procedure as being within the scope of practice of physical therapy. Legal opinions in the form of affirmative court decisions also play a role in defining scope of practice, as they have in this specific example. The Model Practice Act offers additional definition language under Paragraph 10 for testing that allows for electrodiagnostic procedures. The definition of the practice of physical therapy in the MPA gives a clear description of current practice. This definition forms a well-organized and structured outline for the scope of contemporary physical therapy practice. A few additional points regarding this model definition are important to highlight. The wording “patients with mechanical, physiological and developmental impairments, functional limitations and disability or other health and movement-related conditions” is sufficiently broad to allow for inclusion of any type of patient that physical therapists encounter. Physical therapists must examine and evaluate each patient prior to initiating treatment interventions. Determining “a diagnosis” rather than “diagnosis” or “the diagnosis” is a subtle but very important point. Direct patient access to physical therapy services is now a reality in the majority of jurisdictions. Physical therapists must determine a diagnosis regarding the patient’s specific condition for which they will be providing treatment intervention prior to making patient management decisions. A diagnosis from a referral source does not rule out a physical therapist’s responsibility to arrive at a diagnosis specific to the condition for which the therapist’s treatment plan and intervention will be directed. By contrast, an inappropriate phrase and one strongly advised against, is “a physical therapy diagnosis.” “Diagnosis for physical therapy,” on the other hand, would be appropriate. Although diagnostic labels, tests or tools shall vary, the process of diagnosis is consistent among health professionals and should not be compartmentalized by provider. The evaluative and diagnostic process should also include a prognosis or an expectation of outcome associated with treatment intervention. This shall also include time or outcome expectations. The end result of the evaluative process is the design of the treatment intervention. The effects of the treatment intervention are assessed regularly in order to make modifications to the intervention. It is not necessary or advisable to list the tests and measures used by physical therapists within the definition of the “Practice of physical therapy.” The use of this definition of the “Practice of physical therapy,” should prevent any unreasonable restrictions on current or developing evaluative procedures used by physical therapists. In Paragraph 4.b., it is appropriate to list some of the typical interventions used in physical therapy. This helps to exemplify the breadth and scope of practice based on education and training. A stand-alone list of physical agents or modalities is not recommended. Similarly, parts of the patient’s/client’s body that may be treated are not listed out. For example, a physical therapist may perform physical therapy for the pelvic floor or temporomandibular joint, both of which may include internal treatments, when the physical therapist has been trained in these specialized areas. Because of political sensitivities over the term “manipulation,” it shall occasionally be necessary to find an acceptable alternative that still authorizes, and in no way limits, the use of manipulative therapy procedures by physical therapists. An acceptable alternative is to retain in Paragraph 4.b the term “manual therapy” or “manual

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therapy techniques” (without using the term “manipulation”) and then further define “manual therapy” in statutes or rules. In 1998 the American Medical Association approved specific CPT coding for use by M.D. physicians and physical therapists for “manual therapy techniques.” This code also contains the terms “mobilization” and “manipulation” as part of the CPT code description.

A physical therapist may refer a patient/client to another healthcare practitioner when information is sought to inform the plan of care and/or to obtain services for the patient/client that are beyond the scope of practice of the physical therapist. The physical therapist may:

• Refer an individual to another provider and conclude care, or not develop a plan of care

• Refer an individual to another provider and continue the plan of care at the same time

If an additional description or clarification is needed for “debridement and wound care” or “needle insertion” it should be further specified in statutes or rules. (See Guidelines for Rules.)

18. “Restricted [certificate/license]” for a physical therapist assistant means a [certificate/license] on which the board has placed any restrictions and/or condition as to scope of work, place of work, duration of certified or licensed status, or type or condition of patient or client to whom the certificate holder or licensee may provide services.

19. “Restricted license” for a physical therapist means a license on which the board has placed any restrictions and/or conditions, as to scope of practice, place of practice, supervision of practice, duration of licensed status, or type or condition of patient or client to whom the licensee shall provide services.

20.“Supervision” means the process by which a physical therapist oversees and directs safe and effective delivery of patient/client care through appropriate verbal, written, or electronic communication. This may be accomplished with the physical therapist located onsite or remotely as deemed appropriate based on the patient/client needs. Commentary Version 7 of the Model Practice Act has added a definition of “supervision” to underscore the fact that the physical therapist is ultimately the party responsible for the safe and effective delivery of patient care, and that the physical therapist is responsible for determining the level of supervision and direction that is appropriate. While some sections or rules may specify onsite supervision is required, this underscores that even if not required in statute or rule, onsite supervision may be appropriate and therefore necessary based on the needs of the patient/client. It is also important to note that within patient management, “direction” and “supervision” are functions that belong solely to the licensed physical therapist. The physical therapist assistant shall receive help from a physical therapy aide when performing certain tasks or procedures, but the physical therapist assistant does not assume the responsibility to “direct and supervise” the provision of care. That responsibility remains with the supervising physical therapist and, by law, cannot be relinquished to another.

21. “Telehealth” is the use of electronic communications to provide and deliver a host of health-related information and healthcare services, including, but not limited to physical therapy related information and services, over large and small distances. Telehealth encompasses a variety of healthcare and health promotion activities, including, but not limited to, education, advice, reminders, interventions, and monitoring of interventions. Commentary As telehealth has emerged as a critical mode of delivery of physical therapy, it bears stating that the PT/PTA and patient/client relationship can be fully established in the absence of actual physical contact between the PT/PTA

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and the patient/client. Telehealth is not a new treatment, or an expansion of scope of practice, but a means to deliver physical therapy care to those in need. The physical therapist is still responsible for the care of the patient and for making determinations of the best means to deliver that care. The standards of care and practice, laws, and regulations currently required to be followed for any in-person encounter must also be followed for any encounter via telehealth. The way in which components of intervention are rendered and the supervision levels required may be further clarified in rule. Many jurisdictions have provisions for offsite supervision of physical therapist assistants. The way in which components of intervention are rendered by physical therapist assistants under offsite supervision, or interventions rendered directly to a patient by a physical therapist through some means of electronic communications, shall be areas of statute or rules needing further clarification.

22. “Testing” means standard methods and techniques used to gather data about the patient/client, including but not limited to imaging, electrodiagnostic and electrophysiologic tests and measures. Commentary The definition of “Practice of physical therapy,” Paragraph 4a, includes a reference to “testing.” That statutory definition is purposely and necessarily broad and does not specify any particular tests (see Commentary under Paragraph 4). This statutory Paragraph 10 accomplishes two things: it incorporates the profession’s accepted standard definition of “tests and measures,” and it also includes a reference to particular diagnostic testing procedures that are within the scope of physical therapy practice but have occasionally been challenged legally or legislatively. Some jurisdictions already have, and others shall wish to include, rules that specify additional training requirements and certification procedures relative to physical therapists performing electrodiagnostic and electrophysiologic procedures.

Optional for PT Compact Members “Compact privilege” means the authorization granted by a remote state to allow a licensee from another member state to practice as a physical therapist or work as a physical therapist assistant in the remote state under its laws and rules. The practice of physical therapy occurs in the member state where the patient/client is located at the time of the patient/client encounter.

Article 2: Board of Physical Therapy 2.01 Board of Physical Therapy

Commentary The language in this section is constructed upon the model of an autonomous licensing board. The title for this section could easily be modified, if necessary, to apply to other board structures. For example, if a jurisdiction board is actually a panel within a larger Board of Healing Arts, the title might be The Physical Therapy Panel of the State Board of Healing Arts. A. The board of physical therapy shall consist of [seven] members appointed by the Governor. [Four] members shall be physical therapists who are residents of this jurisdiction, possess unrestricted licenses to practice physical therapy in this jurisdiction and have been practicing in this jurisdiction for no less than five years before their appointments. [One] member shall be a physical therapist assistant who is a resident of this jurisdiction and possesses an unrestricted [certificate/license]. The Governor shall also appoint [two] public members who shall be residents of this jurisdiction and who are not affiliated with, nor have a financial interest in, any healthcare profession and who have an interest in consumer rights. The Governor shall, to the greatest extent possible, appoint individuals to achieve diversity on the board.

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Commentary Most jurisdictions have licensing board members who are appointed by an elected official, usually the Governor. Public members are commonly included on boards, but often there is only one public member. Some jurisdictions currently have fewer than five total board members, while larger jursidictions have far greater numbers serving on their boards. The language in the Model Practice Act of having no fewer than seven board members is based on the recommendation that boards have a minimum of two public board members. With that minimum, there should also be at least three professional members. The following ratios of professional to public members are the recommended ratios for various board sizes:

Board Size

Professional Members – PT Members

PTA Members

Public Members

7 4 1 2

8 4 1 3

9 5 1 3

10 6 1 3

A board comprising a majority of professionals along with a well-represented component of public members is capable of addressing the many complex and technical issues related to educational preparation and practice procedures. Public representation on boards is essential. Public members heighten the sensitivity of the board to public concerns and consumer protection. Physical therapist and physical therapist assistant members of the board must reside in the jurisdiction, have practiced for a period of five years preceding their appointments, and have no restrictions on their licenses. The Model Practice Act makes no reference to a nomination process or guarantee of a position on the board from a professional association. This does not preclude a professional association or any other organization from making a nomination. Requirements for a nomination from the physical therapy professional association in the statute is an inappropriate link between a public board and a private professional association. Public appointees should be competent to serve and effectively advocate for the public. Public members should not be members of any other healthcare discipline or be close enough to one that they shall have a financial or professional interest in the decisions made. In addition to those actually working as healthcare providers, this model language precludes appointment of spouses or immediate family members and those employed by any healthcare provider or organization. The intent is to obtain representation by public members who can be uncompromised in their interests and advocacy on behalf of the public.

B. Board members shall serve staggered four-year terms. Board members shall serve no more than two successive four year terms or for more than ten consecutive years. By approval of the majority of the board, the service of a member shall be extended at the completion of a four-year term until a new member is appointed or the current member is reappointed. Commentary A four-year term provides sufficient time to become thoroughly familiar with board functions and processes. Serving two consecutive four-year terms for a total of eight years should not be as imposing an obstacle as serving two five-year terms. The ten consecutive year provision addresses the circumstances in which someone is appointed to fill a partial term and, in addition, fills two consecutive terms.

C. The board may request the Governor remove any member of the board for misconduct, incompetence or neglect of duty.

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Commentary Many statutes specify that a member shall be removed for cause and list several causes, but they do not specify a mechanism. The Governor appoints those who serve on licensing boards, often subject to legislative approval, and should also retain the power to remove members, with certain restrictions. The causes for removal, the process for board consideration and action, and the recommendation to the Governor for removal should all be specified in rules. Such language in statutes and rules shall also preclude mass reappointment of board members due to political reasons, i.e. change in Governor or party affiliation. Preventing mass changeover will also help preserve the board’s history and continuity.

D. Board members are eligible for [compensation and] reimbursement of necessary expenses pursuant to [cite applicable statute relating to [compensation and/or reimbursement] for attending each board meeting or for representing the board in an official board-approved activity. Commentary Most jurisdictions provide a per diem and reimbursement for members, but the method varies. Reimbursement procedures should be specified by reference to applicable statutes or in rules.

E. A board member who acts within the scope of board duties, without malice and in the reasonable belief that the member’s action is warranted by law, is immune from civil liability. Commentary Commentary Typically, members have absolute or qualified immunity from liability or suit while serving on a licensing board. This paragraph points out that even this protection has its limits if a board member’s conduct is determined to be unwarranted or with malice. Although many jurisdictions have separate statutes dealing with board member immunity from liability, each jurisdiction’s law should be carefully analyzed to ensure that no further mention need be made in the jurisdiction’s practice act. In light of the increased threat of litigation against jurisdiction administrative bodies, it is better to ensure, by way of the statute, the immunity of board members when acting without malice and in the scope of their duties.

2.02 Powers and Duties of the Board

The board shall: 1. Evaluate the qualifications of applicants for licensure [and certification]. Commentary Establishing application requirements and reviewing credentials and other application material is often the first interaction a board has with a prospective licensee. This is the first duty and power listed. “Qualifications” such as graduation from an accredited education program or passing the national licensing examination are generally identical from jurisdiction to jurisdiction. Additional jurisdiction “requirements” are often specified in rules and include specific application questions or details that shall be particular to a given jurisdiction. Meeting the qualifications includes also meeting board requirements if statute language as in Qualifications for Licensure and Certification, Article 3.02A is used in a practice act. This is because the “qualifications” as listed under 3.02.A also include meeting jurisdiction “requirements” that shall be further defined in rules.

2. Provide for the examination of physical therapists and physical therapist assistants. Commentary This language authorizes testing of both physical therapists and physical therapist assistants by standardized national examinations approved by the board. The name of the examinations can be specified in rules.

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3. Issue licenses [or certificates] to persons who meet the qualifications of this [act]. Commentary Boards are authorized by this paragraph to issue the appropriate license or certificate after all qualifications (including board requirements) as stated in statutes and rules have been met.

4. Regulate the practice of physical therapy by interpreting and enforcing this [act]. Commentary A significant responsibility of licensing boards is interpreting and enforcing the statutes and rules of the practice act. Interpreting the practice act often is derived from a consistent pattern of board actions over time that guides further actions consistent with the statutes and rules. Substantive board policy and opinions are also derived from these consistent actions and interpretations. Rules provide a more formal process for recording and compiling substantive board policy, decisions and opinions. Board decisions shall also provide a valuable guide to the court in the event of an appeal from the administrative hearing level. Jurisdictions shall also have other administrative statutes relating to substantive board policies or opinions. Discipline, including consent orders that are part of the disciplinary process, is a component of the board’s authority to regulate and enforce the practice act. The statutory authority of the board for this role should be clearly stated so that an assistant attorney general, in their role of protecting the interest of the jurisdiction, does not tie the hands of board members in their statutory role of interpreting and enforcing the practice act.

5. Have the authority to establish committees, advisory panels, and task forces to further the work of the

board.

Commentary The board may need specific topics researched or discussed in more detail than typical board meeting time allows. Committees, advisory panels, and task forces can perform the research and report back to assist the board in making decisions and acting.

6. Adopt and revise rules consistent with this [act]. Such rules, when lawfully adopted, shall have the effect of law. Commentary This rule-making authority is essential to the regulatory process. The Model Practice Act attempts to include only necessary, empowering or authorizing language in statutes, leaving the remainder of administrative process and procedure to rules. It is important to clearly define that legally promulgated rules have the effect of statutory law, especially where there is any chance that rulemaking shall only be given the weight of policy. Policy decisions, normally, are not legally enforceable. Jurisdictions vary considerably in the process used to adopt rules. Some licensing boards have wide latitude and discretion; others are under Governor or jurisdiction legislative oversight nearly as restrictive as that required to change the statutes. There are generally other administrative codes or laws that address the rule-making procedure. (See additional discussion in Guidelines for Rules.)

7. Meet at least once each quarter in compliance with the open meeting requirements of [cite applicable statute]. A majority of filled board members positions shall constitute a quorum for the transaction of business. The board shall keep an official record of its meetings. Commentary

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This language sets a minimum meeting frequency to comply with the law. Board meetings are subject to open meeting laws, and administrative procedures acts specify when executive sessions are permissible or advisable. Of necessity, boards require that a majority of members be present to conduct business. Recordkeeping is legally required.

8. Establish mechanisms for assessing the continuing competence of physical therapists to practice physical therapy.

9. Establish mechanisms for assessing the continuing competence of physical therapist assistants to work in the profession of physical therapy. Commentary This paragraph empowers the board to set the requirements for assessing continuing competence to practice physical therapy. The public has been increasingly concerned that licensed professionals demonstrate competence to practice, and all healthcare professions are developing appropriate models to provide for the valid and measurable assessment of continuing competence. Mandatory continuing education as the sole method for meeting requirements for licensure renewal is not recommended. There is no empirical evidence that mandatory continuing education ensures continuing competence of licensees. This Model Practice Act recommends that demonstrating continued competence to practice physical therapy applies only to license renewal of physical therapists. Models or processes that shall be considered for assessing the continuing competence of physical therapists are outlined in Guidelines for Rules.

10. Establish and collect fees for sustaining the necessary operation and expenses of the board. Commentary This clause empowers boards to establish and collect fees. Placing the listing of specific fees in the rules gives greater latitude for changes in fee structure that shall occur from time to time. Rules should include a breakout of all the fees, including application fees for licensure and certification, testing fees, renewal fees, reinstatement fees, late penalties, etc.

11. Elect officers from its members necessary for the operations and obligations of the board. Terms of office shall be one year. Commentary Eligibility requirements and any particular duties related to the various offices should be specified in rules.

12. Provide for the timely orientation and training of new professional and public appointees to the board regarding board licensing and disciplinary procedures, this [act], and board rules, policies and procedures. Commentary Several practice acts fail to include requirements for orientation and training of new board members. For the benefit and protection of the public, timely and adequate training of new appointees needs to be a statutory requirement. Responsibility for board orientation and training should be that of the board officers assisted by staff. Appropriate materials provided to a new appointee shall include the statutes and rules, substantive board policies,

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other board operational policies, contracts, minutes, sunset reviews, legislative audits, procedures and historical documents.

13. Maintain a current list of all persons regulated under this [act]. This information includes each person’s name, current business and residential address, email address, telephone numbers, and license [or certificate] number. Commentary Boards should exercise discretion in how they distribute or share such information, subject to the jurisdiction’s open records act. For example, board policy shall need to include whether information is shared or sold to patient/client’sor organizations for commercial purposes. The public should have access to information regarding those licensed or certified by the jurisdiction. A jurisdiction board directory of licensees and certificate holders shall be one appropriate mechanism for sharing this information. Technological advances shall provide other avenues of electronic access to this information. It is important to note that home addresses and telephone numbers are not public information unless they are the only address and telephone numbers of record, as stated in Rights of Consumers, Article 4.12. An email address is becoming increasingly important for board communication with licensees but also is not a public record under Rights of Consumers, Article 4.12.

14. Provide information to the public regarding the complaint process. Commentary Boards should provide the public with assistance to facilitate the complaint process. The board should have easy- to-follow information available to aid a person who wishes to file a complaint against a licensee or certificate holder. Some jurisdictions require the posting of a public notice in each physical therapy facility that includes contact information for filing a complaint with the Board. Some jurisdictions require the posting of copies of jurisdiction licenses of those individuals providing services in that facility. Such a requirement with the actual language to be used could be specified in rules.

15. Employ necessary personnel to carry out the administrative work of the board. Board personnel are eligible to receive compensation pursuant to [cite specific statute]. Commentary The board should have statutory authority to employ necessary personnel to carry out duties of the board. The board must comply with jurisdiction administrative employment guidelines, including relevant compensation guidelines. Final decisions to hire, release, give direction relative to duties, review for pay increases, etc., should reside with the board.

16. Enter into contracts for services necessary for enforcement of this [act]. Commentary This provides for additional activities that shall be needed to carry out the work of the board. This shall include contracts for investigators, administrative law judges or hearing officers, board consultants, outside legal counsel where permitted by law or regulation, and for other services deemed necessary by the board.

17. Report final disciplinary action taken against a licensee [or certificate holder] to a national disciplinary database recognized by the board or as required by law. Commentary

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The ending phrase, “…or as required by law,” is in reference to the federally mandated reporting system known as the Healthcare Integrity and Protection Data Bank (HIPDB). Since 1999, jurisdiction boards have been required to report “final adverse action” against anyone regulated by the board to the HIPDB. This requirement is a result of the Health Insurance Portability and Accountability Act (HIPAA), which was signed into law in 1996. The Affordable Care Act of 2010 required a transfer of data from HIPDB to the National Practitioner Data Bank (NPDB). As of 2013, HIPDB was no longer operational; the functions of HIPDB are now with the NPDB. Naming the Federation of State Boards of Physical Therapy as the jurisdictional board’s agent or intermediary for reporting adverse action to the HIPDB facilitates the gathering of data and jurisdictional access to that information in the Federation’s national database of disciplinary actions. The Federation of State Boards of Physical Therapy will automatically supply this information when it sends a score report for an applicant currently licensed or certified in another jurisdiction. The effect of this program will be to prevent someone from moving from one jurisdiction to another to escape disciplinary consequences. Grounds for Denial of License [and Certificate]; Disciplinary Action, Article 4.04, contains the statute clause allowing previous disciplinary action to be sufficient grounds to continue a disciplinary action in the new jurisdiction or to deny the applicant a license or certificate.

18. Report information of alleged unlawful conduct by licensees [or certificate holders], unlicensed individuals, other healthcare providers, and entities to the appropriate county, jurisdiction, or federal authority. Commentary Reporting requirements are imposed by law through other agencies related to law enforcement, public protection or the courts. Jurisdictional boards should have clear authority to comply with such reporting requirements.

Jurisdictions may consider sharing information, records, and documents received or generated by the physical therapy licensing board pursuant to an investigation. Although they cannot act, sharing information of this type prior to resolution of the complaint may alert other jurisdictions of a potential threat to the public’s safety. This is similar to the agreement within the Compact to share investigative information pertaining to a licensee [certificate holder] in any member state. Compact member states will abide by the specifics from the Compact statute regarding sharing investigative information.

19. Publish, at least annually, final adverse action taken against a licensee [or certificate holder]. Commentary The public has the right to know about disciplinary actions taken against any regulated healthcare provider. The purpose of discipline is to remove the risk of harm to the public, correct deficiencies in conduct, and address violations of the law. Discipline is first corrective in nature but shall become punitive if violations are repeated or are serious enough to constitute a threat of harm or actual harm to the public. Whether it is potential or actual harm and whether the discipline is corrective or punitive, the public has the right to access public records pertaining to final disciplinary actions against those regulated by the practice act. Paragraphs 17 and 18 specify making “final disciplinary action” known to others. Boards shall also be required to release general information about pending complaints; for example, “the licensee has two pending complaints being processed or under investigation.” The particular open meeting laws of a jurisdiction will also affect what information a board must release. The board shall also need to address, in rules and in consultation with legal counsel, the extent to which complaint information appears in the minutes of their proceedings. There are various confidentiality laws that shall guide such decisions. Information being released or published could also be in other forms, and the model statute language speaks of at least two. First, boards must publish at least annually a notice of final disciplinary action against any licensed physical therapist or certified physical therapist assistant. This could occur through the board’s own newsletter, through a professional association

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newsletter, or through local print media. Second, boards should develop a method to easily accommodate consumer requests for status on any given licensee or certificate holder. A board website shall suffice.

20. Publish, at least annually, board rulings, opinions, and interpretations of statutes or rules in order to guide persons regulated pursuant to this [act]. Commentary Boards are frequently asked by licensees or other members of the public to provide advisory opinions clarifying definitions or practice issues. This clause gives boards authority to issue such advisory opinions and to publish them periodically as a guide to those regulated under the practice act.

21. Participate in or conduct performance audits. Commentary Many jurisdictions conduct regular performance audits of their boards or jurisdiction agencies using an agency such as an Office of the Auditor General. Such audits should suggest improvements in board performance. Boards may find FSBPT resources including but not limited to the Board Assessment Resource, Examination, Licensure, and Disciplinary Database, Healthy Practice Guidelines, and Model Board Action Guidelines helpful to prepare for the audit. The audit results shall also be important if policy makers question the need for the existence of a board. Substantiation of actions taken for public protection demonstrates continued public benefit from the board. This, or an additional clause, shall also require an annual reporting process to the Governor.

22. Have the authority to fully participate in a national Exam, Licensure, and Disciplinary Database as defined by rule. Commentary "Exam, Licensure and Disciplinary Database (ELDD)" means an integrated process for collecting, storing, and sharing information on physical therapist and physical therapist assistant licensure/certification and enforcement activities related to physical therapist and physical therapist assistant licensure laws that are administered by a nonprofit organization composed of and controlled by licensing boards." The preferred Exam, Licensure, and Disciplinary Database named in rules is the FSBPT’s ELDD. Even though states are required to report disciplinary actions to the National Practitioner Databank (NPDB), this is not sufficient. Boards should participate in another profession-specific database, such as the FSBPT ELDD, to maximize public protection. In order to find out if someone has been reported to the NPDB, a state board must send a query to the NPDB for that information, the information is not automatically sent to the Board. The Board also has to pay to query the NPDB for that specific person; the FSBPT automatically notifies all jurisdictions of the disciplinary record associated with an individual (existing license or open score transfer) in the FSBPT’s Exam, Licensure, and Disciplinary Database (ELDD) for no charge. “Fully participate” must be defined in the rules. Fully participate means supplying licensure and discipline data meaning identifying information that includes but is not limited to the licensee's name, address, nationally recognized unique number of identification (such as the FSBPT ID number), date of birth, and physical therapist/physical therapist education. It is necessary to have at least one unique identifier to confirm identity and avoid mistakes in matching data to individuals. By applying for physical therapist or physical therapist assistant licensure[certification], individuals shall consent to allowing the board to share their licensure and discipline data with the ELDD. Jurisdictions should be concerned with the security of the information provided to the ELDD. Unless specific permission is granted by the individual, such as releasing a score to a school, access to the information should be restricted to sharing only with other member jurisdictions. Whenever possible, such as for research purposes, information released by the ELDD should only be in the aggregate without reference to any person’s name or

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other individual identifiers. FSBPT maintains a high level of security for ELDD data and follows these recommendations.

23. Have the authority to obtain biometric-based information from every physical therapist or physical therapist assistant applicant for licensure[certification] and submit this information to the Federal Bureau of Investigation for a criminal background check. Commentary FBI background checks should be in accordance with 28 U.S.C. §534 and 42 U.S.C. §14616. In order to be considered for FBI criminal background check approval the state code must comply with the requirements of Federal statute P.L. 92-544 which consists of the following criteria:

a. The statute must exist as a result of a legislative enactment; b. It must require the fingerprinting of applicants who are to be subjected to a national criminal history background check; . c. It must expressly or by implication authorize the use of FBI records for the screening of applicants; d. It must identify the specific category of applicants/licensees falling within its purview, thereby avoiding overbreadth; e. It must not be against public policy; and f. It must not authorize receipt of the CHRI by a private entity

However, jurisdictions should consult their state ID bureaus regarding the recommended statutory language in order to meet the requirements of P.L. 92-544. A list of the ID bureaus can be found at https://www.fbi.gov/services/cjis/identity-history-summary-checks/state-identificationbureau- listing

24. Have the authority to determine and collect, at the time of new licensure [or certification] and licensure [or certification] renewal, a core set of data elements deemed necessary for the purpose of workforce assessment and planning. The data elements shall be used to create and maintain a healthcare workforce database. The Board may enter into agreements with a private or public entity to establish and maintain the database, perform data analysis, and/or prepare reports concerning the physical therapy workforce. The Board shall promulgate rules to perform duties pursuant to this [act]. Commentary Collecting a core set of data elements, or minimum data set, for physical therapists/physical therapist assistants

allows workforce information to be standardized. Some jurisdictions may have a data set specific to physical

therapy providers while others will have a data set for multiple health care professions.

In some jurisdictions, the Board may be required to provide this data either upon request or as required to other

state agencies, the Legislative Assembly, the public etc. The Board may choose to add this requirement in the

statutory language or in rules.

Whenever possible, information should be released by the Board only in the aggregate without reference to any

person’s name or other individual identifiers. A Board may choose to add language to that effect in the statutory

language or to rules.

25. Have the authority to require a licensee [certificate holder] to complete educational activities. Commentary

At times it may be necessary for the board to require licensees [certificate holders] to complete educational activities that are non-disciplinary or outside the typical continuing competence requirements. For example, a board may choose (if able) to require a licensee [certificate holder] to complete education on a topic if a complaint is lodged but found to not have enough merit to move forward with a formal investigation and disciplinary

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process, however the behavior of the PT or PTA warrants intervention by the board. A board may also have a topic of concern (e.g., COVID-19 pandemic) that justifies additional educational activities to be completed.

Optional for PT Compact Members

26. Participate in a national licensure compact. Commentary Including language to allow the Board to participate in a national licensure compact removes all questions as to the ability of the Board to implement necessary procedures to be compliant with the requirements of membership in a licensure compact.

2.03 Disposition of Funds

(No model language is offered under this section heading. See Commentary for further information.) Commentary No model language is offered under this section, but the heading is noted in the Model Practice Act because this is the proper location to include this language within a practice act. This section would not include fees or the setting of various fees, but it would cover such topics, for example, as specifying 1) which jurisdiction fund monies are deposited into, general or cash fund 2) how funds are used to cover board expenses, including compensation for appointees’ expenses and 3) whether there is a division of fees between a jurisdiction’s general fund and that used specifically by the physical therapy board. There shall also be references or a deferring to other jurisdiction statutes that guide or direct jurisdiction agency funding issues.

Article 3: Examination and Licensure 3.01 National Examination

A. The board shall provide for a national examination within the jurisdiction.

B. To be eligible to sit for the national examination, the candidate must meet nationally recognized

requirements that support the integrity of the examination and are further defined by rule. 1. The physical therapist examination is a national examination that tests entry-level competence related to physical therapy theory, examination and evaluation, diagnosis, prognosis, treatment intervention, prevention, and consultation. 2. The physical therapist assistant examination is a national examination that tests for requisite knowledge and skills in the technical application of physical therapy services.

C. Candidates must agree to abide by security and copyright provisions related to the national licensure examination. If the board determines that an applicant has violated any of these provisions or engaged in or attempted to engage in any other conduct that subverts or undermines the integrity of the examination process or validity of examination results, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time.

D. Any violation of security and copyright provisions related to the national licensure examination, subversion or attempts to subvert the national examination shall be reported by the board to the Federation of State Boards of Physical Therapy.

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E. If the board determines that an applicant has engaged or has attempted to engage in conduct that subverts or undermines the integrity of the examination process, including a violation of security and copyright provisions related to the national licensure examination, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time. Commentary The entry-level examinations for licensure and certification are provided at testing centers in each state. The examination for a physical therapist is “competency specific” and covers the entire scope of practice, including theory, examination and evaluation, diagnosis, prognosis, treatment intervention, prevention and consultation that are consistent with the exam blueprint. This list of competencies is included in the definition of the “Practice of physical therapy.” (See Definitions, Article 1.02.) Examinations used for the measurement of entry-level competence are in most cases protected by copyright laws. The National Physical Therapy Examinations are protected by copyright. Individuals who share questions from any board-approved examination by memorizing, giving away, attempting to give away, receiving recalled questions or trafficking in the same, shall be subject to legal action and/or potentially severe discipline including being prohibited from testing for licensure or losing an existing license. This is also addressed under Grounds for Denial of License [and Certificate]; Disciplinary Action, Section 4.04 and 4.07.

3.02 Qualifications for Licensure [and Certification]

A. An applicant for a license as a physical therapist shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a professional physical therapy education program accredited by a

national accreditation agency approved by the board. 3. Pass a national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under

this [Act]. Commentary The detailed procedure and requirements for license application should be outlined in rules rather than statutes. For example, the board shall decide what questions to include in the application form about criminal records, substance abuse or any other conduct that shall constitute grounds for denial of a license. (See Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04.) Rather than a vague statement about moral character, such questions will provide more specific information to a board about fitness to practice in addition to the qualifications for practice determined through graduation and passing an entry-level exam. Jurisdictions may choose to require additional exams for licensure. A common example is a jurisprudence exam testing knowledge of a state’s laws and rules. All licensed physical therapists (PTs) and licensed [certified] physical therapist assistants (PTAs) should be familiar with the practice act and rules under which they are allowed to work. Many jurisdictions have administrative code that applies to applicants and licensees[certificate holders] of many different disciplines. Applicants and licensees [certificate holders] must meet these requirements to become licensed. Additionally, a jurisdiction may pass laws requiring additional coursework and assessment for applicants within that jurisdiction either at time of initial application or upon renewal. The model practice act provides statutory language enabling any and all of the above examples of additional exams.

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An important qualification for licensure is graduation from an accredited educational program. It is not recommended that the actual accrediting agency be named in the statutes. The agency currently accrediting physical therapy education is the Commission on Accreditation in Physical Therapy Education (CAPTE). This agency can be identified either by rule or by board policy. The model language specifies that it is the accrediting agency, rather than each educational program, that needs the approval of the board. The U.S. Supreme Court (Dent v. West, 1889) upheld the constitutional right of jurisdiction licensing boards to set educational requirements for entry into practice. Accreditation, at least for U.S. professional programs, is the means of assuring standardized professional education, thereby giving licensing boards a degree of comfort in licensing a new graduate from any accredited educational program outside their jurisdiction, or granting licensure by endorsement to an applicant previously licensed in another jurisdiction who graduated from an accredited educational program. The examination approved by the board currently in all jurisdictions is the National Physical Therapy Examination of the Federation of State Boards of Physical Therapy. Board requirements shall also include passing a jurisprudence or law exam.

B. An applicant for a license as a physical therapist who has been educated at a school that has not been

accredited by an agency approved by the board shall: 1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education

of physical therapists educated in an accredited entry-level program as determined by the board. Graduation outside the United States from a professional education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated at a school that has not been accredited by an agency approved by the board shall have: a. Graduated from a physical therapist education program that prepares the applicant to engage without restriction in the practice of physical therapy; b. Provided written proof that the applicant’s school of physical therapy is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass a national examination approved by the board. 5. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 6. Submit to a criminal records check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed under this [Act].

Commentary The term “substantially equivalent,” as defined here in model statute, should be delineated specifically in rules. Rule language should contain, at minimum, the requirement that any credentials evaluation 1) utilize the appropriate edition of the FSBPT CourseworkTool for Foreign Educated Physical Therapists in order to determine educational equivalency at the date of graduation; 2) require that a physical therapist trained in credential reviewing participates in the evaluation; and 3) require that quality assurance standards be met by the credentials review agency.

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The Illegal Immigration Reform and Immigrant Responsibilities Act of 1996 requires prescreening of applicants educated at a school that has not been accredited by an agency approved by the board for physical therapist licensure before granting work visas or a change in immigrant status. Screening includes credentials review, English proficiency examinations and determination of prior license or authority to practice in the country where the professional education was completed. Physical therapy licensing boards and their staff spend considerable time processing applications for licensure by applicants educated at a school that has not been accredited by an agency approved by the board. It is important that consistency occurs in the licensing standards from jurisdiction to jurisdiction and that the entire application process is sufficiently detailed both in statute and in rules. The inclusion of supervised clinical practice for the foreign educated physical therapist would provide the opportunity for integration and progression into the United States healthcare delivery system. With variations in healthcare delivery and culture, a supervised clinical experience would provide direct learning and ease of transition of the foreign educated physical therapist.

C. An applicant for a [certificate/license] as a physical therapist assistant shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a physical therapist assistant education program accredited by a national accreditation agency approved by the board. 3. Pass a national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this [Act].

Commentary As with the application process for a physical therapist, the application process for licensure or certification as a physical therapist assistant should be specified in rules. Jurisdictions will need to determine whether to accept education as a physical therapist as a prerequisite to sit for the physical therapist assistant exam. At this time, there is minimal evidence to allow or deny an individual educated as a physical therapist the opportunity to become licensed as a physical therapist assistant. It may be argued that the knowledge and skills taught within the physical therapist assistant program represent a subset of the knowledge and skills that are taught within a physical therapist education program. There is no evidence to support the concern that graduates of a physical therapist program who become licensed as physical therapist assistants will knowingly or unknowingly use skills such as differential diagnosis, assessment of prognosis, and design plan of care; activities that they were taught in their physical therapist education program but are not within the scope of work of a physical therapist assistant. Jurisdictions should specify in rules if any additional requirements have to be met prior to licensure of a graduate of a physical therapist program as a physical therapist assistant such as supervised clinical practice as a physical therapist assistant, working under a restricted license, education regarding the role of the physical therapist assistant, etc.

D. An applicant for a [certificate/license] as a physical therapist assistant who has been educated at a school that has not been accredited by an agency approved by the board shall:

1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education

of physical therapist assistants educated in an accredited entry-level program as determined by the board. Graduation outside the United States from an education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence

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of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated at a school that has not been accredited by an agency approved by the board shall have: a. Graduated from a physical therapist assistant educational program that prepares the applicant to work as a physical therapist assistant; b. Provided written proof that the applicant’s physical therapist assistant school is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass a national examination approved by the board. 5. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 6. Submit to a criminal records check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under

this [Act]. Commentary Although the physical therapist assistant does not have the same level of standing as a professional healthcare provider with the U.S. Citizenship and Immigration Services, it has become necessary to regulate physical therapist assistants educated at a school that has not been accredited by an agency approved by the board. The Centers for Medicare and Medicaid Services published a regulation in 2008 (number CMS-138) regarding Medicare reimbursement. This CMS regulation requires a foreign-educated physical therapist assistant to show certification of education which is substantially equivalent to an entry-level physical therapist assistant’s education in the United States. Additionally, physical therapist assistant education programs have been developed outside the United States and a tool exists to determine substantially equivalent education. The term “substantially equivalent,” as defined here in model statute, should be delineated specifically in rules. Rule language should contain, at minimum, the requirement that any credentials evaluation 1) utilize the appropriate edition of the Coursework Tool for Foreign Educated Physical Therapist Assistants (PTA Tool 2007) in order to determine educational equivalency at the date of graduation; 2) require that a physical therapist trained in credential reviewing participates in the evaluation; and 3) require that quality assurance standards be met by the credentials review agency. Jurisdictions should require at minimum a credentials review, English proficiency examinations and determination of prior license or authority to practice in the country where the professional education was completed. Physical therapy licensing boards and their staff spend considerable time processing applications for licensure by applicants educated at a school that has not been accredited by an agency approved by the board. It is important that consistency occurs in the licensing standards from jurisdiction to jurisdiction and that the entire application process is sufficiently detailed both in statute and in rules. The inclusion of supervised clinical practice for the foreign trained physical therapist assistant would provide the opportunity for integration and progression into the United States healthcare delivery system. With variations in healthcare delivery and culture, a supervised clinical experience would provide direct learning and ease of transition of the foreign trained physical therapy assistant.

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E. . An applicant for a [certificate/license] as a physical therapist assistant who has completed a United States

Armed Services program of training not accredited by a national accreditation agency approved by the board shall:

1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the

education of physical therapist assistants educated in an accredited entry-level program as determined by the board. Successful completion of a United States Armed Services program of training accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure who has completed a United States Armed Services program of training shall have:

a. Completed a physical therapist assistant training program that prepares the applicant to work as a physical therapist assistant; b. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and c. Completed any additional education as required by the board.

3. Pass national examination approved by the board. 4. Pass additional examinations [e.g., jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified]

under this [Act].

Commentary This section allows a military trained PTA to be evaluated for substantial equivalency.

3.03 Licensure [and Certification] by Endorsement

A. The board shall issue a license to a physical therapist who has a current unrestricted license [certificate]

from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant's initial licensure.

Commentary Jurisdictions will confidently grant licensure by endorsement to physical therapists currently licensed in other jurisdictions when greater regulatory consistency is achieved from jurisdiction to jurisdiction. A phrase common in many practice acts in their endorsement or reciprocity sections is: “…having licensing requirements substantially similar to those prescribed in this [act] at the time the license was originally granted.” That language is closer to reciprocity than to endorsement. The qualifications for licensure of foreign-educated physical therapists in 3.02.B, combined with this qualification for endorsement, will ultimately help achieve uniformity and actual endorsement in this aspect of regulation. Any other jurisdictional “requirements” for endorsement should be specified in the rules associated with an application for endorsement. These shall include submission of verification of a current license in the jurisdiction of previous residency, affidavit of previous practice within a specified period of time, absence of pending or current disciplinary action or restricted license, continuing competence history if mandatory for licensing requirements, or the requirement to take a jurisprudence examination.

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Because of many challenges, FSBPT discourages boards from trying to reinterpret licensing test scores obtained

prior to 1996. Many of the reinterpretation processes require jurisdictional boards to apply decision processes that

are no longer within acceptable professional standards, such as basing a passing score on a prescribed number of

standard deviations below the mean score on the test form. These processes have been abandoned because they

can result in large differences in outcomes among similarly qualified candidates as a function of the test form,

comparison group, and other factors. And because these processes require complex calculations of historical data,

the decisions jurisdictional boards make based on the calculations take a long time and are often erroneous. It

would be hard for a jurisdictional board to argue that a test score from more than two decades ago is a good

indicator of a candidate’s current ability to practice safely and effectively. A passing licensing test score in another

jurisdiction, at the time of licensure, should be considered a passing score in any other jurisdiction absent any

other concerns about the candidate’s ability to practice safely and competently.

As the PT Compact and other legislative efforts such as universal recognition and allowing health care practitioners from out of state licensees provide services via telehealth without licensure, jurisdictions may consider evaluating their current endorsement requirements for applicants with a pre-1996 examination score or educated at a school that has not been accredited by an agency approved by the board. These individuals may be able to provide services in the jurisdiction (e.g., compact privilege), but find significant barriers to becoming licensed.

B. The board shall issue a license [certificate] to a physical therapist assistant who has a current unrestricted

license [certificate] from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant's initial licensure.

Commentary Jurisdictions will confidently grant licensure by endorsement to physical therapists currently licensed in other jurisdictions when greater regulatory consistency is achieved from jurisdiction to jurisdiction. A phrase common in many practice acts in their endorsement or reciprocity sections is: “…having licensing requirements substantially similar to those prescribed in this [act] at the time the license was originally granted.” That language is closer to reciprocity than to endorsement. The qualifications for licensure of foreign-educated physical therapists in 3.02.B, combined with this qualification for endorsement, will ultimately help achieve uniformity and actual endorsement in this aspect of regulation. Any other jurisdictional “requirements” for endorsement should be specified in the rules associated with an application for endorsement. These shall include submission of verification of a current license in the jurisdiction of previous residency, affidavit of previous practice within a specified period of time, absence of pending or current disciplinary action or restricted license, continuing competence history if mandatory for licensing requirements, or the requirement to take a jurisprudence examination.

3.04 Exemptions from Licensure [or Certification]

A. This [act] does not restrict a person licensed or certified under any other law of this jurisdiction from engaging in the profession or practice for which that person is licensed if that person does not represent, imply or claim that he/she is a physical therapist, physical therapist assistant, or a provider of physical therapy as defined in Article 1, 1.02B. Commentary The importance of this model language is in not granting blanket exemption status to other healthcare professionals through language such as “Other licensed healthcare providers are exempt from the provisions of this [act].” Other professionals have occasionally attempted to exploit this language by interpreting it to mean that

7th Edition MPA Commentary 26

they are completely exempt from all provisions of the physical therapy practice act, including title protection. This is something never intended in licensure laws. This model language, combined with other language in the Model Practice Act under Definitions, Article 1.02, Examination and Licensure, Article 3, and Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02 provides clarification of physical therapy services and ensures public protection by providing a deterrent against misrepresentation and the illegal practice of physical therapy. The Model Practice Act does not include and recommends against exempting other practitioners such as massage therapists, athletic trainers, chiropractors, etc., who shall be providing services with similar components to physical therapy.

B. The following persons are exempt from the licensure [certification] requirements of this [act] when engaged in the following activities:

1. A person in an entry-level professional education program approved by the board who is satisfying supervised clinical education requirements related to the person’s physical therapist education while under onsite supervision of a physical therapist.

2. A person satisfying a clinical education experience under the onsite supervision of a physical therapist as required by the board.

3. A physical therapist who is practicing in the United States Armed Services, United States Public Health Service or Veterans Administration pursuant to federal regulations for jurisdiction licensure of healthcare providers. If such person, while federally employed as a physical therapist shall engage in the practice of physical therapy outside the course and scope of such federal employment, he/she shall then be required to obtain a license in accordance with this [act].

4. A physical therapist who is licensed in another jurisdiction of the United States or credentialed to practice physical therapy in another country if that person is teaching, demonstrating or providing physical therapy services in connection with teaching or participating in an educational seminar of no more than 60 days in a calendar year.

5. A physical therapist who is licensed in another jurisdiction of the United States if that person is rendering advice or professional or expert opinion.

6. A physical therapist who is licensed in a jurisdiction of the United States or credentialed in another country, if that person by contract or employment is providing physical therapy to patients/clients affiliated with or employed by established athletic teams, athletic organizations or performing arts companies temporarily practicing, competing or performing in the jurisdiction for no more than 60 days in a calendar year.

7. A physical therapist who is licensed in a jurisdiction of the United States and who enters this jurisdiction to provide physical therapy during a declared local, jurisdictional or national disaster or emergency. This exemption applies for no longer than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

8. A physical therapist licensed in a jurisdiction of the United States who is forced to leave his/her residence or place of employment due to a declared local, jurisdictional or national disaster or emergency and due to such displacement seeks to practice physical therapy. This exemption applies for no more than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

C. A physical therapist assistant who is licensed [certified] in a jurisdiction of the United States and is assisting a physical therapist engaged specifically in activities related to [subparagraphs (B) 2, 3, 5, 6, 7, and 8 of this section] is exempt from the requirement of [licensure/certification] under this [act]. Commentary The purpose of exemption from licensure is to allow a person who is practing or working in physical therapy for a specific period of time in the state, due to compelling reasons, to provide physical therapy services without the

7th Edition MPA Commentary 27

requirement of state licensure. The exemptions included in the Model Practice Act apply to physical therapist students and physical therapist assistant students in entry level programs or other persons satisfying clinical education requirements and physical therapists or physical therapist assistants who are licensed[certified] in other jurisdictions. The categories of persons who are exempt from state licensure should be limited. Physical therapy students in clinical internships are exempt because they are in a physical therapy education program and they are under the direct, onsite supervision of a licensed physical therapist. While in clinical training they need the authority to practice the full scope of physical therapy. Physical therapist assistant students in clinical internships are exempt because they are in a physical therapist assistant education program and they are under the direct, onsite supervision of a licensed physical therapist. While in clinical training they need the authority to work within the full scope of a physical therapist assistant. Applicants for a physical therapist or physical therapist assistant license [certification] that are not current students may be required to complete supervised clinical experience as a requirement for licensure. These individuals are exempt because they are under the direct, onsite supervision of a licensed physical therapist. While in supervised clinical training, physical therapist applicants need the authority to practice the full scope of physical therapy. Physical therapist assistant students in required supervised clinical work are exempt because they are under the direct, onsite supervision of a licensed physical therapist. While in clinical training they need the authority to work within the full scope of a physical therapist assistant. Physical therapists in federal employment, such as in the Veterans Administration, U.S. Public Health Service, or the military services, have historically been exempt from licensure while practicing specifically in those governmental environments. The statute language above reflects changing federal regulations that now require federally employed healthcare professionals to be licensed in at least one jurisdiction, although not necessarily the jurisdiction where they are practicing. However, if the person chooses to practice outside of the confines of their federal employment while in a jurisdiction other than that of their licensure (i.e., employment outside of their normal business hours), they would be required to obtain licensure in the jurisdiction of practice. Paragraph B.4 provides exemption for physical therapists participating either as instructors or as students in post- graduate education. Frequently these individuals are participating in offerings outside the jurisdiction where they are licensed, and occasionally patient contact and treatment may be part of their educational experience. This exemption is for no more than 60 days in a calendar year. A longer period of time would constitute a fellowship or an advanced clinical residency and should require licensure in that jurisdiction. Physical therapists participating in a fellowship or residency shall hold a current license in good standing in any jurisdiction. If that fellowship or residency occurs in another jurisdiction and extends beyond 60days, the therapist is expected to obtain licensure in the jurisdiction of the fellowship or residency. Paragraph B.5 provides exemption for consultation. Exemption from licensure is provided specifically for consultation with another health professional who is licensed in another jurisdiction. This exemption extends only to consultation and does not extend to any other aspect of patient management, including treatment intervention. Paragraph B.6 provides exemption for licensed physical therapists traveling with a sports team or performing arts company who enters the jurisdiction for a limited time to provide physical therapy to the members of the team or company. Practice under this exemption is authorized only for those individual licensees who are affiliated with the visiting organization since no public contact is anticipated. Paragraphs B.7 and B.8 address large-scale natural disasters that induce licensed physical therapists to enter a jurisdiction temporarily to provide their services as part of disaster assistance, or where licensed physical therapists are temporarily displaced as a result of a natural disaster and wish to practice in another jurisdiction temporarily or until licensure is achieved by endorsement.

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Paragraph C provides an exemption for a physical therapist assistant, licensed or certified in another jurisdiction, to assist a physical therapist in the situations described in Exemptions from Licensure [or Certification], Article 3.04 (Paragraphs B.2, B.3, B.5, B.6 and B.7). This exemption is necessary because the physical therapist assistant shall be participating in patient treatment interventions in these specific situations that are typically restricted to persons licensed or certified by the jurisdiction. Subject to this exemption, a physical therapist assistant would still be under the supervision of a licensed physical therapist.

3.05 License [or Certificate] Renewal

A. A physical therapist applying for renewal of the license shall:

1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under

this [Act].

B. A physical therapist assistant applying for renewal of the license [certificate] shall:

1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under

this [Act].

Commentary Although at this time, there is no specific model language for statute or regulation suggested for jurisdictions when shifting to a continuing competence model, there are some elements that are recommended. First, the language must state “continuing competence” activities rather than continuing education. Second, a minimum number of continuing competence units for re-licensure should be established. Third, an approval process of “continuing competence” activities should be established. Fourth, a determination must be made of the minimum standard continuing competence activities must meet in order to gain approval. Fifth, the jurisdiction must retain the ability to designate an outside body to do the approval of “continuing competence” activities. Finally, the jurisdiction should in some way require evidence of accomplishment by the participant of the required minimum standard. Additionally, there are suggested principles to consider when implementing a continuing competence model which will need to be communicated:

• Continuing competence should be self-directed by the PT or PTA.

• Evaluation/assessment of current competence is critical for the PT or PTA. The results of an evaluation or assessment should be used by the PT or PTA to then select appropriate development activities.

• PTs and PTAs should have a wide variety of activities available to demonstrate their competence; there is not one “right” way to demonstrate competence.

Many jurisdictions have administrative code that applies to licensees of many different disciplines. Licensees [certificate holders] must meet these requirements in order to renew their license [certification].

3.06 Changes of Name, Address or Telephone Number

Each licensee [and certificate holder] is responsible for reporting a name change and changes in business and home address, email address and telephone numbers to the board within 30 days. Commentary

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Jursidictions should specify in rules the terms of license and certification renewal and the exact renewal date. It should be stated clearly in rules that all licensees and certificate holders are responsible for keeping the board advised of their current home and practice addresses and telephone numbers. Failure to receive a renewal notification should not constitute an excuse for failure to renew on time. It should be further specified that failure to meet the renewal timeframe constitutes practicing without a license or certificate and will be treated as such under authority of Unlawful Practice; Classification; Civil Penalties; Injunctive Relief, Article 4.09. Timely renewal is the responsibility of the licensee or certificate holder even where an employer shall be funding the expense of renewal.

3.07 Reinstatement of License [or Certificate]

A. The board may reinstate a lapsed license [or certificate] upon completion of a reinstatement application including payment of fees, as defined by rule.

B. If a physical therapist’s license has lapsed for a specified time period, as defined by rules, that person shall

fulfill all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to practice physical therapy by one or more of the following as determined by the board:

1. Complete supervised clinical practice as defined by rules with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during

lapsed licensure period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed practice in another jurisdiction.

C. If a physical therapist assistant’s [certificate/license] has lapsed for a specified time period, as defined by rule,

that person shall fulfill all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to work as a physical therapist assistant by one or more of the following as determined by the board:

1. Complete supervised clinical practice as defined by rules with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during

lapsed licensure [certification] period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed [certified] work as a physical therapist assistant in another jurisdiction.

D. The board may reinstate a suspended or revoked physical therapist’s license upon completion of the

requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of competence to practice physical therapy through the following activities: 1. Complete supervised clinical practice, as defined by rule, with a restricted license. 2. Demonstrate or complete continued competence requirements, defined by rule, required during the

suspended or revoked licensure period. 3. Successfully complete assessment tool(s) and/or pass examination(s) approved by the board.

E. The board may reinstate a suspended or revoked physical therapist assistant’s [certificate/license] upon

completion of the requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of the physical therapist assistant’s competence to work in the profession of physical therapy through the following activities.

1. Complete supervised clinical practice with a restricted license [certificate]under a qualified and approved supervisor.

2. Demonstrate or complete continued competence requirements, defined by rule, required during the suspended or revoked licensure [certification] period.

3. Successfully complete assessment tool(s) and/or pass examination(s) approved by the board. Commentary

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When a license has been allowed to lapse for a lengthy period of time it shall be an indication of a break in continuity of practice and professional development, and potentially, a loss of ongoing competence. It is recommended that a four-year time period be used to determine when the further requirement of reapplication for licensure should be instituted. The board should have the discretion to assess continuing competence to practice physical therapy in the case of a lapse in practice of four or more years. Competence assessment shall include the options of 1) a supervised internship, 2) remedial or refresher coursework, and 3) retesting, or 4) any combination of these options. Further provisions for applicant interview by the board should be specified. In cases where a licensee relocates and practices in another jurisdiction and subsequently returns and wishes to practice in the original jurisdiction of licensure, the requirement for successfully demonstrating competence, as stated in Paragraph B above, shall be satisfied by verification of licensure and practice in the other jurisdiction. Reinstatement is used rather than endorsement and granting a new license in order to retain a previous exam history, license number and, if applicable, disciplinary history. During a period of remedial action prior to reinstatement of license without restrictions, the physical therapist’s practice shall be with a restricted license as directed by the board. This type of remediation, outside of a disciplinary action, is an example of the appropriate use of a restricted license. A lapse of a certificate disqualifies a physical therapist assistant from working as a physical therapist assistant until appropriate renewal and reinstatement requirements are met and fees are paid. As the physical therapist assistant resumes employment, the supervising physical therapist should direct appropriate remedial measures for a physical therapist assistant who lacks current experience or has inadequate skills. Paragraphs D and E address important considerations if a revoked license or certificate shall someday be eligible for reinstatement. At the time of a revocation, the consent decree should stipulate the conditions, if any, under which the board would consider an application for reinstatement. The specific requirements shall be helpful to a later board when an application is considered. In this situation, a board would likely convene a hearing to review the application and evaluate the fitness of the applicant to, once again hold a license or certificate. All other requirements related to demonstration of continuing competence applicable to any other reinstatement situation would also apply in such a case. Reinstatement is also preferable in this situation to a new application license so that prior history is maintained through a single license number. A restricted license does not notate merely a disciplinary action. Restricted licenses shall result from re-entry, etc.

[3.08 Fees]

This is optional statutory language for jurisdictions requiring maximum fee ceilings within their statutes. The board shall establish and collect fees not to exceed:

1.________ dollars for an application for an original license [or certificate]. This fee is nonrefundable. 2.________ dollars for a certificate of renewal of a license [or certificate]. 3.________ dollars for an application for reinstatement of a license [or certificate]. 4.________dollars for each duplicate license [or certificate]. 5. ________dollars for other administrative fees [e.g., criminal records report, pass through or

processing fees]

Commentary This is optional language to use if fee ceilings or ranges are required in statute rather than being addressed in rules. Using this model, a ceiling for fees would be established in statute, and the actual fees would be established in rules. The language here sets the same dollar amount for licenses and certificates in the different categories. The fees for licensees and certificate holders could easily be established at different amounts in rules for each of the categories. Optional for PT Compact Members

7th Edition MPA Commentary 31

6.________dollars for each compact privilege. Article 4: Regulation of Physical Therapy 4.01 Ethics in the Physical Therapy Profession

A. A physical therapist shall adhere to the recognized standards of ethics of the physical therapy profession as established by rule. Commentary A profession’s code of ethics encourages a higher standard of conduct; whereas jurisdiction laws establish minimum levels of acceptable conduct. Professional associations are recognized as the promulgators of a profession’s code of ethics. This language establishes that ethical conduct in the jurisdiction is legally mandated as the minimum standard of lawful practice. Inclusion of this language empowers a board to be more than the “gatekeepers” or “hand-slappers”, some feel is the historical and only duty of licensing boards. A similar clause is included in the model language under the Grounds for Denial of a License [and Certificate], Disciplinary Action, Article 4.04. The model language is “generic” in that it does not specifically reference the American Physical Therapy Association's (APTA's) Code of Ethics, with its accompanying Guide for Professional Conduct (See Appendix B). This generic approach is preferred by many jurisdictions' legal counsel, in order to avoid mention in statue of professional associations and links to documents not under jurisdiction approval authority. The link can be specifically and appropriately made in rules by reference to a specific version of the APTA Code of Ethics and Guide for Professional Conduct.

B. A physical therapist assistant shall adhere to the recognized standards of ethicsal conduct of the physical therapy profession as established by rule.

Commentary

A profession’s code of ethics encourages a higher standard of conduct; whereas jurisdiction laws establish minimum levels of acceptable conduct. Professional associations are recognized as the promulgators of a profession’s code of ethics. This language establishes that ethical conduct in the jurisdiction is legally mandated as the minimum standard of lawful practice. Inclusion of this language empowers a board to be more than the “gatekeepers” or “hand-slappers;” some feel is the historical and only duty of licensing boards. A similar clause is included in the model language under the Grounds for Denial of a License [and Certificate], Disciplinary Action, Article 4.04. The model language is “generic” in that it does not specifically reference the American Physical Therapy Association's (APTA's) Standards of Ethical Conduct for the physical therapist assistant (See Appendix C). This generic approach is preferred by many jurisdictions' legal counsel, in order to avoid mention in statue of professional associations and links to documents not under jurisdiction approval authority. The link can be specifically and appropriately made in rules by reference to a specific version of the APTA Standards of Ethical Conduct for the Physical Therapist Assistant and Guide for Conduct of the Physical Therapist Assistant.

4.02 Use of Titles and Terms; Restrictions; Classification of Violation

A. A physical therapist shall use the letters “PT” or the term “physical therapist” immediately following his or

her name to designate licensure as a heath care practitioner under this [act]. Commentary

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Abbreviations or terms denoting educational degrees, certifications, or honorary status designations may follow, as applicable. These abbreviations should be used in all correspondence related to practice, including advertisements.

Optional for PT Compact Members A physical therapist shall use the letters “PT” or the term “physical therapist” immediately following his or her name to designate licensure under this [act] or authorization to practice under a compact privilege.

B. A person or business entity, its employees, agents or representatives shall not use in connection with that

person’s name or the name or activity of the business, the words “physical therapy,” “physical therapist,” “physiotherapy,”“ physiotherapist,” “physio,” “registered physical therapist,” “doctor of physical therapy,” the letters “PT,”“DPT,”“LPT,”“RPT,” or any other words, abbreviations or insignia indicating or implying directly or indirectly that physical therapy is provided or supplied, unless such services are provided by or under the direction of a physical therapist licensed pursuant to this [act]. A person or business entity shall not advertise or otherwise promote another person as being a “physical therapist” or “physiotherapist” unless the individual so advertised or promoted is licensed as a physical therapist under this act. A person or business entity that offers, provides or bills any other person for services shall not characterize those services as “physical therapy” or “physiotherapy” unless the individual performing those services is a person licensed as a physical therapist under this [act].

Optional for PT Compact Members

A person or business entity, its employees, agents or representatives shall not use in connection with that person’s name or the name or activity of the business, the words “physical therapy,” “physical therapist,” “physiotherapy,”“ physiotherapist,” “registered physical therapist,” “doctor of physical therapy,” the letters “PT,”“DPT,”“LPT,”“RPT,” or any other words, abbreviations or insignia indicating or implying directly or indirectly that physical therapy is provided or supplied, unless such services are provided by or under the direction of a physical therapist licensed pursuant to this [act] or authorized to practice under a compact privilege. A person or business entity shall not advertise or otherwise promote another person as being a “physical therapist” or “physiotherapist” unless the individual so advertised or promoted is licensed as a physical therapist under this act or authorized to practice under a compact privilege. A person or business entity that offers, provides or bills any other person for services shall not characterize those services as “physical therapy” or “physiotherapy” unless the individual performing those services is a person licensed as a physical therapist under this [act] or authorized to work under a compact privilege.

C. Physical therapists who have graduated from a DPT program may use the title "Doctor of Physical Therapy." A physical therapist holding a DPT or other doctoral degree shall not use the title "Doctor" without also clearly informing the public of his or her profession as a physical therapist.Use of the title shall be in accordance with jurisdictional law.

D. A physical therapist assistant shall use the letters “PTA” immediately following his or her name to designate

[certification/ licensure] under this [act].

Commentary Abbreviations or terms denoting educational degrees, certifications, or honorary status designations may follow, as applicable. These abbreviations should be used in all correspondence related to practice, including advertisements.

Optional for PT Compact Members

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A physical therapist assistant shall use the letters “PTA” or the term “physical therapist assistant” immediately following his or her name to designate [certification/ licensure] under this [act] or authorization to work under a compact privilege.

E. A person shall not use the title “physical therapist assistant,” the letters “PTA,” or any other words,

abbreviations or insignia in connection with that person’s name to indicate or imply, directly or indirectly, that the person is a physical therapist assistant unless that person is [certified/ licensed] as a physical therapist assistant pursuant to this [act].

Optional for PT Compact Members

A person shall not use the title “physical therapist assistant,” the letters “PTA,” or any other words, abbreviations or insignia in connection with that person’s name to indicate or imply, directly or indirectly, that the person is a physical therapist assistant unless that person is [certified/ licensed] as a physical therapist assistant pursuant to this [act] or authorized to work under a compact privilege.

F. A person or business entity that violates paragraphs (B) or (E) of this section is guilty of a [cite specific legal sanction].The board shall have authority to impose a civil penalty, in an amount not to exceed [specify number of dollars] per violation, against any person or business entity that violates paragraphs (B) or (E). In addition, the board shall seek an injunction against conduct in violation of paragraphs (B) or (E) in any court of competent jurisdiction. For purposes of this [act], the board, in seeking an injunction, need only show that the defendant violated paragraphs (B) and (E) of this section to establish irreparable injury or a likelihood of a continuation of the violation. Commentary “PT” is the professional and regulatory designation required by practice acts and used by physical therapists in the United States. It should immediately follow the licensee’s name. The model statute language prohibits substituting but does not restrict adding other letter designations indicating an academic degree (e.g., MS, PhD), professional degree (e.g., DPT), certification (e.g., ATC), or honorary status (e.g., FAPTA). All these additional designations should follow the standard “PT” designation. For example, a board-certified orthopedic specialist with a doctoral degree in physical therapy would be appropriately designated as Jane Doe, PT, DPT, OCS. The jurisdiction legislature grants scope of practice privileges and imposes certain restrictions on the use of titles and terms for public protection. The use of the title “physical therapist” connotes education and training in a unique body of knowledge and skills exclusive to physical therapists. Title protection encompasses names and titles, as well as the letters and abbreviations that are associated with licensure. Paragraph B above addresses all such titles, designations and abbreviations applicable to physical therapy licensure, including archaic terms and some that shall be future terms. Archaic designations such as RPT or LPT, while they should be protected, should not be used. Rules shall be considered that prohibit the use of these archaic designations protecting the term “physiotherapy,” which is a historically significant as well as current international title of the profession, prevents the misleading use of this term by other individuals or professionals. A claim that physical therapy or physiotherapy is a generic term is misleading, and any terms implying that physical therapy is being provided should be protected. This term protection is not against the use of various physical agents, modalities or procedures by others but rather is against the inappropriate labeling of those modalities and procedures as physical therapy. Any violation of this term protection paragraph would be addressed in paragraph A of Article 4.09.

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Those therapists holding a DPT or any doctoral degree such as a PhD or EdD, are entitled to use "Dr" as a prefix to their name in honor of the professional degree they have earned. However, DPT or PhD are academic degrees, not a clinical designator. It is important that the public perceive the critical difference between the word "physician" and the use of the title "Dr." Therefore, in order to minimize confusion, physical therapists should identify themselves and their profession when first meeting a patient. A physical therapist may not use the title of “Dr.”in a manner which would mislead a patient into assuming that he or she is anything other than a physical therapist. Paragraphs D and E provide title protection for physical therapist assistants. In this instance, title protection is granted without a corresponding granting of a scope of practice. (See Definitions, Article 1.02.E; Examination and Licensure, Article 3.01-3.04; Patient Care Management, Article 4.03.)

4.03 Patient/Client Care Management

A. A physical therapist is fully responsible for managing all aspects of the physical therapy care of each patient/client. A physical therapist shall provide:

1. The initial evaluation, determination of diagnosis, prognosis, and plan of treatment intervention and documentation of each encounter of each patient/client;

2. Periodic reevaluation and documentation of each patient/client; 3. The documented discharge of the patient/client, including the patient’s/client’s response to treatment

intervention at the time of discharge. Commentary Physical therapists are professionally and legally responsible for the treatment interventions they personally render as well as those components of intervention rendered by personnel under the physical therapist’s supervision. This responsibility is not diminished when persons assisting the physical therapist are licensed, certified or otherwise regulated. The practice of physical therapy includes examination, evaluation and testing for purposes of determining a diagnosis, a prognosis, a plan of treatment intervention, and an assessment of the ongoing effects of treatment. These responsibilities are evaluative in nature and can only be performed by a physical therapist. The initial evaluation is essential to determine if physical therapy services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. An evaluation is needed before implementing any physical therapy treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation shall include, but is not limited to:

a) A history of current condition and treatment previously provided b) A relevant systems review c) Prior functional level d) Specific standardized and non-standardized tests, assessments, and tools e) Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written or

electronic report(s) f) Objective, measurable, and functional descriptions of a patient/client's deficits using comparable and

consistent methods g) Summary of clinical reasoning and consideration of contextual factors with recommendations h) Plan of care with specific treatment techniques and/or activities to be used in treatment sessions that

should be updated as the patient/client's condition changes i) Communication to the patient and /or others, as indicated, the prospective plan of treatment and

outlined goals j) Frequency and duration of treatment plan k) Functional, measurable, and time-framed long-term and short-term goals based on appropriate and

relevant evaluation data l) Rehabilitation prognosis

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A reevaluation is indicated when there are new clinical findings, a rapid change in patient status, or failure to respond to physical therapy interventions. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries and shall include modifications and renewal to the treatment plan of care. Reevaluation is a more comprehensive assessment that includes some or all the components of the initial evaluation, such as:

a) Data collection with objective measurements taken based on appropriate and relevant assessment tests and tools using comparable and consistent methods

b) Making a judgment as to whether skilled care is still warranted c) Organizing the composite of current problem areas and deciding a priority/focus of treatment d) Identifying the appropriate intervention(s) for new or ongoing goal achievement e) Modification of intervention(s) f) Revision in plan of care if needed g) Correlation to meaningful change in function, and h) Deciphering effectiveness of intervention(s).

The physical therapist shall ensure that patients are provided appropriate treatment that is delivered in a reasonably safe manner, that, where known standards of practice exist, such treatment adheres to applicable standards, and that recognized standards of ethics, as established by rule or otherwise, are followed. In the event the evaluation or re-evaluation reveals a condition or suspected condition which is beyond the PT scope of practice, the therapist shall communicate these findings to the patient’s primary care provider or make a referral to an appropriate provider of care. Paragraphs A.1 through A.3 of the model statute require physical therapists to document the services they personally provide.

B. A physical therapist shall assure the qualifications of all physical therapist assistants and physical therapy aides under their direction and supervision.

Commentary The use of personnel assisting the physical therapist is a patient care management decision made by each physical therapist. The physical therapist must determine whether personnel assisting the physical therapist are qualified to perform the designated activity, and their qualifications should be verified and documented. For the physical therapist assistant, this should at least include documentation of educational training and regulatory credentialing. For physical therapy aides, this should at least include written evidence of on-the-job training by the physical therapist.

C. For each patient/client on each date of service, a physical therapist shall provide all the treatment intervention that requires the education, skills and knowledge of a physical therapist and shall determine the use of physical therapist assistants or physical therapy aides to ensure that the delivery of care that is safe, effective, and efficient. Commentary This language requires the physical therapist to personally provide those services that require his or her expertise and to determine the appropriate tasks that shall be assigned to assisting personnel for each patient on every date of service. The physical therapist must ensure that the use of supervised personnel is an efficient use of resources and is based on patient safety and treatment efficacy. There are limits to a physical therapist’s capacity to fulfill the responsibilities of direct patient care as well as to fulfill a supervisory role over other personnel. Jurisdictions shall wish to adopt rules that specify a reasonable limit

7th Edition MPA Commentary 36

on the number of physical therapist assistants, aides, and students that a physical therapist shall personally supervise.

1. A physical therapist assistant shall work under a physical therapist’s supervision. A physical therapist assistant shall document the care they provide.

Commentary The language of this section provides authorization for the physical therapist assistant to work in an offsite setting and under the general supervision of a physical therapist. If a jurisdiction opts for a different supervision level it should be specified in this section. For example, a jurisdiction requiring onsite supervision of a physical therapist assistant could insert “onsite” prior to the word “supervision” in the first sentence. Any other supervisory limits or requirements and procedures related to communication and documentation should be specified here or clarified in rules.

2. A physical therapist may use physical therapy aides for designated routine tasks. A physical therapy aide shall work under the supervision of a physical therapist.

Commentary Jurisdictions are encouraged to adopt the basic language in Paragraph C.2 that limits the use of aides to working only under the supervision of a physical therapist or allowing use of an aide in an offsite setting only when directly helping a physical therapist assistant or performing tasks which are not patient-related. The phrase “designated routine tasks” in the model definition of a physical therapy aide is distinctly different from “selected components of intervention” as used in the model definition for physical therapist assistants. If a jurisdiction chooses to enact more explicit restrictions on the duties of a physical therapist aide, a more detailed definition of “designated routine tasks” should be included in rules. There are many situations in extended care, home health or school settings, where physical therapists train others to carry out certain exercises or activities for the benefit of patients/clients. However, unless a physical therapist is onsite and providing supervision as an integral part of a physical therapy plan of care and treatment intervention these activities should not be represented as physical therapy services. In this provision, as in 1.02.9 , “direction” and “supervision” are functions that belong solely to the licensed physical therapist. The physical therapist assistant shall receive help from a physical therapy aide when performing certain tasks or procedures, but the physical therapist assistant does not assume the responsibility to “direct and supervise” the provision of care. That responsibility remains with the supervising physical therapist and, by law, cannot be relinquished to another.

D. The physical therapist shall communicate the plan of care with, and obtain informed consent from, the patient/client or the patient’s legally authorized representative. Commentary

Informed consent, at a minimum, occurs at the outset of physical therapy care and is updated when there are changes/modifications to the plan. Informed consent is not a passive, one-time, one-way push of information from the provider of physical therapy services to the patient/client (legally authorized representative). Instead, it is a process by which the patient/client is given an explanation of the treatment plan of care (or specific treatment being performed), the opportunity to ask questions and be made aware of any risks and ultimately decide whether or not to move forward with the proposed intervention. Informed consent is a two-way ongoing process

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between the provider and the patient/client respecting the right of the patient/client to make decisions regarding their healthcare.

The nature of physical therapy treatments often requires close contact between PT/PTA and the patient/client, which may warrant more frequent communication to maximize patient/client understanding of the intent or necessity of the physical proximity. It is incumbent upon the provider to describe actions necessary to address the patient/client dysfunction while considering cultural, social, and personal boundary sensitivities of the patient/client.

Informed consent may be written or verbal, in-person or via electronic communications. The treatment setting may impact the format of informed consent and the provider should consider setting in the informed consent process. An indepent outpatient receiving care may require a different approach to informed consent than the indiviudal in an institutional setting in which a informed consent covers a broad range of inpatient services/care. In any setting, however, the patient/client has the right to receive a clear explanation of care and the opportunity to give or deny consent.

The provider should document informed consent was obtained from the patient/client. Written consent may be the most ideal format, however depending upon the environment or situation, verbal consent may be appropriate provided it is fully conveyed in the documentation.

E. A physical therapist’s responsibility shall include accurate documentation and billing of the services provided. Commentary

F. A physical therapist assistant’s responsibility shall include accurate documentation and billing of the services provided. Commentary

G. Nothing in this [Act] shall prohibit a licensee[certificate holder] from providing physical therapy to animals for which the licensee[certificate holder] has completed the education and training as further established by rule. Commentary The practice of physical therapy continues to evolve including the treatment of animals. While there is currently no consistent standard of specified education and training, it is appropriate to note that additional rule development in a jurisdiction may address minimum standards to demonstrate competency to provide physical therapy to animals.

4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action

A. The following are grounds for denial of a license [and certificate] or disciplinary action. Commentary The following language itemizes the various causes or grounds for which a physical therapist, and in many cases a physical therapist assistant, shall be denied a license or certificate or disciplined under the provisions of the law.

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Others who practice physical therapy unlawfully come under the powers granted a licensing board in Unlawful Practice; Classification; Civil Penalties; Injunctive Relief, Article 4.09. In many practice acts, this list is referred to as “unprofessional conduct.” The term “grounds for denial of a license and disciplinary action” is more descriptive and is the recommended title for this section. This section needs to be comprehensive enough to cover all areas of potential violation. 1. Violating any provision of this [act], board rules or a written order of the board. Commentary This clause provides the broadest foundation for disciplinary action. It encompasses statutes, rules and written disciplinary orders. 2. Obtaining or attempting to obtain a license [or certificate] by fraud or misrepresentation. Commentary Individuals who do not meet licensure qualifications and requirements may resort to falsifying or omitting information when applying for licensure or certification. Examples would be when an applicant by endorsement withholds information of disciplinary action in another jurisdiction, or when an applicant for renewal falsely claims to have completed continuing competence requirements. Optional for PT Compact Members 2. Obtaining or attempting to obtain a license [or certificate] or compact privilege by fraud or misrepresentation. 3. Attempting to engage in conduct that subverts or undermines the integrity of the examination or the

examination process including, but not limited to, a violation of security and copyright provisions related to the national licensure exam, utilizing in any manner recalled or memorized examination questions from or with any person or entity, failing to comply with all test center security procedures, communicating or attempting to communicate with other examinees during the test, or copying or sharing examination questions or portions of questions.

Commentary Exam cheating and other forms of attempted cheating on the licensure examination are addressed in this model statute language. The Federation of State Boards of Physical Therapy is authorized under exam contract and under the express written approval of each examinee to take action against those who attempt to cheat on the examination. This paragraph empowers a jurisdictional board to take the necessary action prior to or after the licensing process if an applicant violates the integrity of the examination process. 4. Practicing or offering to practice beyond the scope of the practice of physical therapy. Commentary The determination of what constitutes practice “beyond the scope” of physical therapy is predominantly the responsibility of licensing board members. Scope of practice changes as contemporary practice evolves and boards need the latitude to determine the appropriateness of physical therapy procedures as they relate to both established and evolving scope of practice. The definition of “the practice of physical therapy” should also serve as a primary resource for determining violations of scope of practice. 5. Acting in a manner inconsistent with generally accepted standards of physical therapy practice, regardless of

whether actual injury to the patient/client is established. Commentary

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There are a number of other authoritative sources for the board to consult in addition to statute and rules when determining “generally accepted standards of physical therapy practice.” These might include published standards of physical therapy practice, case law or other source documents. Injury does not need to be established when professional conduct is substandard or potentially injurious to a patient. 6. Failing to adhere to the recognized standards of ethics of the physical therapy profession as established by

rule. Commentary This clause empowers a licensing board to discipline licensees or certificate holders for unethical conduct as promulgated by rules. (See Ethicss in the Physical Therapy Profession, Article 4.01 and Commentary.) There is clear legal precedence for jurisdiction regulatory boards utilizing the established ethical standards of the profession in disciplinary matters. 7. Failing to complete continuing competence requirements as established by rule. Commentary Authority to enact continuing competence requirements is contained under several paragraphs of the Model Practice Act (see Legislative Intent, Article 1.01, Powers and Duties of the Board, Article 2.02.8, License [or Certificate] Renewal, Article 3.05.A). This paragraph provides board authority to take disciplinary action if a physical therapist fails to meet the continuing competence standards established by law, including fulfilling any remedial requirements. 8. Failing to maintain adequate patient/client records. For the purposes of this paragraph, “adequate

patient/client records” means legible records that contain at minimum sufficient information to identify the patient/client, an evaluation of objective findings, a diagnosis, a plan of care, a treatment record and a discharge plan.

Commentary The importance of maintaining a thorough and timely written record of physical therapy services provided to every patient/client and patient response to treatment should be self-evident. It is the written record that ultimately supports the effectiveness and appropriateness of the physical therapist’s patient/client evaluation, plan of care and treatment intervention. This paragraph establishes a legally minimum standard for physical therapist patient documentation and allows the board to take disciplinary action against therapists who maintain faulty or incomplete patient records. 9. Failing to supervise physical therapist assistants, physical therapy aides, or a person in an entry-level

professional education program approved by the board who is satisfying supervised clinical education requirements related to the person’s education in accordance with this [act] and board rules.

Commentary A physical therapist remains responsible for the entire scope of patient management including the supervision of physical therapist assistants, physical therapy aides, and students completing clinical education experiences. The practice act and rules govern supervisory requirements. See Definitions, Article 1.02; Patient Care Management, Article 4.03; and Guidelines for Rules. 10. Failing to report to the board, where there is direct knowledge, any unprofessional, incompetent or illegal

acts that appear to be in violation of this [act] or any rules established by the board. Commentary Regulatory boards, by means of the disciplinary process, bear the responsibility for the public’s expectation of qualified services from duly scrutinized practitioners. This responsibility is passed on to the licensed professionals by the requirement that they must bring to the Board’s attention direct knowledge of incompetent, unprofessional

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or illegal practices. The reporting of these acts serves to protect the public from harm as a result. The paragraph authorizes disciplinary action against a licensee who fails to report ‘direct knowledge’ to the physical therapy board. A licensee or certificate-holder is not obligated to report hearsay when he or she has no direct knowledge of a possible violation. 11. Engaging in sexual misconduct. For the purpose of this paragraph sexual misconduct includes:

a. Engaging in or soliciting sexual relationships, whether consensual or non-consensual, while a physical therapist or physical therapist assistant-patient/client relationship exists. b. Making advances, requesting favors or expressing thoughts, feelings, or making gestures that are sexual in nature, or that reasonably may be construed by a patient/client as sexual in nature, by any means including verbal, physical contact, or via electronic communications. c. Intentionally viewing a completely or partially disrobed patient/client in the course of treatment if the viewing is not related to patient/client diagnosis or treatment under current practice standards.

Commentary To violate the provisions of this law, physical therapists or physical therapist assistants do not need to actually engage in sexual relations since even the solicitation of such a relationship is a violation. The violation is not excused even in the case of a consensual sexual relationship with a patient. Sexual misconduct also includes activities specified in Paragraph 11.B above that defines sexual harassment and includes inappropriate touching and violations of established boundaries. Paragraph 11.C expands sexual misconduct to inappropriate examination or treatment that exposes a patient unnecessarily or for improper motives. The patient provider relationship is therapeutic and not social or emotional. It inherently establishes boundaries and a power differential between the healthcare provider and the patient. Any conduct that exploits the vulnerability of the patient should clearly be a violation of law. 12. Sexual contact between a physical therapist and patient/client after termination of the physical therapist-

patient/client Relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

Commentary Even after the termination of physical therapy services it is possible that a physical therapist may be culpable for a violation of this Act if the physical therapist demonstrates an abuse of their relationship with the patient/client in order to gain sexual contact with the patient/client. Boards should be able to liberally construe the timing and connection of the interactions and sexual contact between a physical therapist and patient/client even if the sexual contact occurs after the termination of physical therapy services, and not be bound by a definition that ends a physical therapists’ responsibilities for their behavior or actions solely at the termination of services, especially if services are terminated for the purpose of sexual contact with a patient/client. 13. Sexual contact between a physical therapist assistant and patient/client after termination of the physical

therapist assistant-patient/client relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

Commentary Even after the termination of physical therapy services it is possible that a physical therapist assistant may be culpable for a violation of this Act if the physical therapist assistant demonstrates an abuse of their relationship with the patient/client in order to gain sexual contact with the patient/client. Boards should be able to liberally construe the timing and connection of the interactions and sexual contact between a physical therapist assistant and patient/client even if the sexual contact occurs after the termination of physical therapy services, and not be bound by a definition that ends a physical therapist assistant’s responsibilities for their behavior or actions solely at the termination of services, especially if services are terminated for the purpose of sexual contact with a patient/client.

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14. Abusing the physical therapist-patient/client relationship to exert undue influence or exploiting persons over whom the licensee has supervisory, evaluative, or other authority

Commentary Factors that can contribute to positional power imbalance include the physical therapist’s knowledge of the evaluation and treatment of a diagnosis, the patient/client dependence on the physical therapist to address pain and decreased function and the vulnerability that can arise due to this pain and decreased function. A power imbalance can also exist as related to cultural background(s), socio-economic status, educational background, health literacy, mental and emotional status of others. While the focus here in statute relates to the power imbalance the physical therapist may hold over the patient/client, it is worth noting that power imbalance may also work in the reverse such that a patient holds an imbalance of power, consider an older patient working with a younger or recent graduate where the patient/client has years of life-experience beyond that of the younger or recent graduate physical therapist.

15. Abusing the physical therapist assistant-patient/client relationship to exert undue influence or exploiting persons over whom the licensee [certificate holder] has supervisory or other authority

Commentary Factors that can contribute to positional power include the patient/client dependence on the knowledge of the physical therapist assistant and the vulnerability that can arise due to pain and decreased function. A power imbalance can also exist as related to cultural background(s), socio-economic status, educational background, health literacy, mental and emotional status of others. While the focus here in statute relates to the power imbalance the physical therapist assistant may hold over the patient/client, it is worth noting that power imbalance may also work in the reverse such that a patient holds an imbalance of power, consider an older patient working with a younger or recent graduate where the patient/client has years of life-experience beyond that of the younger or recent graduate physical therapist assistant. 16. Having had a license [or certificate] revoked or suspended, other disciplinary action taken, or an application

for licensure [or certification] refused, revoked or suspended by the proper authorities of another jurisdiction, territory or country.

Commentary This paragraph gives the board the authority to review any disciplinary action taken against a licensee or certificate holder by another jurisdiction when granting a license or certificate or in any subsequent disciplinary case. The board should consider the relationship between the risk to the public resulting in the disciplinary action taken by another jurisdiction, as well as the appropriate level of discipline for the circumstances that formed the basis of the action. NOTE: In the specific instance where an investigative process or disciplinary action was initiated but not completed, and the licensee or certificate holder then applies in another jurisdiction, this should be addressed by the rules that specify the requirements of application or endorsement. Rules or application questions should address whether the applicant has any pending complaints or investigations from other jurisdictions. Failure to disclose and then subsequent discovery would be grounds for disciplinary action under Paragraph 4.04.2 of this section that describes attempting to obtain a license by fraud or misrepresentation. Optional for PT Compact Members

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12. Having had a license [or certificate] or compact privilege revoked or suspended, other disciplinary action taken, or an application for licensure [or certification] or compact privilege refused, revoked or suspended by the proper authorities of another jurisdiction, territory or country.

17. Having been convicted of or pled guilty to a felony with a nexus to the practice of a physical therapist or

work of a physical therapist assistant in the courts of this jurisdiction or any other jurisdiction, territory or country. Conviction, as used in this paragraph, shall include a deferred conviction, deferred prosecution, deferred sentence, finding or verdict of guilt, an admission of guilt, an Alfred plea, or a plea of nolo contendere.

Commentary Although this paragraph gives the board broad authority to review any felony conviction of a licensee/certificate holder, the board should consider the relationship or nexus between the felony to the practice of the physical therapist or work of a physical therapist assistant and the risk to the public’s welfare and safety when determining whether and what level of disciplinary action is appropriate. Additional considerations may include but are not necessarily limited to the time since the felony conviction, mitigating/extenuating circumstances, and any additional infractions of the law. 18. Aiding and abetting the unlicensed practice of physical therapy. Commentary The most frequent use of this paragraph occurs when someone not licensed or certified is providing services represented as physical therapy without the legal and appropriate supervision of a physical therapist. An example might be a situation where a physical therapist performs only the initial evaluation of a patient and subsequent care is provided by other individuals without the involvement and supervision of the therapist but which is represented and billed as physical therapy. The therapist in this case could be held accountable for abetting this illegal practice by unlicensed personnel. 19. Directly or indirectly requesting, receiving or participating in the dividing, transferring, assigning, rebating or

refunding of an unearned fee, or profiting by means of a credit or other valuable consideration such as an unearned commission, discount or gratuity in connection with the furnishing of physical therapy services. This does not prohibit the members of any regularly and properly organized business entity recognized by law comprising physical therapists from dividing fees received for professional services among themselves as they determine necessary.

Commentary This model language is fairly common statute language dealing with kickbacks, rebates and unearned fees. It does not directly address employment relationships with referral sources. Some jurisdictions have legislatively prohibited referral for profit relationships associated with employment of physical therapists by physicians by inserting the word “wages” into the language of this paragraph. While it is unlawful to pay or receive any remuneration to or from a referral source, it is lawful under this clause for physical therapist within a physical therapist-owned practice to divide profits among themselves. 20. Promoting any unnecessary device, treatment intervention or service resulting in the financial gain of the

practitioner or of a third party. 21. Providing treatment intervention unwarranted by the condition of the patient or continuing treatment

beyond the point of reasonable benefit. Commentary Professional practitioners have a fiduciary responsibility to place patient welfare above all other concerns when providing health or medical services. Physical therapist services and product recommendations should be entirely

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based on patient need and benefit and uninfluenced by financial benefits the physical therapist might receive. This paragraph establishes that this ethical standard of fiduciary responsibility is also the legal standard of practice in the jurisdiction. These two sections prohibit the provision of unnecessary devices, unnecessary treatment intervention, or overutilization of services. Paragraph 20 focuses on motives of financial gain, whereas Paragraph 21 focuses on treatment effectiveness and appropriateness. 22. Participating in underutilization or overutilization of physical therapy services for personal or institutional

financial gain. Commentary This paragraph establishes the legal obligation of the professional practitioner to maintain independent judgment and ensure patient benefit regardless of the limitations or opportunities presented by the prevailing healthcare environment or particular employment directives. Under a fee-for-service payment system an increase of intervention shall result in greater financial gain to the provider or employer. In a managed care system the denial or limitation of intervention shall result in greater financial gain to a provider or employer. These types of conflicts are inherent in either system of payment. This paragraph allows the board to take disciplinary action should patients be exploited by overutilization or underutilization of physical therapy services. 23. Charging fraudulent fees for services performed or not performed. Commentary This language empowers a licensing board to address circumstances involving the charging of fraudulent fees and billing practices. A board shall still need to wrestle with the issue of when or if a clearly unreasonable fee shall reach the proportion of being considered fraudulent. 24. Making misleading, deceptive, untrue or fraudulent representations in violation of this [act] or in the

practice of the profession. Commentary Professional accountability encompasses integrity and truthfulness in the practice and promotion of physical therapy services. This language empowers a board to deny licensure or certification or to take disciplinary action against individuals who intentionally violate the public trust. Possible violations shall include private or public representations of one’s ability to diagnose or provide treatment for conditions outside the scope of physical therapy practice, or false or misleading advertisement or promotion regarding one’s services. The language is broad enough to apply to business operations, employment-related issues, billing practices or any other activity related to the operation of physical therapy services that shall be misleading, deceptive, untrue or fraudulent to the public. This clause is not intended in any way to restrict or limit legally appropriate advertisement or promotion. 25. Practicing as a physical therapist or working as a physical therapist assistant when physical or mental

abilities are impaired by the use of controlled substances or other habit-forming drugs, chemicals or alcohol, or by other causes.

Commentary This paragraph grants the board authority to initiate and carry out disciplinary action when an individual’s abilities shall be impaired by substance use. The safety and welfare of patients is of highest priority and is the focus of this statute language. The treatment of the impaired professional recognizes the need to pursue active rehabilitation in cases of substance abuse, as discussed in Substance Abuse Recovery Program, Article 4.11. 26. Practicing physical therapy with a mental or physical condition that impairs the ability of the licensee to

practice with skill and safety. Commentary

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This paragraph grants a board the authority to impose restrictions on a licensee relating to a determination that the individual’s ability to practice physical therapy with skill and safety is impaired by mental or physical conditions, whether temporary or permanent. Examples might be a physical therapist who is recovering from a closed-head injury, or an individual who suffers from a neurological condition that impairs his or her physical performance to practice physical therapy, or a licensee who is dealing with an episode of severe depression. The board could determine whether and for how long the licensee’s practice should be restricted to ensure protection of the public. The Americans with Disabilities Act shall pose additional legal restraints when a board relies on this provision. 27. Practicing after having been adjudged mentally incompetent by a court of competent jurisdiction. Commentary Mental incompetence is a judgment made outside the scope of a physical therapy licensing board’s responsibility. Concern for patient safety and concern that a patient receives appropriate care shall merit board action restricting or denying licensure in a situation where a court of law has made the determination of mental incompetence (see Investigative Powers; Emergency Action; Hearing Officers, Article 4.05, which authorizes and empowers the board to require a licensee to be examined for mental or physical ability to practice). 28. Interfering with an investigation or disciplinary proceeding by failure to cooperate, by willful

misrepresentation of facts, or by the use of threats or harassment against any patient/client or witness to prevent that patient/client or witness from providing evidence in a disciplinary proceeding or any legal action.

Commentary The board must have access to all relevant information to adequately protect the public and enforce this act. Any attempt to interfere with or cover up the facts of an investigation or disciplinary proceeding would be a violation of this statute, and potentially subject a licensee or certificate holder to further disciplinary action. 29. Failing to maintain patient/client confidentiality without documented authorization of the patient/client or

unless otherwise required by law. All records used or resulting from a consultation by telehealth, as defined in [Definitions, Article 1.02], are part of a patient’s/client’s records and are subject to applicable confidentiality requirements.

Commentary Patient/provider confidentiality is an inherent responsibility of professional practice. Initial patient registration information generally contains provisions for the proper and legal release of medical information upon written approval by the patient. This paragraph establishes that violation of this patient/provider trust will also be a violation of law. There shall be other federal or jurisdiction disclosure laws related to confidentiality that shall modify the provisions of this paragraph. There is additional language in the Model Practice Act that addresses provider/patient confidentiality under Rights of Consumers, Article 4.12.G.

4.05 Investigative Powers; Emergency Action; Hearing Officers

Commentary Most jurisdictions have entire sections of administrative law known as an Administrative Procedures Act that directs the disciplinary process. Procedural aspects of discipline need to be delineated in rules if they are not addressed in a jurisdiction’s Administrative Procedures Act. This section of the model statute addresses the board’s authority to investigate complaints and discipline licensees and certificate holders, including:

• Initiation and handling of complaints

• Investigation

• Informal disposition of complaints

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• Summons and complaint issued by the board

• Pre-hearing discovery

• Subpoena and injunctive authority

• Informal interviews or hearings

• Formal hearings

• Settlement, consent orders, disciplinary actions

A. To enforce this [act], the board is authorized to: 1. Receive complaints filed against licensees [or certificate holders] and conduct a timely investigation. Commentary Public access to the complaint process should be clearly established by the law. There should be a standard complaint form, allowing for complaints to be received verbally or in writing. The complainant must provide their name and address for follow-up contact. However, it should be specified that confidentiality will be maintained if the complainant so requests and within the limits of law. Jurisdiction confidentiality laws shall be a factor in drafting conforming rules. (See Guidelines for Rules.) 2. File complaints against licensees [or certificate holders] or individuals engaging in the unlawful or unlicensed

practice of physical therapy and conduct a timely investigation. Commentary

Board members may become aware of possible infractions of the laws and rules through multiple sources about the unlawful or unlicensed practice of physical therapy. This standard empowers the Board to file a complaint to report the unlawful or unlicensed practice of physical therapy. Some examples may include, but are not limited to, a physical therapist or physical therapist assistant practicing with an expired license or individuals purporting to provide physical therapy when they are not authorized to do so.

3. Conduct an investigation at any time and on its own initiative without receipt of a written complaint if the

board has reason to believe that there shall be a violation of this [act]. Commentary Board members may become aware of possible infractions of the laws and rules through inquiries to board members or staff from physical therapists, the public or other sources about the legal appropriateness of a physical therapist’s practices. As well, information may come to the board through the complaint investigation process that identifies other practitioners in possible illegal actions. Boards need the latitude to investigate these concerns without being required to wait for a formal complaint to be submitted. This standard allows more latitude than “probable cause” or “reasonable cause.” 4. Issue subpoenas to compel the attendance of any witness or the production of any documentation relative to

a case. Commentary A subpoena shall be used to access, review and obtain records in addition to compel the testimony of any witnesses in an investigation or disciplinary proceeding. The use of subpoenas in unannounced site investigations is occasionally a necessary part of investigating complaints. The issuance of subpoenas shall be dependent upon individual jurisdiction laws. Specific model language regarding the confidentiality of patient records is further recommended. (See Rights of Consumers, Article 4.12.H.)

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5. Take emergency action ordering the summary suspension of a license [or certificate] or the restriction of a

physical therapist’s practice or a physical therapist assistant’s work, pending proceedings by the board. Commentary This language grants a board the authority to respond quickly to a complaint having serious implications for public protection. Jurisdiction boards have sometimes been required to wait weeks or months before a hearing could be conducted, putting the public at risk. In the absence of an Administrative Procedures Act, conforming rules shall be necessary to specify parameters for the use of this authority, for example, how soon a hearing must be held and what type of conduct or imminent danger warrants use of this authority. Optional for PT Compact Members Take emergency action ordering the summary suspension of a license [or certificate] or compact privilege or the

restriction of a physical therapist’s practice or a physical therapist assistant’s employment, pending proceedings by the board.

6. Appoint hearing officers authorized to conduct hearings. Hearing officers shall prepare and submit to the

board findings of fact, conclusions of law and a recommendation for board action that shall be reviewed and voted on by the board.

Commentary When the disciplinary process reaches the formal level, the preferred procedure is to use an independent hearing officer to conduct the hearing. Administrative Procedures Acts shall specify that hearing officers shall be administrative law judges. If that is the case, the reference to “administrative law judges” shall be more appropriate than “hearing officers.” Hearing procedures should be specified in rules or referenced in a uniform Administrative Procedures Act. 7. Require a physical therapist to be examined in order to determine his or her mental or physical ability to

practice physical therapy. Commentary There shall be times when a licensee or applicant’s mental, physical or professional competence could impair their ability to practice physical therapy with skill and safety. This paragraph empowers a board to direct appropriate evaluations for such competence if the circumstances warrant. The Americans with Disabilities Act shall pose additional restraints. Paragraph 4.04.23 under Grounds for Denial of a License [and Certificate] Disciplinary Action authorizes the board to take action that shall limit or prevent practice determined by the board to be unsafe to the public. 8. Require a physical therapist assistant to be examined in order to determine his or her mental or physical

ability to work in the profession of physical therapy. Commentary There shall be times when a licensee or applicant’s mental, physical or professional competence could impair their ability to work in the profession of physical therapy with skill and safety. This paragraph empowers a board to direct appropriate evaluations for such competence if the circumstances warrant. The Americans with Disabilities Act shall pose additional restraints. Paragraph 4.04.23 under Grounds for Denial of a License [and Certificate]; Disciplinary Action authorizes the board to take action that shall limit or prevent practice determined by the board to be unsafe to the public.

B. If the board finds that the information received in a complaint or an investigation does not merit

disciplinary action against a licensee [or certificate holder] it shall take one of the following actions:

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1. Dismiss the complaint. Commentary A complaint is dismissed if there is no violation of the law or rules. 2. Issue an advisory letter to the licensee [or certificate holder]. An advisory letter is non-disciplinary and

notifies a licensee [or certificate holder] that, while there is not evidence to merit disciplinary action, the board believes that the licensee [or certificate holder] should become educated about the requirements of this [act] and board rules.

Commentary The Model Practice Act consistently advocates a broader role for licensing boards than merely punishing practitioners who violate the law. This paragraph grants a board the authority to address issues of conduct it believes shall be problematic but that do not rise to the level of a violation of law. This paragraph is pre-emptive in its approach by authorizing a board to give guidance in the spirit of public protection about a physical therapist’s practices which shall avert future violation of law or potential risk to the public. An advisory letter is instructive and not disciplinary or punitive. The advisory letter is not considered a disciplinary action and thus does not require reporting to HIPDB. Each jurisdiction will need to determine the limits of disclosure pursuant to their open records act. Other questions that might be addressed in rules include whether an advisory letter is retained in a licensee’s file, for how long, and whether it can be used in any way in future disciplinary proceedings. Optional for PT Compact Members B. If the board finds that the information received in a complaint or an investigation does not merit

disciplinary action against a licensee [or certificate holder] or compact privilege holder it shall take one of the following actions:

1. Dismiss the complaint. Commentary A complaint is dismissed if there is no violation of the law or rules. 2. Issue an advisory letter to the licensee [or certificate holder] or compact privilege holder. An advisory letter is

non-disciplinary and notifies a licensee [or certificate holder] that, while there is not evidence to merit disciplinary action, the board believes that the licensee [or certificate holder] or compact privilege holder should become educated about the requirements of this [act] and board rules.

4.06 Hearings

[No model statute language is offered under this section heading. See Commentary for additional information.] Commentary At the very minimum, there should be a statute paragraph referring to the jurisdiction’s Administrative Procedures Act. For jurisdictions that might have or feel that they have an inadequate Administrative Procedures Act, this statute section is appropriately placed at this point in the physical therapy practice act. Topics under this section may include:

• Authority to request hearings

• Authority to take disciplinary action after hearings

• Authority and procedure for notice of a formal hearing

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• The right of anyone appearing before the board to be represented by counsel

• Authority to administer the oath to witnesses

• The right of a board to waive the technical rules of evidence in hearings

• The right to file a motion for rehearing or review of a board decision within a specified time period

• The right to appeal a disciplinary action 4.07 Disciplinary Actions; Penalties

Upon proof that any grounds prescribed in [Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04], have been violated, the board shall take the following disciplinary actions singly or in combination.

Commentary Discipline serves two essential purposes: to protect the health, safety and welfare of the public, and to provide corrective action for those individuals who have been disciplined. The board needs the discretion to take appropriate disciplinary action against a licensee or certificate holder who has violated any law or rule and to determine appropriate action on a case-by-case basis based on at least the following considerations: (a) The seriousness of the infraction, (b) The detriment to the health, safety and welfare of the public, (c) Past and pending disciplinary actions relating to the licensee or certificate holder, (d) The potential for remediation. Based on these considerations, the options for action that a board may take include: 1. Issue a censure. Commentary A censure is the mildest form of discipline and shall be used where violations of the law or rules do not merit more serious disciplinary action. A censure shall include corrective actions, advice or admonitions from the board. A censure remains a part of the licensee or certificate holder’s file and is considered disciplinary action reportable to a national disciplinary data base. 2. Restrict a license [or certificate]. The board shall require a licensee [or certificate holder] to report regularly to

the board on matters related to the grounds for the restricted license [or certificate]. Commentary Use of a restricted license or certificate can also be in combination with other disciplinary actions. Boards must have authority to place restrictions on a license or certificate relating to scope or place of practice, supervision of practice, types of patients serviced and the duration of the restrictions. Probation is not one of the options for discipline in this model act since probation is simply one form of a restricted license. A restricted license, as presented in this model, is generally not intended to be used for purposes other than a disciplinary situation. For example, it should not be used to replace the lack of authority to issue a temporary license or interim permit. There are three exceptions for use of a restricted license other than for disciplinary actions: 1) with a voluntary substance abuse program, 2) with a professional re-entry after a lapse of a license for two or more renewal periods, and 3) supervised clinical practice for a foreign-educated applicants. 3. Suspend a license [or certificate] for a period prescribed by the board. Commentary Suspension is a disciplinary action that prohibits a physical therapist’s ability to practice or a physical therapist assistant’s ability to work for a specified, temporary period of time. Investigative Powers; Emergency Action;

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Hearing Officers, Article 4.05, Paragraph A.4, grants the board the authority to take emergency action temporarily suspending a license or certificate during the investigative process when potential danger to the public requires immediate action. The conditions and process for when and how this action shall be imposed should be further clarified in rules. Reinstatement requirements should always be included in rules or in a final agency order. 4. Revoke a license [or certificate]. Commentary The most severe penalty enacted by the board is the revocation of a license to practice physical therapy or a certificate allowing work as a physical therapist assistant. Licenses and certificates that are revoked should never be automatically reinstated and application for reinstatement should be necessary. The revocation order shall specify the conditions, if applicable, under which reinstatement will be considered. Rules should address the process whereby an individual shall have a revoked license or certificate restored. (See Reapplication for Licensure after Revocation in Guidelines for Rules under Article 4.07.) Optional for PT Compact Members 4. Revoke a license [or certificate] or compact privilege. 5. Refuse to issue or renew a license [or certificate]. Commentary There shall be circumstances, such as a fraudulent application, discipline imposed by another state, or current investigation, when a board shall refuse to issue or renew a license or certificate. This model language grants a board the authority to withhold licensure or certification based on serious illegal or unprofessional conduct that threatens the public safety or welfare. (See Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04.) 6. Impose a civil penalty of at least ___________ but not more than ____________. (Include minimum and

maximum dollar amounts of civil penalties.) Commentary Most jurisdictions have provisions for imposing fines or civil penalties associated with disciplinary decisions. Jurisdictions vary considerably on the use of these monetary penalties. Some jurisdictions use fines for punitive measures while others use fines to recover the cost of an investigation or disciplinary proceeding. It is recommended that the range of fines or penalties be specified either in statute or rules. The Model Practice Act, in Fees, Article 3.08, does not address fines or penalties, so these should be clarified under this section or in the rules. 7. Accept a voluntary surrendering of a license [or certificate] based on an order of consent from the board. Commentary This provision grants specific authority to accept a voluntary surrender of a license or certificate under circumstances when a licensee or certificate holder wishes to surrender the license or certificate in lieu of continuing a disciplinary proceeding. Acceptance of surrender of a license or certificate should be accompanied by findings and conclusions relating to violations of law and reported as disciplinary action. Such acceptance, in the consent order, shall jurisdiction that the voluntary surrender has the same effect as a revocation. This allows the public record to reflect the basis on which the license or certificate was surrendered. The board may decline to accept a voluntary surrender and proceed with an investigation and hearing based upon the particulars of the disciplinary situation.

4.08 Procedural Due Process

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Actions of the board shall be taken subject to the right of notice, opportunity to be heard and the right of appeal in accordance with [specify the jurisdiction] law relating to administrative law and procedure. Commentary This provision ensures the licensee or certificate holder due process of law. Most jurisdictions have separate statutory provisions related to this right that should be referred to under this paragraph.

4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief

A. It is unlawful for any person or business entity, its employees, agents or representatives not licensed as a

physical therapist under this [act] to engage in the practice of physical therapy. Any person who violates this paragraph [(A) or Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02], is guilty of [cite specific criminal sanction, e.g., class 1 misdemeanor] and subject to any other remedies specified in this [act].

Commentary This section authorizes board action against persons who are not regulated providers of physical therapy but who falsely claim to provide, or attempt to provide, physical therapy services in violation of the practice act. The possible ways a person may make such a false claim are specified in Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02. Therefore, it is essential that 4.02 be cited in this paragraph and also included in a practice act in combination with this paragraph. The specific civil sanctions may vary from jurisdiction to jurisdiction but jurisdictions generally consider a first-time violation of this statute a misdemeanor. The jurisdiction attorney general’s office, a county or a city attorney would be responsible for prosecuting unlawful practice, but these agencies may be reluctant to devote resources to pursue a violation unless injury to the public is evident. The threat of prosecution shall, in and of itself, impose an impediment to persons who would otherwise violate the provisions of this statute. Optional for PT Compact Members A. It is unlawful for any person or business entity, its employees, agents or representatives not licensed as a

physical therapist under this [act] or holding a compact privilege to engage in the practice of physical therapy. Any person who violates this paragraph [(A) or Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02], is guilty of [cite specific criminal sanction, e.g., class 1 misdemeanor] and subject to any other remedies specified in this [act].

B. The board shall investigate any person or business entity to the extent necessary to determine whether the

person or business entity is engaged in the unlawful practice of physical therapy. If an investigation indicates that a person or business entity is practicing physical therapy unlawfully, the board shall inform the person or the business entity of the alleged violation. The board may refer the matter for prosecution regardless of whether the person or business entity ceases the unlawful practice of physical therapy.

Commentary Under Investigative Powers; Emergency Action; Hearing Officers, Article 4.05, the board is authorized to investigate, issue subpoenas and compel witnesses in any case involving someone regulated under the practice act. This section extends the board’s authority of investigation to persons not regulated under the practice act. Where an investigation reveals this type of a violation, the board is empowered to inform the violator and request that he or she immediately cease and desist the unlawful behavior. The threat of the board referring the case for legal action if the violator does not stop the unlawful conduct shall be the main deterrent of this clause.

C. The board shall apply to any court of competent jurisdiction for an order enjoining any person or business

entity from committing any violation of this [act]. Injunction proceedings under this paragraph shall be in addition to, and not in lieu of, all penalties and other remedies prescribed in this [act].

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Commentary In addition to the threat of action that an investigation and subsequent cease and desist letter shall pose, the board should be empowered to pursue a cessation of illegal action through the appropriate jurisdiction authority when necessary. This is the sole intent of an injunction. Subsequent violations of the injunction are considered contempt and handled by the court thereafter. Most often an injunction is obtained through the jurisdiction attorney general’s office. An injunction does not preclude additional actions, penalties or remedies that may be imposed according to law.

D. If a person or business entity knowingly violates this [act] or board rules, fraudulently uses or permits the use

of a license [or certificate] number, or knowingly aids or requires another person to violate this [act] or board rules, the board shall impose upon such person a civil penalty of not more than [dollar amount of penalty] for the first violation and not more than [dollar amount of penalty] for each subsequent violation.

Commentary This paragraph applies to those outside the regulation of the physical therapy act, but could also include those regulated by the act: physical therapists and physical therapist assistants who participate in violations of the law. This is often the case where a physical therapist shall assist, condone or supposedly lend the authority of his or her license illegally to someone not regulated by the practice act. In such a case, in addition to the disciplinary provisions cited in Unlawful Practice; Classification; Civil Penalties; Injunctive Relief, Article 4.09, someone regulated under the act shall also be exposed to the monetary penalties stated above. This paragraph could be applied to a non-physical therapist employer or supervisor who shall exert influence on a licensee, requesting or requiring conduct in violation of the practice act. Optional for PT Compact Members D. If a person or business entity knowingly violates this [act] or board rules, fraudulently uses or permits the use

of a license [or certificate] or compact privilege number, or knowingly aids or requires another person to violate this [act] or board rules, the board shall impose upon such person a civil penalty of not more than [dollar amount of penalty] for the first violation and not more than [dollar amount of penalty] for each subsequent violation.

[Optional Statute]

E. The board shall transmit all monies it collects from civil penalties pursuant to this [act] to the [specify the

disposition of these funds if different from other funds]. Commentary A jurisdiction shall make the determination that money received from civil penalties goes into the physical therapy fund or the operating funds of the board or whether the money goes into the general fund of the jurisdiction. Depositing civil penalties into the general fund is the customary procedure that provides a barrier against the temptation of using civil penalties to increase the funds of the board.

4.10. Reporting Violations; Immunity

A. A person, including but not limited to a licensee [or certificate holder], corporation, insurance company,

healthcare organization or healthcare facility and jurisdiction or local governmental agencies, shall report to the board any conviction or determination by an agency or court that a licensee [or certificate holder] has committed an act that constitutes a violation of [Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04].

Commentary This paragraph provides board authority to directly solicit and require reporting by any individual or organization taking any action against a licensee, certificate holder or applicant related to Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04. This reporting requirement requires a formal conviction,

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determination or finding against the regulated individual so as to eliminate the possibility of imposing penalties for unconfirmed violations. This language also requires a licensee to report his or her own legal entanglements that resulted in conviction, determination or finding consistent with the violations contained in Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04. When jurisdictions adopt these reporting standards they should communicate the reportable grounds to all agencies who shall have taken action against regulated individuals to enhance their understanding and cooperation with the reporting mandates of this section.

B. A person is immune from civil liability, whether direct or derivative, for reporting such facts as set forth in A

above to the board in good faith and participating in the board’s investigation and subsequent disciplinary process, if applicable.

Commentary This paragraph is a necessary companion to Paragraph A, above, to protect an individual who reports information or findings to the board as long as the reporting is in good faith. A person reporting a false or bad faith claim of “suspected” conduct would not be granted immunity from civil liability.

C. The board shall not disclose the identity of a person who provides information unless such information is

essential to proceedings conducted pursuant to [Investigative Powers; Emergency Action; Hearing Officers and Hearings, Articles 4.05 and 4.06], or unless required by a court of law.

Commentary This paragraph gives the board authority to protect the identity of someone providing information that shall be used in a board decision. There are various disclosure laws that shall govern what a board shall and shall not disclose. Those laws generally focus on the right of an accused to face his or her accuser if an action comes to the point of formal discipline. Board legal counsel will be able to advise boards in these matters.

4.11. Substance Abuse Recovery Program

A. The board shall permit a licensee [or certificate holder] to actively participate in a board-approved substance

abuse recovery program if: 1. The board has evidence that the licensee [or certificate holder] is impaired. 2. The licensee [or certificate holder] enters into a written agreement with the board for a restricted

license [or certificate] and complies with all the terms of the agreement, including making satisfactory progress in the program and adhering to any limitations on his or her practice or employment imposed by the board to protect the public. Failure to enter into such an agreement shall activate an immediate investigation and disciplinary proceeding by the board.

3. As part of the agreement established between the licensee [or certificate holder] and the board, the licensee [or certificate holder] signs a waiver allowing the substance abuse program to release information to the board if the licensee [or certificate holder] does not comply with the requirements of this section or is unable to practice or work with reasonable skill or safety.

Commentary This model language is placed here as opposed to Grounds for Denial of a License[ and Certificate]; Disciplinary Action, Article 4.04 because entry and participation in a substance abuse recovery program shall be initiated in a way other than through the formal disciplinary process. A person regulated by this statute could (and should) report a substance abuse problem to the board. This self-reporting could be handled through voluntary participation in a recovery program monitored by the board in lieu of discipline. Successful recovery from substance abuse provides a benefit to society in general, to the profession’s position of public trust and to the impaired practitioner. After a sufficient period of supervision and recovery, a physical therapist or physical therapist assistant who is otherwise free from actionable activities under the disciplinary provisions of a practice act shall be able to return to or maintain a productive career.

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This section does not preclude disciplinary action against an impaired physical therapist or physical therapist assistant who declines to participate in voluntary recovery or who violates the conditions of an approved recovery program (see Paragraph 22 under Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04). This section provides two options: the licensee or certificate holder shall either participate in the substance abuse program or face disciplinary proceedings. The public will be further protected by Paragraph 2 that requires the licensee or certificate holder to adhere to any limitations imposed by the board as a condition of participation in a recovery program. This model language does not provide for confidential participation in a substance abuse recovery program. Entering into a written agreement requiring participation in such a program constitutes an official action by the board and would be part of the public record. Jurisdictions wishing to adopt a confidential program should seek local legal counsel.

4.12. Rights of Consumers

A. The public shall have access to the following information:

1. A list of licensees [and certificate holders] that includes license [or certificate] number, date of license [or certificate] expiration, status of license [or certificate], and employment information. 2. A list of final adverse actions taken by the board. 3. The address, website, email and phone number of the board.

Commentary This entire section contains clauses that have historically been scattered throughout various sections of practice acts. All of them have a common interest in consumer advocacy. A practice act, by its very nature, is focused on public protection, so this is a more natural grouping of similar topics giving greater focus to the board’s role in advocating for the physical therapy patient. Optional for PT Compact Members A. The public shall have access to the following information:

1. A list of licensees [and certificate holders] that includes license [or certificate] number, date of license [or certificate] expiration and status of license [or certificate]. 2. A list of final adverse actions taken by the board. 3. A list of compact privilege holders

3. The address, website, email and phone number of the board.

B. Each licensee [and certificate holder] shall display a copy of his or her license [or certificate] in a location

accessible to public view or produce a copy immediately upon request. Commentary Patients need to know the names and qualifications of the persons providing their care. Posting licenses and certificates ensures that the public can identify the name and qualifications of the provider as well as their valid license or certificate status. In home health or community settings where the posting of a license shall not be feasible, this language allows the provider to produce a licensure upon request. As most jurisdictions have licensure information posted electronically, licensees [and certificate holders] may produce an electronic copy or verification of licensure upon demand. Other identification such as nametags with titles is discretionary according to the facility or agency standards or requirements, but when worn these identifiers should also include appropriate title and letter designations. Optional for PT Compact Members Each licensee [and certificate holder] and compact privilege shall display a copy of his or her license [or

certificate] in a location accessible to public view or produce a copy immediately upon request.

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C. Each licensee [and certificate holder] shall provide the public with information on how to file a complaint with

the board against a licensee [or certificate holder]. Commentary This section places the responsibility for consumer education about the complaint process upon the individual physical therapist and physical therapist assistant. The board is likewise directed to educate the public about the complaint process under Powers and Duties of the Board, Article 2.02, paragraph 13. Compliance could occur via posting of a notice containing the board address and telephone number with a brief statement of the right of consumers to file complaints. Optional for PT Compact Members Each licensee [and certificate holder] and compact privilege holder shall provide the public with information on

how to file a complaint with the board against a licensee [or certificate holder] or compact privilege holder.

D. Any person may submit a complaint regarding any licensee, [certificate holder] or any other person

potentially in violation of this [act]. Confidentiality shall be maintained subject to law. Commentary Most jurisdictions allow a confidential complaint, but not an anonymous complaint. This means that the name of the complainant will be held confidential as long as possible or as the law requires. With any complaint due process shall eventually require disclosure of the complainant in order for a licensee/certificate holder to fully defend their actions. The purpose of this paragraph is to remove barriers to the public’s filing of complaints against those regulated by practice acts or others who shall be in violation of a practice act.

E. The home address, email address and home telephone numbers of physical therapists and physical therapist

assistants are not public records and shall be kept confidential by the board unless they are the only addresses and telephone numbers of record.

Commentary Some information required by a board and used in regulation of licensees is not necessarily public information. This paragraph clarifies which information is confidential and for board use only.

F. A patient/client has freedom of choice in selection of services and products. Commentary The rights of consumers of healthcare services include the right to know and the right to choose. In order for consumers to be able to “choose” effectively, there is an obligation on the part of providers to furnish accurate and sufficient information so that consumers can make informed choices. This model language emphasizes the responsibility that all physical therapists have to inform their patients about freedom of choice in all aspects of services being provided. The patient should know that they may raise questions about procedures or even refuse treatment. These principles should apply at the time products or equipment is recommended. They shall also apply when a physical therapist recommends or refers a patient to a physician and should offer the patient at least two or three options, answering questions fairly about each physician they are recommending to the patient.

G. Information relating to the physical therapist-patient/client relationship is confidential and shall not be

communicated to a third party who is not involved in that patient’s/client’s care without the written

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authorization of the patient/client. The physical therapist-patient/client privilege does not extend to cases in which the physical therapist has a duty to report or disclose information as required by law.

H. Information relating to the physical therapist assistant-patient/client relationship is confidential and shall not be communicated to a third party who is not involved in that patient’s/client’s care without the written authorization of the patient/client. The physical therapist assistant-patient/client privilege does not extend to cases in which the physical therapist assistant has a duty to report or disclose information as required by law.

Commentary This model language is similar to language used by other healthcare disciplines. Written authorization allows information to be communicated to a referring physician, insurance company and perhaps other family members. But the written authorization should be specific as to what information can be released. The last two sentences clarify that this privilege does not extend to withholding information that is required by law to be reported to the board concerning an investigation. Patient record confidentiality is further addressed in Paragraph I that follows. Boards have a further obligation regarding confidentiality of patient records when obtained by subpoena.

I. The board shall keep all information relating to the receipt and investigation of complaints filed against

licensees [or certificate holders] confidential until the information is disclosed in the course of the investigation or any subsequent proceeding or until disclosure is required by law. Patient/client records, including clinical records, files, any other report or oral statement relating to diagnostic findings or treatment of patients/clients, any information from which a patient/client or their family might be identified, or information received and records or reports kept by the board as a result of an investigation made pursuant to this [act] shall not be available to the public and shall be kept confidential by the board.

Commentary Disclosure of information related to a complaint investigation prior to official action or ruling of the board could disrupt the disciplinary process and have a detrimental and possibly irreversible influence on both the complainant and the individual being investigated. Once final disciplinary action is taken, further information becomes public knowledge and can be disclosed. The board has further reporting requirements under Board of Physical Therapy, Article 2.01, and Powers and Duties of the Board, Article 2.02, that relate to reporting to a national database and the publication of final disciplinary actions.

Patient/client records should be afforded a high level of protection. If patient records are obtained in an investigation and retained in an investigative file they remain confidential and are not accessible as public records. Optional for PT Compact Members Except as directed by the physical therapy compact, the board shall keep all information relating to the receipt and investigation of complaints filed against licensees [or certificate holders] or compact privilege holders confidential until the information is disclosed in the course of the investigation or any subsequent proceeding or until disclosure is required by law. Patient records, including clinical records, files, any other report or oral statement relating to diagnostic findings or treatment of patients, any information from which a patient or his family might be identified, or information received and records or reports kept by the board as a result of an investigation made pursuant to this [act] shall not be available to the public and shall be kept confidential by the board.

Guidelines for Rules 2

Guidelines for Rules

Introduction

The Model Practice Act for Physical Therapy does not include recommended model language for administrative rules. When jurisdictions make regulatory changes to their practice acts using language from this model act, conforming rules will be required to complete the regulatory design. Individual jurisdictions are traditionally responsible for writing rules to accompany the statutory language adopted by the legislature. One of the driving philosophies behind creating this Model Practice Act was to keep the statutory language as concise as possible and free of procedural activity or description. Rules are the place where procedural descriptions and processes are addressed. There will need to be some structure, policy and operational definitions to help make the administrative rules a functional and complementary part of a practice act. Some jurisdictions have relatively large statutory sections and small rule sections to their practice acts. Others are just the opposite. The Model Practice Act, in keeping with statutory recommendations, is concise and anticipates the “smaller statutes/larger rules” structure. To provide assistance to jurisdictions as they work to revise practice acts, Guidelines for Rules examines each of the four Articles of the model practice act language and lists several conforming rules that should be developed. This is by no means an exhaustive list of potential rules. It follows the same order as the Articles, so it should be easy to coordinate the two. Regardless of the organizational structure of the rules adopted by each jurisdiction, there should be a system to facilitate correlation of the rules with the corresponding statutes. The use of “board policies” is a way to organize procedural activities that are strictly internal and operational and have no effect on those regulated by the practice act or by any other external group or individual. An example might be a board policy on office supply and equipment purchases and the authorization for such acquisitions. This should not be confused with written board “positions” or “opinions” that serve to interpret or give guidance on how the board interprets the statutes or rules. Boards should not use policies as a means to avoid the admittedly more difficult task of changing a statute or adopting rules. If a topic or issue of concern directly affects those licensed or regulated under a practice act, and if it is not a matter of internal board or office procedure, it should be addressed through rules if not in the statutes.

ARTICLE 1: GENERAL PROVISIONS 1.01 Legislative Intent Jurisdictions should to add a statement of purpose or philosophy about administrative rules and cite the specific statute that grants authority to promulgate such rules. The authorizing statute in the model act is in Powers and Duties of the Board, Article 2.02. Here is an example of an opening paragraph loosely adapted from Hawaii’s rules section of a previous version of their practice act: “The [name of jurisdiction] Board of Physical Therapy shall adopt rules pursuant to [citing the specific authority granted by statute in Article 2.02 Board of Physical Therapy to effectuate this [act] and its licensing laws, and to carry out its purpose of protecting the health, safety and welfare of consumers of services provided by or under the direction of a physical therapist licensed under this act. The enumeration of specific matters that shall properly be made the subject of rules shall not be construed to limit the board’s broad general power to make all rules necessary to fully effectuate the purpose of this chapter.”

1.02 Definitions Physiotherapy/Physiotherapist Definition There may be a need to have further operational definitions of terms not addressed in the Definitions section of the statutes. Statutory construction varies from jurisdiction to jurisdiction and frequently the definition of terms used in statute must be contained in the definition section, whereas definition of terms used in administrative

Guidelines for Rules 3

rules are contained in the rules definition section. The following definition of the terms “physiotherapy,” “physiotherapist,” and “physio” could be contained in either statute or rules: “Physiotherapy,” “physiotherapist,” and “physio” are the international terms for physical therapy and physical therapist respectively. These terms are not used by physical therapists in the United States, but they are protected titles and terminology under [cite the specific Use of Titles statute for protected terms] and, therefore, are not to be used in any manner by any other person or organization that could mislead consumers of healthcare and induce the false belief that physical therapy or physiotherapy is being provided by any person not licensed under this [act].

Practice of physical therapy Jurisdictions should consider adopting rules addressing the scope of certain procedures authorized under the practice act. For example, rules might define the scope of wound debridement to include sharp, enzymatic, selective, and pharmacological wound debridement. Other procedures that might be addressed in rules are whether physical therapists can use certain machines and perform procedures such as electroneuromyography, needle EMG, dry needling, etc. that are not specifically addressed in the statutory language. This provides licensees with guidance to their proper scope while providing jurisdictions with the flexibility to evaluate and determine whether certain procedures/machines are properly within the scope of physical therapy.

ARTICLE 2: BOARD OF PHYSICAL THERAPY 2.01 Board of Physical Therapy Board Appointments Rules should be developed outlining the process of appointment to the board. The nomination process varies from jurisdiction to jurisdiction. In some jurisdictions, the statute or rules specify that appointments to the board must be made from a list supplied to the governor from the APTA state chapter. In other jurisdictions the board may use its own nomination process where a mail ballot determines the top five recommendations to pass on to the governor. A suggestion is to include in rules the following: “The governor shall appoint any qualified person to the Board of Physical Therapy meeting the requirements outlined in [citing statute area] and in [citing rules outlining additional qualifications] herein. A list of qualified candidates shall be provided to the governor by the Physical Therapy Board or by any other interested group or individal. Any qualified person may also submit his or her own name to the governor for consideration.” As discussed earlier, rules shall also include recommendations to the governor to consider geographic distribution, gender, ethnicity, diversity, and practice settings in the appointment process. (See rationale under Board of Physical Therapy Article 2.01.) The use of the phrase “as prescribed by law,” usually addresses other statutory requirements for appointment by the governor, such as senate confirmation of all appointments. Adopting a rule requesting that the governor consider geographic distribution, gender, ethnicity and practice settings in the selection process will have more of an influence on the organizations or individuals recommending individuals for appointment than on the governor when making the appointment.

Terms of Board Appointment Rules should be developed delineating specific dates, or years of appointment, and the dates of staggered or overlapped terms of office. This facilitates smoother transitions so that only one or two members of a board are appointed in any year to avoid disruptions caused by multiple appointments in a single year.

Removal of Board Members The entire process for removal of a board member for misconduct should be outlined in rules. This should include the specific grounds for removal, the options for correction of a problem prior to removal, and the procedures used to request removal of a board member by the governor.

Expense Reimbursement

Guidelines for Rules 4

Rules should include guidelines for reimbursement of board members’ expenses, per diem, travel, etc., and reference any other applicable regulations or operational procedures addressing reimbursement.

2.02 Powers and Duties of the Board Rule Development The process for administrative rule development should be detailed. This includes proper notice, public hearings and final approval mechanisms of changes to, or adoption of, any existing or proposed rule based upon each jurisdiction’s specific Administrative Procedures Act or authorizing statute.

Official Board Records The maintenance of official records, confidentiality of certain records and of other discussion, and distribution of board minutes are necessary inclusions in rules, as is automatic distribution of minutes and to whom they should be sent.

Assessing Continuing Competence Specific mechanisms for assessing continuing competence shall be included in this section or in License [or Certificate] Renewal, Article 3.05.

Election of Board Officers The process for the election of board officers should be detailed in rules. This includes eligibility, the dates of elections and any other restrictions, e.g., concurrent terms in the same office.

Orientation The process for orientation of new board members should be developed and outlined in rules. Proper orientation and training for board members should be a high priority of every licensing board.

Reporting to appropriate authorities In order to protect the public, the Board should report findings of unlawful conduct that shall be in violation of other state or federal laws. In this section the board should outline the types of violations (e.g. criminal conduct) that will be referred and to which agencies. The Board should determine at what point in the disciplinary process the information should be referred to other agencies.

ARTICLE 3: EXAMINATION AND LICENSURE 3.01 Examination Rules specifying the examination process, the procedure for applicants or licensees who subvert or undermine the examination process (including due process), the reporting of scores, etc., should be developed. The following language should be placed in rules to describe the kinds of behaviors that the Board considers to be subverting or undermining the integrity of the examination or examination process: “Examples of conduct that subverts or undermines the examination or examination process shall include, without limitation, utilizing in any manner of communication, including copying, duplication, written notes or any electronic medium, recalled or memorized examination questions from or with any person or entity, failing to comply with all test center security procedures, attempting to communicate with other examinees during the test, or copying and sharing examination questions or portions of questions. Any such violation shall be recorded in the official records of the board. Board action shall include the following: 1. Disqualify the applicant, permanently or for a specified period of time, from eligibility for the examination. 2. Disqualify the applicant who has failed the examination from eligibility to retake the examination. 3. Disqualify the applicant, permanently or for a specific period of time, from eligibility for licensure. 4. Revoke, suspend or impose probationary conditions on any license [or certificate] issued to such applicant.”

Guidelines for Rules 5

Failing the Examination Rules may specify the number of times the applicant can re-take the national examination. If limitations are specified, any requirements for reapplication, submitting additional fees, or other requirements for retaking the examination. It should be specified in rules that if an applicant completely a supervised clinical experience prior to attempting the national examination and subsequently fails the national examination the assumption of competence is deemed void and no approval for continued clinical practice should be extended, even under supervision, until competence is demonstrated by successful passing of the national examination.

3.02 Qualifications for Licensure [and Certification] Qualifications for licensures describe the basic preparation necessary to "qualify" for practice or work in physical therapy, i.e. graduation from an appropriate school, passage of an entry examination, completion of the application process. These qualifications are the same from jurisdiction to jurisdiction. In addition to these basic qualifications, many jurisdictions establish additional requirements that applicants must fulfill prior to licensure or certification, i.e. passage of a jurisprudence exam, submission of letters of recommendation, passage of English proficiency examinations. Requirements for licensure differ from jurisdiction to jurisdiction and need to be detailed in rule.

Application Procedures All procedures for making application for original licensure or certification, for licensure of physical therapist graduates of programs from non-approved accredited agencies, for endorsement, for renewal, for re-licensure after a lapse, etc., should be included in detail within rules. This includes reference to various application forms (application forms themselves should not be included in rules), various application fees, and any other supporting documentation required under the application procedures. Some jurisdictions require that the specific questions asked of applicants for original licensure/certification or renewal must be delineated in rules.

Disciplinary Database A rule should be developed requiring the board to check the Federation of State Boards of Physical Therapy’s database for any previous disciplinary actions taken against any applicant.A score transfer report from the Federation would be an acceptable check of an applicant’s license.This should occur with anyone applying for licensure by endorsement, or for certification, where the applicant was previously regulated in another state. This should also include a requirement that the applicant report all previous jurisdictions of licensure or certification, not just the one of previous residence.

Credential Review Agencies A list of board-approved educational credential review agencies should be included in rules, and with a description of the process by which an agency becomes board-approved A list of the kinds of information that must be submitted to the credential review agency should be noted. The jurisdiction’s requirement to use the applicable FSBPT Coursework Tool for Foreign Educated Physical Therapists and/or FSBPT Coursework Tool for Foreign Educated Physical Therapist Assistants could also be specified in rules.

English Proficiency Examinations Rules should specify the exact English proficiency examinations and scores required for licensure.

Waiving Requirements for Applicants Educated at a School that has not been Accredited by an Agency Aproved by the Board Under Qualifications for Licensure [and Certification], Article 3.02, when an applicant educated outside of the United States graduates but from a program accredited by an agency approved by the board then several of the requirements under this section may be waived by the board. Rules should be formulated that address whether or not there are instances when these requirements should be waived.

Guidelines for Rules 6

Rule language should contain, at minimum, the requirement that any credentials evaluation 1) utilize the appropriate edition of the FSBPT Coursework Tool for Foreign Educated Physical Therapists or Physical Therapist Assistants in order to determine educational equivalency at the date of graduation; 2) require that a physical therapist trained in credential reviewing participates in the evaluation; and 3) require that quality assurance standards be met by the credentials review agency. All procedures for making application for original licensure or certification, for licensure of physical therapists or physical therapist assistants educated at a school that has not been accredited by an agency approved by the board, for endorsement, for renewal, for re-licensure after a lapse, etc., should be included in detail within rules. This includes reference to various application forms (application forms themselves should not be included in rules), various application fees, and any other supporting documentation required under the application procedures. Some jurisdictions require that the specific questions asked of applicants for original licensure/certification or renewal must be delineated in rules.

3.03 Licensure [and Certification] by Endorsement Rules should clearly state the process for obtaining endorsement. Any requirements beyond the completed application process, proof of graduation and score transfers should be clarified, such as verification of licensure in good standing. Rules should be written for specifically and separately for applicants that have/have not been educated at a school accredited by a board approved agency. These requirements might include submission of verification of a current license in the state of previous residency, affidavit of previous practice within three years, absence of pending or current disciplinary action or restricted license, continuing education history if mandatory for licensing requirements, specific continuing education required such as in HIV or MRSA continuing education, or the requirement to take a jurisprudence examination. 3.04 Exemptions from Licensure [or Certification] Declared State or National Emergencies Jurisdictions should consider including in rules the discretion to modify requirements for licensure renewal and endorsement under declared county, state, and/or national emergency situations. For example, in situations such as natural disasters, armed forces reserve call-ups or overseas military duty, the board should be granted flexibility in the area of license or certificate issuance or renewal. Jurisdictions might want to seek an executive order to authorize licensure renewal extensions in order to prevent unlawful practice with a lapsed license for licensees impacted by state, national, or local disasters.

Professional Education Registering A rule could be included for “registering” physical therapists or physical therapist assistants who provide or participate in continuing education courses in a state and who are not licensed in that state. When clinical education courses involve actual patient contact, or when participants practice procedures upon each other, it shall be desirable to enact a registration process to ensure that the exemption granted to instructors and participants in these continuing education offerings is specifically restricted to short-term courses never extending past 60 days. Physical therapists or physical therapist assistants traveling with bona fide sports teams or performing arts organizations would also need an exemption with a time limit, such as the 60 days noted previously. If this time limit were exceeded, licensure would be required. The board shall choose to only require registration for those courses exceeding, for example, 30 days.

3.05 License [or Certificate] Renewal Rules should address licensure and certificate renewal in a timely manner and should specify the information required for renewal. It is appropriate here to include the requirement and responsibility of those regulated to provide the board with current business or other mailing addresses. Rules should state that failure to have a current address on file with the board is not sufficient reason for the licensee’s or certificate holder’s failure to renew in a timely manner.

Guidelines for Rules 7

Continuing Competence Criteria that the board uses for determining continuing competence requirements associated with licensure or certification renewal should be clearly outlined in rules. Refer to discussion under Powers and Duties of the Board, Article 2.02.

3.06 Changes of Name, Address or Telephone Number It should be stated clearly in rules that all licensees and certificate holders are responsible for keeping the board advised of their current home and practice addresses telephone numbers, and electronic contact information, if available. Failure to receive a renewal notification should not constitute an excuse for failure to renew on time. It should be further specified that failure to meet the renewal timeframe constitutes practicing without a license or certificate and will be treated as such under authority of Unlawful Practice; Classification; Civil Penalties; Injunctive Relief, Article 4.09.

3.07 Reinstatement of License [or Certificate] Rules should address the process for reinstatement of lapsed licenses or certificates.

Professional Reentry An appropriate use of a restricted license would be for persons reentering the profession after an absence from practice or work in the profession. Rules shall be needed to address the specific requirements for reentering the profession in such circumstances.

Restricted License or Certificate The model statute language specifies the existence of restricted licenses and certificates. Rules should be developed providing further clarification to the processes and procedures for such restrictions, e.g., criteria stating under what circumstances and for whom restricted licenses or certificates can be imposed; the procedures for imposing restrictions, for determining the extent of the restrictions, and for lifting the restrictions. For example, it is important to include a statement in rules to the effect that, in addition to disciplinary actions, a restricted license can also be used with physical therapists or physical therapist assistants in professional reentry programs or physical therapists or physical therapist assistants in voluntary substance abuse programs. Where a restricted license is imposed as part of discipline, reinstatement of an unrestricted license should not be automatic but should always be associated with an appearance or re-hearing of the licensee or certificate holder before the board. Any supervision requirements for someone under restriction should be addressed in rules.

3.08 Fees A section of rules should list all fees and types of fees that are imposed by the board upon persons regulated by this [act]. Penalties for late or lapsed licenses or certificates are also “fees” and should be included in the same area as other fees. Rules should state that there will be additional testing fees associated with computerized testing (fees paid directly to a testing center for use of its facility, equipment, etc.) that are not part of the board fees, but are acknowledged and authorized.

ARTICLE 4: REGULATION OF PHYSICAL THERAPY 4.01 Ethics in the Physical Therapy Profession Recognized Standards of Ethics Ethics in the Physical Therapy Profession, Article 4.01 is the requirement to adhere to the recognized standards of ethics of the physical therapy profession. An operational definition of the standards of ethics of the profession is strongly suggested. It could be included either in this area of rules or later under rules associated with Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04. Jurisdictions may choose to author their own code of ethics or use the American Physical Therapy Association’s. An example using APTA’s would be as follows:

Guidelines for Rules 8

“The recognized standards of ethics” of the physical therapy profession shall be the American Physical Therapy Association (APTA) Code of Ethics and the accompanying Guide for Professional Conduct. “The recognized standards of ethical conduct” for the physical therapist assistant shall be the American Physical Therapy Association (APTA) Standards of Ethical Conduct for the Physical Therapist Assistant and the accompanying Guide for Professional Conduct for the Physical Therapist Assistant. Jurisdictions should review their Administrative Procedures Act on how to properly incorporate documents by reference or consider itemizing ethical standards in rules.

4.02 Use of Titles and Terms; Restrictions; Classification of Violation “RPT,” “LPT,” and “LPTA” Prohibited The only rule suggested under Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02, is a rule prohibiting the use of the letters “RPT” and “LPT” by licensed physical therapists. Even though these are “protected terms” under the restricted use of titles, they are archaic terms and don’t reflect the level of professionalism of contemporary physical therapy practitioners. An example of rule language would be: “RPT” and “LPT” are archaic letter designations for the physical therapist. While they remain protected designations under Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02, they are not to be used by physical therapists or any other persons. The proper letter designation of a licensed physical therapist is “PT.” Improper use of this designation shall result in disciplinary action. “LPTA” is an archaic letter designation for the physical therapist assistants. While they remain protected designations under Use of Titles and Terms; Restrictions; Classification of Violation, Article 4.02, they are not to be used by physical therapist assistants or any other persons. The proper letter designation of a licensed physical therapist assistant is “PTA.” Improper use of this designation shall result in disciplinary action.

4.03 Patient Care Management This section of rules should contain any conditions or specifications relating to patient care management within the specific jurisdiction, including qualifications and/or conditions of supervisions of other personnel including communication and documentation requirements.

4.05 Investigative Powers; Emergency Action; Hearing Officers Receiving Complaints Rules should specify how complaints against licensees or certificate holders can be submitted. A complaint form could be used, whether completed by the complainant or by board staff if telephone or electronic complaints are permitted. Overly burdensome requirements place further obstacles and extends the response time in dealing with consumer complaints. Rules should include what information must be included in a complaint (e.g., name of physical therapist, date of service, allegation, etc.). The rule should also include timeframes for board processing of complaints to provide assurance to complainants that all complaints are taken seriously and processed accordingly.

4.07 Disciplinary Actions; Penalties Administrative Procedures Act In addition to the practice act and other laws, all jurisdictions have an Administrative Procedures Act (APA), or similar law, that governs the processes by which government agencies take action against individuals regulated by the jurisdiction. Jurisdictions should consult their APA prior to developing rules.

Censure Rules should be developed that address the scope, duration and procedures for the issuance of a censure.

Guidelines for Rules 9

Restricted License [or Certificate] Rules should be developed giving further clarification to the processes and procedures for such restrictions, e.g., criteria stating under what circumstances and for whom restricted licenses or certificates could be imposed; the procedures for imposing restrictions, for determining the extent of the restrictions, and for lifting the restrictions. A restricted license can also be used with for re-entry or in voluntary substance abuse programs. Where a restricted license is imposed as part of formal discipline, reinstatement of an unrestricted license should not be automatic, but should always be associated with an appearance or rehearing of the licensee or certificate holder before the board. The supervision required of a licensee under such restriction should be addressed in rules.

Reapplication for License [or Certificate] after Revocation Rules should include the process for reapplication for license or certificate after revocation. A license is usually revoked with no mention of timeframe for potential reapplication. It is appropriate to consider establishing an amount of time, such as one year, which must pass before a person can reapply for licensure and what requirements will apply.

Voluntary Surrender of a License [or Certificate] Rules should require that acceptance of surrender of a license or certificate should be accompanied by admissions or findings of fact and conclusions of law relating to violations of law and reported as disciplinary action. Rules should reflect that a voluntary surrender has the full force and effect of a revocation for reporting purposes.

3.11 Substance Abuse Recovery Program Voluntary Substance Abuse Program Rules should outline the process for a licensee who is allowed by the board to participate in a voluntary substance abuse program. Criteria for board authorization of substance abuse programs should be established as well as reporting requirements for licensees who participate in a substance abuse program.

7th Edition MPA Appendix A 1

Appendix A: Model Statute Language Changes The following are the changes in the model statute language made from the Sixth to the Seventh Edition of the Model Practice Act. The following formatting allows for review of all substantive changes made; most formatting changes or simple edits are not included here. Strike-through is deleted language from the Sixth Edition. Underline is new language in the Seventh Edition. The Model Statutes with Commentary section provides explanations for these changes.

Physical Therapy Practice Act

[Include proper numerical statute reference, e.g., Chapter # and/or Title #]

Article 1: General Provisions 1.01 Legislative Intent This [act] is enacted for the purpose of protecting the public health, safety, and welfare, and provides for jurisdiction administrative control, supervision, licensure, and regulation of the practice of physical therapy. It is the legislature’s intent that only individuals who meet and maintain prescribed standards of competence and conduct may engage in the practice of physical therapy as authorized by this [act]. This [act] shall be liberally construed to promote the public interest and to accomplish the purpose stated herein.

1.02 Definitions

As specifically used in this [act], the following terms have the meanings set forth below, unless the context requires otherwise.

1. “Board” means the [specify the jurisdiction] board of physical therapy.

2. “Competence” is the application of knowledge, skills, and behaviors required to function effectively, safely, ethically and legally within the context of the patient/client’s’s role and environment.

3. “Consultation by telehealth” means that a physical therapist seeking assistance from, or renderings professional or expert opinion or advice to another physical therapist or professional healthcare provider via electronic communications, telehealth, or in-person computer technology from a distant location.

4. “Continuing competence” is the lifelong process of maintaining and documenting competence through ongoing self-assessment, development, and implementation of a personal learning plan, and subsequent reassessment.

5. “Electronic Communications” means the science and technology of communication (the process of exchanging information) over any distance by electronic transmission of impulses including activities that involve using electronic communications to store, organize, send, retrieve, and/or convey information.

6. “Examination” means a national examination approved by the board for the licensure of a physical therapist or the [certification/licensure] of a physical therapist assistant.

7. “Jurisdiction of the United States” means any state, the District of Columbia, the Commonwealth of Puerto Rico, or any American territory.

8. “Nexus to practice” means the criminal act of the applicant or licensee [certificant] posing a risk to the public’s welfare and safety relative to the practice of physical therapy.

7th Edition MPA Appendix A 2

9. “Onsite supervision” means supervision provided by a physical therapist who is continuously onsite and present in the department or facility where services are provided. The supervising therapist is immediately available to the person being supervised and maintains continued involvement in the necessary aspects of patient/client care.

10. “Patient/client” means any individual receiving physical therapy from a licensee [or certificate holder] under this Act.

11. “Physical therapist assistant” means a person who is [certified/licensed] pursuant to this [act] and who assists the physical therapist in selected components of the physical therapy treatment intervention.

12. “Physical therapist assistant-patient/client relationship” means the formal or inferred relationship entered into by mutual consent between a licensed [certified] physical therapist assistant and a patient/client or their legally authorized representative established once the physical therapist assistant assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged or treatment is formally transferred to another practitioner or as further defined by rule.

13. “Physical therapist” means a person who is a licensed healthcare practitioner pursuant to this [act] to

practice physical therapy. The terms “physiotherapist” or “physio” shall be synonymous with “physical therapist” pursuant to this [act].

14. “Physical therapist-patient/client relationship” means the formal or inferred relationship entered into by mutual consent between a licensed physical therapist and a patient/client or their legally authorized representative established once the physical therapist assumes or undertakes the care or treatment of a patient/client and continues until either the patient/client is discharged or treatment is formally transferred to another healthcare practitioner or as further defined by rule.

15. “Physical therapy” means the care and services provided in-person or via telehealth by or under the

direction and supervision of a physical therapist who is licensed pursuant to this [act]. The term “physiotherapy” shall be synonymous with “physical therapy” pursuant to this [act].

16. “Physical therapy aide” means a person trained by or under the direction of a physical therapist who performs designated and supervised routine tasks related to physical therapy services.

17. “Practice of physical therapy” means: a. Examining, evaluating and testing patients/clients with mechanical, physiological and developmental impairments, functional limitations, and disabilities or other health and movement-related conditions in order to determine a diagnosis, prognosis and plan of treatment intervention, and to assess the ongoing effects of intervention. b. Alleviating impairments, functional limitations and disabilities; promoting health; and preventing disease by designing, implementing and modifying treatment interventions that may include, but are not limited to: therapeutic exercise;, needle insertion; patient-related instruction; therapeutic massage; airway clearance techniques; integumentary protection and repair techniques; debridement and wound care; physical agents or modalities; mechanical and electrotherapeutic modalities; manual therapy including soft tissue and joint mobilization/manipulation;, therapeutic massage, prescription, application and, as appropriate, fabrication of assistive, adaptive, orthotic, prosthetic, protective and supportive devices and equipment, airway clearance techniques, integumentary protection and repair techniques, debridement and wound care, physical agents or modalities, mechanical and electrotherapeutic modalities, and patient-related instruction. Functional training in self-care and in home, community or work integration or reintegration,; as well as prescription application and, as appropriate, fabrication of assistive, adaptive, orthotic, prosthetic, protective and supportive devices and equipment.

7th Edition MPA Appendix A 3

c. Reducing the risk of injury, impairment, functional limitation, and disability, including performance of participation-focused physical examinations and the promotion and maintenance of fitness, health, and wellness in populations of all ages. d. Referring a patient/client to healthcare providers and facilities for services and testing to inform the physical therapist plan of care. De. Engaging in administration, consultation, education, and research.

18. “Restricted [certificate/license]” for a physical therapist assistant means a [certificate/license] on patientwhich the board has placed any restrictions and/or condition as to scope of work, place of work, duration of certified or licensed status, or type or condition of patient/client to whom the certificate holder or licensee may provide services.

19. “Restricted license” for a physical therapist means a license on which the board has placed any restrictions and/or conditions as to scope of practice, place of practice, supervision of practice, duration of licensed status, or type or condition of individual to whom the licensee may provide services.

20. Supervision” means the process by which a physical therapist oversees and directs safe and effective delivery of patient care through appropriate verbal, written, or electronic communication. This may be accomplished with the physical therapist located onsite or remotely as deemed appropriate based on the patient/client needs.

21. “Telehealth” is the use of electronic communications to provide and deliver a host of health-related information and healthcare services, including, but not limited to physical therapy related information and services, over large and small distances. Telehealth encompasses a variety of healthcare and health promotion activities, including, but not limited to, education, advice, reminders, interventions, and monitoring of interventions.

22. “Testing” means standard methods and techniques used to gather data about the patient/client, including but not limited to imaging, electrodiagnostic and electrophysiologic tests and measures.

Article 2: Board of Physical Therapy

The Board shall have all of the duties, powers, and authority specifically granted by or necessary for the enforcement of this Act, as well as such other duties, powers, and authority as it may be granted from time to time by applicable law.

2.01 Board of Physical Therapy

A. The board of physical therapy shall consist of [seven] members appointed by the Ggovernor. [Four] members

shall be physical therapists who are residents of this jurisdiction, possess unrestricted licenses to practice physical therapy in this jurisdiction and have been practicing in this jurisdiction for no less than five years before their appointments. [One] member shall be a physical therapist assistant who is a resident of this jurisdiction and possesses an unrestricted [certificate/license]. The Governor shall also appoint [two] public members who shall be residents of this jurisdiction and who are not affiliated with, nor have a financial interest in, any healthcare profession and who have an interest in consumer rights. The Governor shall, to the greatest extent possible, appoint individuals to achieve diversity on the board.

B. Board members shall serve staggered four-year terms. Board members shall serve no more than two successive

four-year terms or for more than ten consecutive years. By approval of the majority of the board, the service of a member may be extended at the completion of a four-year term until a new member is appointed or the current member is reappointed.

7th Edition MPA Appendix A 4

C. If requested by the board,The board may request the Governor may remove any member of the board for misconduct, incompetence, or neglect of duty.

D. Board members are eligible for [compensation and/or] reimbursement of necessary expenses pursuant to [cite

applicable statute relating to [compensation and/or] reimbursement] to cover necessary expenses for attending each board meeting or for representing the board in an official board-approved activity.

E. A board member who acts within the scope of board duties, without malice and in the reasonable belief that the

member’s action is warranted by law, is immune from civil liability. 2.02 Powers and Duties of the Board

The board shall:

1. Evaluate the qualifications of applicants for licensure [and certification].

2. Provide for the examination of physical therapists and physical therapist assistants.

3. Issue licenses [or certificates] to persons who meet the qualifications of this [act].

4. Regulate the practice of physical therapy by interpreting and enforcing this [act].

5. Issue advisory opinions upon request regarding this [act]. Have the authority to establish committees, advisory panels, and task forces to further the work of the board.

6. Adopt and revise rules consistent with this [act]. Such rules, when lawfully adopted, shall have the effect of law.

7. Meet at least once each quarter in compliance with the open meeting requirements of [cite applicable statute]. A majority of filled board members positions shall constitute a quorum for the transaction of business. The board shall keep an official record of its meetings.

8. Establish mechanisms for assessing the continuing competence of physical therapists to practice physical therapy.

9. Establish mechanisms for assessing the continuing competence of physical therapist assistants to work in the profession of physical therapy.

10. Establish and collect fees for sustaining the necessary operation and expenses of the board.

11. Elect officers from its members necessary for the operations and obligations of the board. Terms of office shall be one year.

12. Provide for the timely orientation and training of new professional and public appointees to the board regarding board licensing and disciplinary procedures, this [act], and board rules, policies and procedures.

13. Maintain a current list of all persons regulated under this [act]. This information includes the person’s

name, current business and residential address, email address, telephone numbers, and license [or certificate] number.

14. Provide information to the public regarding the complaint process.

7th Edition MPA Appendix A 5

15. Employ necessary personnel to carry out the administrative work of the board. Board personnel are eligible to receive compensation pursuant to [cite specific statute].

16. Enter into contracts for services necessary for enforcement of this [act].

17. Report final disciplinary action taken against a licensee [or certificate holder] to a national disciplinary database recognized by the board or as required by law.

18. Report information of alleged unlawful conduct by licensees [or certificate holders], unlicensed individuals, other healthcare providers, and entities to the appropriate county, jurisdiction, or federal authority.

19. Publish, at least annually, final adverse action taken against a licensee [or certificate holder].

20. Publish at least annually, board rulings, opinions, and interpretations of statutes or rules in order to guide persons regulated pursuant to this [act].

21. Participate in or conduct performance audits.

22. Have the authority to fully participate in a national Exam, Licensure, and Disciplinary Database as defined by rule.

23. Have the authority to obtain biometric-based information from every physical therapist or physical therapist assistant applicant for licensure[certification] and submit this information to the Federal Bureau of Investigation for a criminal background check.

24. Have the authority to determine and collect, at the time of new licensure [or certification] and licensure [or certification] renewal, a core set of data elements deemed necessary for the purpose of workforce assessment and planning. The data elements shall be used to create and maintain a healthcare workforce database. The Board may enter into agreements with a private or public entity to establish and maintain the database, perform data analysis, and/or prepare reports concerning the physical therapy workforce. The Board shall promulgate rules to perform duties pursuant to this [act].

25. Have the authority to require a licensee [certificate holder] to complete educational activities.

2.03 Disposition of Funds (No model language is offered under this section heading. See Commentary for further information.)

Article 3: Examination and Licensure 3.01 National Examination

A. The board shall provide for a national examination within the jurisdiction. In order to be eligible to sit for the

examination, the candidate must meet nationally recognized requirements that support the integrity of the examination and are further defined in rule.

B. To be eligible to sit for the national examination, the candidate must meet nationally recognized requirements

that support the integrity of the examination and are further defined by rule. 1. The physical therapist examination is a national examination that tests entry-level competence related to physical therapy theory, examination and evaluation, diagnosis, prognosis, treatment intervention, prevention and consultation.

7th Edition MPA Appendix A 6

2. The physical therapist assistant examination is a national examination that tests for requisite knowledge and skills in the technical application of physical therapy services.

CD. Licensure applicants Candidates must agree to abide by security and copyright provisions related to the

national licensure examination. If the board determines that an applicant has violated any of these provisions or engaged in or attempted to engage in any other conduct that subverts or undermines the integrity of the examination process or validity of examination results, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time.

DE. Any violation of security and copyright provisions related to the national licensure examination, subversion or

attempts to subvert the national examination shall be reported by the board to the Federation of State Boards of Physical Therapy.

EF. If the board determines that an applicant has engaged or has attempted to engage in conduct that subverts or

undermines the integrity of the examination process, including a violation of security and copyright provisions related to the national licensure examination, the board may disqualify the applicant from taking or retaking the examination permanently or for a specified period of time.

3.02 Qualifications for Licensure [and Certification]

A. An applicant for a license as a physical therapist shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a professional physical therapy education program accredited by a

national accreditation agency approved by the board. 3. Pass an national examination approved by the board. 4. Pass additional examinations [e.g. jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. B. An applicant for a license as a physical therapist who has been educated at a school that has not been

accredited by an agency approved by the board educated outside of the United States shall: 1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of

physical therapists educated in an accredited entry-level program as determined by the board. Graduation outside the United States from a professional education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated at a school that has not been accredited by an agency approved by the board educated outside of the United States shall have: a. Graduated from a physical therapist education program that prepares the applicant to engage without restriction in the practice of physical therapy; b. Provided written proof that the applicant’s school of physical therapy is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass an national examination approved by the board.

7th Edition MPA Appendix A 7

5. Pass additional examinations [e.g. jurisprudence examination] required by the board as further established by rule.

6. Submit to a criminal records check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed under this [Act].

C. An applicant for a [certificate/license] as a physical therapist assistant shall:

1. Complete the application process including payment of fees. 2. Submit proof of graduation from a physical therapist assistant education program accredited by a national

accreditation agency approved by the board. 3. Pass an national examination approved by the board. 4. Pass additional examinations [e.g. jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. D. An applicant for a [certificate/license] as a physical therapist assistant who has been educated at a school that

has not been accredited by an agency approved by the board educated outside of the United States shall: 1. Complete the application process including payment of fees. 2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of

physical therapist assistants educated in an accredited entry-level program as determined by the board. Graduation outside the United States from an education program accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure educated outside of the United States educated at a school that has not been accredited by an agency approved by the board shall have: a. Graduated from a physical therapist assistant educational program that prepares the applicant to work as a physical therapist assistant; b. Provided written proof that the applicant’s physical therapist assistant school is recognized by its own ministry of education or other appropriate recognition agency; c. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and d. Completed any additional education as required by the board.

3. Pass a board-approved English proficiency examination as required by the board as further established by rule.

4. Pass an national examination approved by the board. 5. Pass additional examinations [e.g. jurisprudence examination] required by the board as further

established by rule. 6. Submit to a criminal records background check. 7. Complete supervised clinical practice as defined by rules with a restricted license. 8. Meet the requirements established by board rule if applicable. 9. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act].

E. . An applicant for a [certificate/license] as a physical therapist assistant who has completed a United States

Armed Services program of training not accredited by a national accreditation agency approved by the board shall:

1. Complete the application process including payment of fees.

7th Edition MPA Appendix A 8

2. Provide satisfactory evidence that the applicant’s education is substantially equivalent to the education of physical therapist assistants educated in an accredited entry-level program as determined by the board. Successful completion of a United States Armed Services program of training accredited by the same accrediting agency that the board approves for programs within the United States constitutes evidence of substantial equivalency. In all other instances, “substantially equivalent” means that an applicant for licensure who has completed a United States Armed Services program of training shall have: a. Completed a physical therapist assistant training program that prepares the applicant to work as a physical therapist assistant; b. Undergone a credentials evaluation as directed by the board that determines that the candidate has met uniform criteria for educational requirements as further established by rule; and c. Completed any additional education as required by the board.

3. Pass the a national examination approved by the board. 4. Pass additional examinations [e.g. jurisprudence examination] required by the board as further

established by rule. 5. Submit to a criminal records check. 6. Meet the requirements established by board rule if applicable. 7. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act].

3.03 Licensure [and Certification] by Endorsement

A. The board shall issue a license to a physical therapist or a license [certificate] to a physical therapist assistant who has a current unrestricted license [certificate] from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant’s initial licensure. B. The board shall issue a license [certificate] to a physical therapist assistant who has a current unrestricted license [certificate] from another jurisdiction of the United States if that person meets all qualifications prescribed in [Qualifications for Licensure and Certification, Article 3.02] at the time of the applicant’s initial licensure.

3.04 Exemptions from Licensure [or Certification]

A. This [act] does not restrict a person licensed or certified under any other law of this jurisdiction from engaging in the profession or practice for which that person is licensed if that person does not represent, imply or claim that he/she is a physical therapist, physical therapist assistant, or a provider of physical therapy as defined in Article 1, 1.02B.

B. The following persons are exempt from the licensure [certification] requirements of this [act] when engaged in

the following activities: 1. A person in an entry-level professional education program approved by the board who is satisfying

supervised clinical education requirements related to the person’s physical therapist education while under onsite supervision of a physical therapist.

2. A person satisfying a clinical education experience under the onsite supervision of a physical therapist as required by the board.

3. A physical therapist who is practicing in the United States Armed Services, United States Public Health Service or Veterans Administration pursuant to federal regulations for jurisdiction licensure of healthcare providers. If such person, while federally employed as a physical therapist, shall engage in the practice of physical therapy outside the course and scope of such federal employment, he/she shall then be required to obtain a license in accordance with this [act].

4. A physical therapist who is licensed in another jurisdiction of the United States or credentialed to practice physical therapy in another country if that person is teaching, demonstrating or providing physical therapy services in connection with teaching or participating in an educational seminar of no more than 60 days in a calendar year.

7th Edition MPA Appendix A 9

5. A physical therapist who is licensed in another jurisdiction of the United States if that person is rendering advice or professional or expert opinion providing consultation by telehealth, as defined in [Definitions, Article 1.02], to a physical therapist licensed healthcare practitioner in this jurisdiction under this [act].

6. A physical therapist who is licensed in a jurisdiction of the United States or credentialed in another country, if that person by contract or employment is providing physical therapy to patients/clients affiliated with or employed by established athletic teams, athletic organizations or performing arts companies temporarily practicing, competing or performing in the jurisdiction for no more than 60 days in a calendar year.

7. A physical therapist who is licensed in a jurisdiction of the United States and who enters this jurisdiction to provide physical therapy during a declared local, jurisdictional or national disaster or emergency. This exemption applies for no longer than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

8. A physical therapist licensed in a jurisdiction of the United States who is forced to leave his/her residence or place of employment due to a declared local, jurisdictional or national disaster or emergency and due to such displacement seeks to practice physical therapy. This exemption applies for no more than 60 days following the declaration of the emergency. In order to be eligible for this exemption the physical therapist shall notify the board of their intent to practice.

C. A physical therapist assistant who is [certified/licensed] in a jurisdiction of the United States and is assisting a

physical therapist engaged specifically in activities related to [subparagraphs (B) 2, 3, 5, 6 and 7 of this section] is exempt from the requirement of [certification/licensure] under this [act].

3.05 License [or Certificate] Renewal

A. A physical therapist applying for renewal of the license shall: 1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed under this [Act].

B. A physical therapist assistant applying for renewal of the license [certificate] shall:

1. Complete a renewal application including payment of fees. 2. Demonstrate evidence of continuing competence as defined by rule. 3. Meet the requirements established by board rule if applicable. 4. Meet other statutory and regulatory requirements applicable to individuals licensed [certified] under this

[Act]. 3.06 Changes of Name, Address or Telephone Number

Each licensee [and certificate holder] is responsible for reporting a name change and changes in business and home address, email address and telephone numbers to the board within 30 days.

3.07 Reinstatement of License [or Certificate]

A. The board may reinstate a lapsed license [or certificate] upon completion of a reinstatement application including payment of fees, as defined by rule.

B. If a physical therapist’s license has lapsed for a specified time period, as defined by rules, that person shall fulfill

all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to practice physical therapy by one or more of the following as determined by the board: 1. Complete supervised clinical practice as defined by rule with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during lapsed

licensure period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed practice in another jurisdiction.

7th Edition MPA Appendix A 10

C. If a physical therapist assistant’s [certificate/ license] has lapsed for a specified time period, as defined by rule, that person shall fulfill all requirements of [3.07 A] and demonstrate to the board’s satisfaction competence to work as a physical therapist assistant by one or more of the following as determined by the board: 1. Complete supervised clinical practice as defined by rules with a restricted license. 2. Demonstrate or complete continued competence requirements, as defined by rule, required during lapsed

licensure [certification] period. 3. Pass examination(s) approved by the board. 4. Provide proof of licensed [certified] work as a physical therapist assistant in another jurisdiction.

D. The board may reinstate a suspended or revoked physical therapist’s license upon completion of the

requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of competence to practice physical therapy through the following activities: 1. Complete supervised clinical practice, as defined by rule, with a restricted license. 2. Demonstrate or complete continued competence requirements, defined by rule, required during the

suspended or revoked licensure period. 3. Successfully complete examinations or assessment tool(s) and/or pass examination(s) approved by the

board. E. The board may reinstate a suspended or revoked physical therapist assistant’s [certificate/license] upon

completion of the requirements in [3.07 A] and evidence of satisfactory completion of all requirements for reinstatement that were stipulated in a consent order at the time of discipline. The board may further require evidence of the physical therapist assistant’s competence to work in the profession of physical therapy through the following activities. 1. Complete supervised clinical practice with a restricted license under a qualified and approved supervisor. 2. Demonstrate or complete continued competence requirements, defined by rule, required during the

suspended or revoked licensure period. 3. Successfully complete examinations or assessment tool(s) and/or pass examination(s) approved by the

board.

[3.08 Fees] (This is optional statute language for states requiring maximum fee ceilings within their statutes.) A. The board shall establish and collect fees not to exceed:

1. ________ dollars for an application for an original license [or certificate]. This fee is nonrefundable. 2. ________ dollars for a certificate of renewal of a license [or certificate]. 3. ________ dollars for an application for reinstatement of a license [or certificate]. 4. ________ dollars for each duplicate license [or certificate]. 5. ________ dollars for other administrative fees [e.g. criminal records report, pass through or processing

fees] Article 4: Regulation of Physical Therapy 4.01 Ethics in the Physical Therapy Profession A. A physical therapist shall adhere to the recognized standards of ethics of the physical therapy profession as

established by rule. B. A physical therapist assistant shall adhere to the recognized standards of ethicsethical conduct of the physical

therapy profession as established by rule. 4.02 Use of Titles and Terms; Restrictions; Classification of Violation A. A physical therapist shall use the letters “PT” or the term “physical therapist” immediately following their his or

her name to designate licensure as a healthcare practitioner under this [act]. B. A person or business entity, its employees, agents or representatives shall not use in connection with that

person’s name or the name or activity of the business, the words “physical therapy,” “physical therapist,”

7th Edition MPA Appendix A 11

“physiotherapy,” “physiotherapist,” “physio,” “registered physical therapist,” “doctor of physical therapy,” the letters “PT,” “DPT,” “LPT,” “RPT,” or any other words, abbreviations or insignia indicating or implying directly or indirectly that physical therapy is provided or supplied, unless such services are provided by or under the direction of a physical therapist licensed pursuant to this [act]. A person or business entity shall not advertise or otherwise promote another person as being a “physical therapist” or “physiotherapist” unless the individual so advertised or promoted is licensed as a physical therapist under this act. A person or business entity that offers, provides, or bills any other person for services shall not characterize those services as “physical therapy” or “physiotherapy” unless the individual performing those services is a person licensed as a physical therapist under this [act].

C. Physical therapists who have graduated from a DPT program may use the title Doctor of Physical Therapy. A

physical therapist holding a DPT or other doctoral degree shall not use the title Doctor without also clearly informing the public of his or her profession as a physical therapist. Use of the title shall be in accordance with jurisdictional law.

D. A physical therapist assistant shall use the letters “PTA” immediately following his or her name to designate

[certification/licensure] under this [act]. E. A person shall not use the title “physical therapist assistant,” the letters “PTA,” or any other words,

abbreviations, or insignia in connection with that person’s name to indicate or imply, directly or indirectly, that the person is a physical therapist assistant unless that person is [certified/licensed] as a physical therapist assistant pursuant to this [act].

F. A person or business entity that violates paragraphs (B) or (E) of this section is guilty of a [cite specific legal

sanction]. The board shall have authority to impose a civil penalty, in an amount not to exceed [specify number of dollars] per violation, against any person or business entity that violates paragraphs (B) or (E). In addition, the board shall seek an injunction against conduct in violation of paragraphs (B) or (E) in any court of competent jurisdiction. For purposes of this [act], the board, in seeking an injunction, need only show that the defendant violated paragraphs (B) and (E) of this section to establish irreparable injury or a likelihood of a continuation of the violation.

4.03 Patient/Client Care Management A. A physical therapist is fully responsible for managing all aspects of the physical therapy care of each

patient/client. A physical therapist shall provide: 1. The initial evaluation, determination of diagnosis, prognosis, and plan of treatment intervention and

documentation of each encounter with each patient/client; 2. Periodic reevaluation and documentation of each patient/client; 3. The documented discharge of the patient/client, including the patient’s/client’s response to treatment

intervention at the time of discharge.

B. A physical therapist shall assure the qualifications of all physical therapist assistants and physical therapy aides under his or her their direction and supervision. C. For each patient/client on each date of service, a physical therapist shall provide all of the treatment

intervention that requires the education, skills, and knowledge of a physical therapist and shall determine the use of physical therapist assistants or physical therapy aides to ensure that the delivery of care that is safe, effective, and efficient. 1. A physical therapist assistant shall work under a physical therapist’s supervision. A physical therapist

assistant shall document the care he/shethey provides. 2. A physical therapist may use physical therapy aides for designated routine tasks. A physical therapy aide

shall work under the supervision of a physical therapist.

7th Edition MPA Appendix A 12

D. The physical therapist shall communicate the overall plan of care with, and obtain informed consent from, the patient/client or their patient’s legally authorized representative. E. A physical therapist’s responsibility shall include accurate documentation and billing of the services provided. F. A physical therapist assistant’s responsibility shall include accurate documentation and billing of the services

provided. G. Nothing in this [Act] shall prohibit a licensee[certificate holder] from providing physical therapy to animals for

which the licensee[certificate holder] has completed the education and training as further established by rule.

4.04 Grounds for Denial of a License [and Certificate]; Disciplinary Action

A. The following are grounds for denial of a license [and certificate] or disciplinary action: 1. Violating any provision of this [act], board rules or a written order of the board. 2. Obtaining or attempting to obtain a license [or certificate] by fraud or misrepresentation. 3. Attempting to engage in conduct that subverts or undermines the integrity of the examination or the

examination process including, but not limited to, a violation of security and copyright provisions related to the national licensure exam, utilizing in any manner recalled or memorized examination questions from or with any person or entity, failing to comply with all test center security procedures, communicating or attempting to communicate with other examinees during the test, or copying or sharing examination questions or portions of questions.

4. Practicing or offering to practice beyond the scope of the practice of physical therapy. 5. Acting in a manner inconsistent with generally accepted standards of physical therapy practice, regardless

of whether actual injury to the patient/client is established. 6. Failing to adhere to the recognized standards of ethics of the physical therapy profession as established

by rule. 7. Failing to complete continuing competence requirements as established by rule. 8. Failing to maintain adequate patient/client records. For the purposes of this paragraph, “adequate

patient/client records” means legible records that contain at minimum sufficient information to identify the patient/client, an evaluation of objective findings, a diagnosis, a plan of care, a treatment record and a discharge plan.

9. Failing to supervise physical therapist assistants, or physical therapy aides, a person in an entry-level professional education program approved by the board who is satisfying supervised clinical education requirements related to the person’s education, or a person satisfying a supervised clinical practice in accordance with this [act] and board rules.

10. Failing to report to the board, where there is direct knowledge, any unprofessional, incompetent, or illegal acts that appear to be in violation of this [act] or any rules established by the board.

11. Engaging in sexual misconduct. For the purpose of this paragraph sexual misconduct includes: a. Engaging in or soliciting romantic or sexual relationships, whether consensual or non-consensual,

while a physical therapist or physical therapist assistant-patient/client relationship exists. b. Making sexual advances, requesting sexual favors or expressing thoughts, feelings, or making

gestures that are sexual in nature, or that reasonably may be construed by a patient/client as sexual in nature, by any means including engaging in other verbal conduct or physical contact, of a sexual nature or via electronic communications. with patients or clients which may

c. Intentionally viewing a completely or partially disrobed patient/client in the course of treatment if the viewing is not related to patient/client diagnosis or treatment under current practice standards.

12. Sexual contact between a physical therapist and patient/client after termination of the physical therapist- patient/client relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

7th Edition MPA Appendix A 13

13. Sexual contact between a physical therapist assistant and patient/client after termination of the physical therapist assistant-patient/client relationship may still constitute sexual misconduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from that relationship.

14. Abusing the physical therapist-patient/client relationship to exert undue influence or exploiting persons over whom the licensee has supervisory, evaluative, or other authority.

15. Abusing the physical therapist assistant-patient/client relationship to exert undue influence or exploiting persons over whom the licensee [certificate holder] has supervisory or other authority.

16. Having had a license [or certificate] revoked or suspended, other disciplinary action taken, or an application for licensure [or certification] refused, revoked or suspended by the proper authorities of another jurisdiction, territory, or country.

17. Having been convicted of or pled guilty to a felony with a nexus to the practice of a physical therapist or work of a physical therapist assistant in the courts of this jurisdiction or any other jurisdiction, territory or country. Conviction, as used in this paragraph, shall include a deferred conviction, deferred prosecution, deferred sentence, finding or verdict of guilt, an admission of guilt, an Alfred plea, or a plea of nolo contendere.

18. Aiding and abetting the unlicensed practice of physical therapy. 19. Directly or indirectly requesting, receiving or participating in the dividing, transferring, assigning, rebating

or refunding of an unearned fee, or profiting by means of a credit or other valuable consideration such as an unearned commission, discount or gratuity in connection with the furnishing of physical therapy services. This does not prohibit the members of any regularly and properly organized business entity recognized by law and comprising physical therapists from dividing fees received for professional services among themselves as they determine necessary.

20. Promoting any unnecessary device, treatment intervention, or service resulting in the financial gain of the practitioner or of a third party.

21. Providing treatment intervention unwarranted by the condition of the patient/client or continuing treatment beyond the point of reasonable benefit.

22. Participating in underutilization or overutilization of physical therapy services for personal or institutional financial gain.

23. Charging fraudulent fees for services performed or not performed. 24. Making misleading, deceptive, untrue or fraudulent representations in violation of this [act] or in the

practice of the profession. 25. Practicing as a physical therapist or working as a physical therapist assistant when physical or mental

abilities are impaired by the use of controlled substances or other habit-forming drugs, chemicals or alcohol, or by other causes.

26. Practicing physical therapy with a mental or physical condition that impairs the ability of the licensee to practice with skill and safety.

27. Practicing after having been adjudged mentally incompetent by a court of competent jurisdiction. 28. Interfering with an investigation or disciplinary proceeding by failure to cooperate, by willful

misrepresentation of facts, or by the use of threats or harassment against any patient/client or witness to prevent that patient/client or witness from providing evidence in a disciplinary proceeding or any legal action.

29. Failing to maintain patient/client confidentiality without documented authorization of the patient/client or unless otherwise required by law. All records used or resulting from a consultation by telehealth, as defined in [Definitions, Article 1.02], are part of a patient’s/client’s records and are subject to applicable confidentiality requirements.

4.05 Investigative Powers; Emergency Action; Hearing Officers

A. To enforce this [act], the board is authorized to: 1. Receive complaints filed against licensees [or certificate holders] and conduct a timely investigation. 2. File complaints against licensees [or certificate holders] or individuals engaging in the unlawful or

unlicensed practice of physical therapy and conduct timely investigations. 3. Conduct an investigation at any time and on its own initiative without receipt of a written complaint if the

board has reason to believe that there may be a violation of this [act].

7th Edition MPA Appendix A 14

4. Issue subpoenas to compel the attendance of any witness or the production of any documentation relative to a case.

5. Take emergency action ordering the summary suspension of a license [or certificate] or the restriction of a physical therapist’s practice or a physical therapist assistant’s employment work pending proceedings by the board.

6. Appoint hearing officers authorized to conduct hearings. Hearing officers shall prepare and submit to the board findings of fact, conclusions of law and a recommendation for Bboard action that shall be reviewed and voted on by the board.

7. Require a physical therapist to be examined in order to determine his or her mental or physical ability to practice physical therapy.

8. Require a physical therapist assistant to be examined in order to determine his or her mental or physical ability to work in the profession of physical therapy.

B. If the board finds that the information received in a complaint or an investigation does not merit disciplinary action against a licensee [or certificate holder] it may take one of the following actions:

1. Dismiss the complaint. 2. Issue an advisory letter to the licensee [or certificate holder]. An advisory letter is non-disciplinary and

notifies a licensee [or certificate holder] that, while there is no evidence to merit disciplinary action, the board believes that the licensee [or certificate holder] should become educated about the requirements of this [act] and board rules.

4.06 Hearings (No model statute language is offered under this section heading. See Commentary for additional information.)

4.07 Disciplinary Actions; Penalties Upon proof that any grounds prescribed in section [Grounds for Denial of License [and Certificate]; Disciplinary Action, Article 4.04], have been violated, the board may take the following disciplinary actions singly or in combination.

1. Issue a censure. 2. Restrict a license [or certificate]. The board may require a licensee [or certificate holder] to report

regularly to the board on matters related to the grounds for the restricted license [or certificate]. 3. Suspend a license [or certificate] for a period prescribed by the board. 4. Revoke a license [or certificate]. 5. Refuse to issue or renew a license [or certificate]. 6. Impose a civil penalty of at least ____________ but not more than ____________. (Include minimum and

maximum dollar amounts of civil penalties.) 7. Accept a voluntary surrendering of a license [or certificate] based on an order of consent from the board.

4.08 Procedural Due Process

Actions of the board shall be taken subject to the right of notice, opportunity to be heard, and the right of appeal in accordance with [specify the jurisdiction] law relating to administrative law and procedure.

4.09 Unlawful Practice; Classification; Civil Penalties; Injunctive Relief A. It is unlawful for any person or business entity, its employees, agents, or representatives not licensed as a

physical therapist under this [act] to engage in the practice of physical therapy. Any person who violates this paragraph [(A) or Use of Titles and Terms, Restrictions; Classification of Violation, Article 4.02], is guilty of [cite specific criminal sanction, e.g., class 1 misdemeanor] and subject to any other remedies specified in this [act].

B. The board shall investigate any person or business entity to the extent necessary to determine whether the

person or business entity is engaged in the unlawful practice of physical therapy. If an investigation indicates that a person or business entity is practicing physical therapy unlawfully, the board shall inform the person or

7th Edition MPA Appendix A 15

the business entity of the alleged violation. The board may refer the matter for prosecution regardless of whether the person or business entity ceases the unlawful practice of physical therapy.

C. The board shall apply to any court of competent jurisdiction for an order enjoining any person or business

entity from committing any violation of this [act]. Injunction proceedings under this paragraph shall be in addition to, and not in lieu of, all penalties and other remedies prescribed in this [act].

D. If a person or business entity knowingly violates this [act] or board rules, fraudulently uses or permits the use

of a license [or certificate] number, or knowingly aids or requires another person to violate this [act] or board rules, the board may impose upon such person a civil penalty of not more than [dollar amount of penalty] for the first violation and not more than [dollar amount of penalty] for each subsequent violation.

[Optional Statute] E. The board shall transmit all monies it collects from civil penalties pursuant to this [act] to the [specify the

disposition of these funds if different from other funds]. 4.10 Reporting Violations; Immunity

A. A person, including but not limited to a licensee [or certificate holder], corporation, insurance company, healthcare organization or healthcare facility and jurisdiction or local governmental agencies, shall report to the board any conviction or determination by an agency or court that a licensee [or certificate holder] has committed an act that constitutes a violation of [Grounds for Denial of a License [and Certificate]; Disciplinary Action, Article 4.04].

B. A person is immune from civil liability, whether direct or derivative, for reporting such facts as set forth in "A"

above to the board in good faith and participating in the board’s investigation and subsequent disciplinary process, if applicable.

C. The board shall not disclose the identity of a person who provides information unless such information is

essential to proceedings conducted pursuant to [Investigative Powers; Emergency Action; Hearing Officers and Hearings, Articles 4.05 and 4.06], or unless required by a court of law.

4.11 Substance Abuse Recovery Program A. The board may permit a licensee [or certificate holder] to actively participate in a board-approved substance

abuse recovery program if: 1. The board has evidence that the licensee [or certificate holder] is impaired. 2. The licensee [or certificate holder] enters into a written agreement with the board for a restricted license

[or certificate] and complies with all the terms of the agreement, including making satisfactory progress in the program and adhering to any limitations on his or her practice or employment imposed by the board to protect the public. Failure to enter into such an agreement shall activate an immediate investigation and disciplinary proceeding by the board.

3. As part of the agreement established between the licensee [or certificate holder] and the board, the licensee [or certificate holder] signs a waiver allowing the substance abuse program to release information to the board if the licensee [or certificate holder] does not comply with the requirements of this section or is unable to practice or work with reasonable skill or safety.

4.12 Rights of Consumers A. The public shall have access to the following information:

1. A list of licensees [and certificate holders] that includes place of employment, address and telephone number of record, license [or certificate] number, date of license [or certificate] expiration, and status of license [or certificate], and employment information.

2. A list of final adverse actions taken by the board. 3. The address, website, email and phone number of the board.

7th Edition MPA Appendix A 16

B. Each licensee [and certificate holder] shall display a copy of his or her license [or certificate] in a location accessible to public view or produce a copy immediately upon request.

C. Each licensee [and certificate holder] shall provide the public with information on how to file a complaint with

the board against a licensee [or certificate holder]. D. Any person may submit a complaint regarding any licensee, [certificate holder] or any other person potentially

in violation of this [act]. Confidentiality shall be maintained subject to law. E. The home address, email address and home telephone numbers of physical therapists and physical therapist

assistants are not public records and shall be kept confidential by the board unless they are the only addresses and telephone numbers of record.

F. A patient/client has freedom of choice in selection of services and products. G. Information relating to the physical therapist-patient/client relationship is confidential and shall not be

communicated to a third party who is not involved in that patient’s/client’s care without the written authorization of the patient/client. The physical therapist-patient/client privilege does not extend to cases in which the physical therapist has a duty to report or disclose information as required by law.

H. Information relating to the physical therapist assistant-patient/client relationship is confidential and shall not be

communicated to a third party who is not involved in that patient’s/client’s care without the written authorization of the patient/client. The physical therapist assistant-patient/client privilege does not extend to cases in which the physical therapist assistant has a duty to report or disclose information as required by law.

IH. The board shall keep all information relating to the receipt and investigation of complaints filed against

licensees [or certificate holders] confidential until the information is disclosed in the course of the investigation or any subsequent proceeding or until disclosure is required by law. Patient/Client records, including clinical records, files, any other report or oral statement relating to diagnostic findings or treatment of patients/clients, any information from which a patient/client or his their family might be identified, or information received and records or reports kept by the board as a result of an investigation made pursuant to this [act] shall not be available to the public and shall be kept confidential by the board.

7th Edition MPA Appendix B 1

Appendix B: Code of Ethics for the Physical Therapist and Guide for Professional Conduct

Code of Ethics for the Physical Therapist

HOD S06-20-28-25 [Amended HOD S06-19-47-67; HOD S06-09-07-12; HOD S06-00-12-23; HOD 06-91-05-05; HOD 06-87-11-17; HOD 06-81-06-18; HOD 06-78-06-08; HOD 06-78-06-07; HOD 06-77-18-30; HOD 06-77-17- 27; Initial HOD 06-73-13-24] [Standard]

Preamble The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient and client

management, consultation, education, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and

responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the

core values, ethical principles, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist

has engaged in unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive. The APTA Guide for Professional Conduct and Core Values for the Physical Therapist and Physical Therapist Assistant provide additional guidance. This Code of Ethics describes the desired behavior of physical therapists in their multiple roles(eg, management of patients/clients, consultation, education, research, and administration), addresses multiple aspects of ethical action (individual, organizational, and societal) and reflects the core vales of the physical therapist (accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility). Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life.

Principles Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals.(Core Values: Compassion and Caring, Integrity) 1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race,

nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical

therapist practice, consultation, education, research, and administration.

7th Edition MPA Appendix B 2

Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Collaboration, Compassion and Caring, Duty)

2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of

patients and clients over the interests of the physical therapist. 2B. Physical therapists shall provide physical therapist services with compassionate and caring behaviors that

incorporate the individual and cultural differences of patients and clients. 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make

informed decisions about physical therapist care or participation in clinical research. 2D. Physical therapists shall collaborate with patients and clients to empower them in decisions about their health

care. 2E. Physical therapists shall protect confidential patient and client information and may disclose confidential

information to appropriate authorities only when allowed or as required by law.

Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Collaboration, Duty, Excellence, Integrity)

3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s or

client’s best interest in all practice settings. 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence

(including current literature and established best practice), practitioner experience, and patient and client values.

3C. Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary.

3D. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment. 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants

and support personnel. Principle #4: Physical therapists shall demonstrate integrity in their relationships with patients and clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public.(Core Value: Integrity) 4A. Physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading

representations. 4B. Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority

(eg, patients/clients, students, supervisees, research participants, or employees). 4C. Physical therapists shall not engage in any sexual relationship with any of their patients and clients,

supervisees, or students. 4D. Physical therapists shall not harass anyone verbally, physically, emotionally, or sexually. 4E. Physical therapists shall discourage misconduct by physical therapists, physical therapist assistants, and other

health care professionals and, when appropriate, report illegal or unethical acts, including verbal, physical, emotional, or sexual harassment, to an appropriate authority with jurisdiction over the conduct.

4F. Physical therapists shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law.

Principle #5: Physical therapists shall fulfill their legal and professional obligations. (Core Values: Accountability,

Duty, Social Responsibility) 5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support

personnel. 5C. Physical therapists involved in research shall abide by accepted standards governing protection of research

participants.

7th Edition MPA Appendix B 3

5D. Physical therapists shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.

5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.

5F. Physical therapists shall provide notice and information about alternatives for obtaining care in the event the physical therapist terminates the provider relationship while the patient or client continues to need physical therapy services.

Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. (Core Value: Excellence)

6A. Physical therapists shall achieve and maintain professional competence. 6B. Physical therapists shall take responsibility for their professional development based on critical self-assessment

and reflection on changes in physical therapist practice, education, health care delivery, and technology. 6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during

professional development activities before integrating the content or techniques into practice. 6D. Physical therapists shall cultivate practice environments that support professional development, lifelong

learning, and excellence.

Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability)

7A. Physical therapists shall promote practice environments that support autonomous and accountable

professional judgments. 7B. Physical therapists shall seek remuneration as is deserved and reasonable for physical therapist services. 7C. Physical therapists shall not accept gifts or other considerations that influence or give an appearance of

influencing their professional judgment. 7D. Physical therapists shall fully disclose any financial interest they have in products or services that they

recommend to patients/clients. 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical

therapy services accurately reflect the nature and extent of the services provided. 7F. Physical therapists shall refrain from employment arrangements, or other arrangements, that prevent physical

therapists from fulfilling professional obligations to patients/clients.

Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally.(Core Value: Social Responsibility)

8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the

health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapists shall advocate to reduce health disparities and health care inequities, improve access to

health care services, and address the health, wellness, and preventive health care needs of people. 8C. Physical therapists shall be responsible stewards of health care resources and shall avoid overutilization or

underutilization of physical therapy services. 8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique

role of the physical therapist.

7th Edition MPA Appendix B 4

Guide for Professional Conduct

Purpose This Guide for Professional Conduct (Guide) is intended to serve physical therapists in interpreting the Code of Ethics for the Physical Therapist (Code) of the American Physical Therapy Association (APTA) in matters of professional conduct. The APTA House of Delegates in June of 2009 adopted a revised Code, which became effective on July 1, 2010. The Guide provides a framework by which physical therapists may determine the propriety of their conduct. It is also intended to guide the professional development of physical therapist students. The Code and the Guide apply to all physical therapists. These guidelines are subject to change as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public. Interpreting Ethical Principles The interpretations expressed in this Guide reflect the opinions, decisions, and advice of the Ethics and Judicial Committee (EJC). The interpretations are set forth according to topic. These interpretations are intended to assist a physical therapist in applying general ethical principles to specific situations. They address some but not all topics addressed in the Principles and should not be considered inclusive of all situations that could evolve. This Guide is subject to change, and the Ethics and Judicial Committee will monitor and timely revise the Guide to address additional topics and Principles when necessary and as needed. Preamble to the Code The Preamble states as follows: The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient and client

management, consultation, education, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and

responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the

core values, ethical principles, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist

has engaged in unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive. This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, duty, and social responsibility. Throughout the document the primary core, values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life. Interpretation: Upon the Code of Ethics for the Physical Therapist being amended effective July 1, 2010, all the

7th Edition MPA Appendix B 5

lettered principles in the Code contain the word “shall” and are mandatory ethical obligations. The language contained in the Code is intended to better explain and further clarify existing ethical obligations. These ethical obligations predate the revised Code. Although various words have changed, many of the obligations are the same. Consequently, the addition of the word “shall” serves to reinforce and clarify existing ethical obligations. A significant reason that the Code was revised was to provide physical therapists with a document that was clear enough such that they can read it standing alone without the need to seek extensive additional interpretation. The Preamble states that “[n]o Code of Ethics is exhaustive nor can it address every situation.” The Preamble also states that physical therapists “are encouraged to seek additional advice or consultation in instances in which the guidance of the Code may not be definitive.” Potential sources for advice and counsel include third parties and the myriad resources available on the APTA Web site. Inherent in a physical therapist’s ethical decision-making process is the examination of his or her unique set of facts relative to the Code. Topics Respect Principle 1A states as follows: 1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. Interpretation: Principle 1A addresses the display of respect toward others. Unfortunately, there is no universal consensus about what respect looks like in every situation. For example, direct eye contact is viewed as respectful and courteous in some cultures and inappropriate in others. It is up to the individual to assess the appropriateness of behavior in various situations. Altruism Principle 2A states as follows: 2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist. Interpretation: Principle 2A reminds physical therapists to adhere to the profession’s core values and act in the best interest of patients/clients over the interests of the physical therapist. Often this is done without thought, but sometimes, especially at the end of the day when the physical therapist is fatigued and ready to go home, it is a conscious decision. For example, the physical therapist may need to make a decision between leaving on time and staying at work longer to see a patient who was 15 minutes late for an appointment. Patient Autonomy Principle 2C states as follows: 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research. Interpretation: The underlying purpose of Principle 2C is to require a physical therapist to respect patient autonomy. In order to do so, a physical therapist shall communicate to the patient and client the findings of his/her examination, evaluation, diagnosis, and prognosis. A physical therapist shall use sound professional judgment in informing the patient and client of any substantial risks of the recommended examination and intervention and shall collaborate with the patient and client to establish the goals of treatment and the plan of care. Ultimately, a physical therapist shall respect the patient’s/client’s right to make decisions regarding the recommended plan of care, including consent, modification, or refusal. Professional Judgment Principles 3, 3A, and 3B state as follows: 3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)

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3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings. 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient and client values. Interpretation: Principles 3, 3A, and 3B state that it is the physical therapist’s obligation to exercise sound professional judgment, based upon his/her knowledge, skill, training, and experience. Principle 3B further describes the physical therapist’s judgment as being informed by three elements of evidence-based practice. With regard to the patient and client management role, once a physical therapist accepts an individual for physical therapy services he/she shall be responsible for: the examination, evaluation, and diagnosis of that individual; the prognosis and intervention; re-examination and modification of the plan of care; and the maintenance of adequate records, including progress reports. A physical therapist shall establish the plan of care and shall provide and/or supervise and direct the appropriate interventions. Regardless of practice setting, a physical therapist has primary responsibility for the physical therapy care of a patient and shall make independent judgments regarding that care consistent with accepted professional standards. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise or that indicate the need for care outside the scope of physical therapy, the physical therapist shall so inform the patient and client and shall refer the patient and client to an appropriate practitioner. A physical therapist shall determine when a patient and client will no longer benefit from physical therapy services. When a physical therapist's judgment is that a patient will receive negligible benefit from physical therapy services, the physical therapist shall not provide or continue to provide such services if the primary reason for doing so is to further the financial self-interest of the physical therapist or his/her employer. A physical therapist shall avoid overutilization of physical therapy services. See Principle 8C. Supervision Principle 3E states as follows: 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel. Interpretation: Principle 3E describes an additional circumstance in which sound professional judgment is required; namely, through the appropriate direction of and communication with physical therapist assistants and support personnel. Further information on supervision via applicable local, state, and federal laws and regulations (including state practice acts and administrative codes) is available. Information on supervision via APTA policies and resources is also available on the APTA Web site. See Principles 5A and 5B. Integrity in Relationships Principle 4 states as follows: 4: Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. (Core Value: Integrity) Interpretation: Principle 4 addresses the need for integrity in relationships. This is not limited to relationships with patients/clients, but includes everyone physical therapists come into contact with professionally. For example, demonstrating integrity could encompass working collaboratively with the health care team and taking responsibility for one’s role as a member of that team. Reporting Principle 4C states as follows: 4C. Physical therapists shall discourage misconduct by healthcare professionals and report illegal or unethical acts to the relevant authority, when appropriate.

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Interpretation: When considering the application of “when appropriate” under Principle 4C, keep in mind that not all allegedly illegal or unethical acts should be reported immediately to an agency/authority. The determination of when to do so depends upon each situation’s unique set of facts, applicable laws, regulations, and policies. Depending upon those facts, it might be appropriate to communicate with the individuals involved. Consider whether the action has been corrected, and in that case, not reporting may be the most appropriate action. Note, however, that when an agency/authority does examine a potential ethical issue, fact finding will be its first step. The determination of ethicality requires an understanding of all of the relevant facts, but may still be subject to interpretation. The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Exploitation Principle 4E states as follows: 4E. Physical therapists shall not engage in any sexual relationship with any of their patient and clients, supervisees or students. Interpretation: The statement is fairly clear – sexual relationships with their patients/clients, supervisees or students are prohibited. This component of Principle 4 is consistent with Principle 4B, which states: Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority (e.g. patients/clients, students, supervisees, research participants, or employees). Next, consider this excerpt from the EJC Opinion titled Topic: Sexual Relationships With Patients/Former Patients: A physical therapist stands in a relationship of trust to each patient and has an ethical obligation to act in the patient's best interest and to avoid any exploitation or abuse of the patient. Thus, if a physical therapist has natural feelings of attraction toward a patient, he/she must sublimate those feelings in order to avoid sexual exploitation of the patient. One’s ethical decision making process should focus on whether the patient and client, supervisee or student is being exploited. In this context, questions have been asked about whether one can have a sexual relationship once the patient and client relationship ends. To this question, the EJC has opined as follows: The Committee does not believe it feasible to establish any bright-line rule for when, if ever, initiation of a romantic/sexual relationship with a former patient would be ethically permissible. The Committee imagines that in some cases a romantic/sexual relationship would not offend … if initiated with a former patient soon after the termination of treatment, while in others such a relationship might never be appropriate. Colleague Impairment Principle 5D and 5E state as follows: 5D. Physical therapists shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report the information to the appropriate authority. Interpretation: The central tenet of Principles 5D and 5E is that inaction is not an option for a physical therapist when faced with the circumstances described. Principle 5D states that a physical therapist shall encourage colleagues to seek assistance or counsel while Principle 5E addresses reporting information to the appropriate authority. 5D and 5E both require a factual determination on your part. This may be challenging in the sense that you might not know or it might be difficult for you to determine whether someone in fact has a physical, psychological, or substance-related impairment. In addition, it might be difficult to determine whether such impairment may be adversely affecting his or her professional responsibilities. Moreover, once you do make these determinations, the obligation under 5D centers not on reporting, but on encouraging the colleague to seek assistance. However, the obligation under 5E does focus on reporting. But note that 5E discusses reporting when a colleague is unable to perform, whereas 5D discusses encouraging colleagues to seek assistance when the impairment may adversely affect his or her professional responsibilities. So, 5D

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discusses something that may be affecting performance, whereas 5E addresses a situation in which someone is clearly unable to perform. The 2 situations are distinct. In addition, it is important to note that 5E does not mandate to whom you report; it gives you discretion to determine the appropriate authority. The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Professional Competence Principle 6A states as follows: 6A. Physical therapists shall achieve and maintain professional competence. Interpretation: 6A requires a physical therapist to maintain professional competence within one’s scope of practice throughout one’s career. Maintaining competence is an ongoing process of self-assessment, identification of strengths and weaknesses, acquisition of knowledge and skills based on that assessment, and reflection on and reassessment of performance, knowledge and skills. Numerous factors including practice setting, types of patients/clients, personal interests and the addition of new evidence to practice will influence the depth and breadth of professional competence in a given area of practice. Additional resources on Continuing Competence are available on the APTA Web site. Professional Growth Principle 6D states as follows: 6D. Physical therapists shall cultivate practice environments that support professional development, life-long learning, and excellence. Interpretation: 6D elaborates on the physical therapist’s obligations to foster an environment conducive to professional growth, even when not supported by the organization. The essential idea is that this is the physical therapist’s responsibility, whether or not the employer provides support. Charges and Coding Principle 7E states as follows: 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.9 Interpretation: Principle 7E provides that the physical therapist must make sure that the process of documentation and coding accurately captures the charges for services performed. In this context, where charges cannot be determined because of payment methodology, physical therapists may review the House of Delegates policy titled Professional Fees for Physical Therapy Services. Additional resources on documentation and coding include the House of Delegates policy titled Documentation Authority for Physical Therapy Services and the Documentation and Coding and Billing information on the APTA Web site. Pro Bono Services Principle 8A states as follows: 8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. Interpretation: The key word in Principle 8A is “or”. If a physical therapist is unable to provide pro bono services he or she can fulfill ethical obligations by supporting organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. In addition, physical therapists may review the House of Delegates guidelines titled Guidelines: Pro Bono Physical Therapy Services. Additional resources on pro bono physical therapy services are available on the APTA Web site. 8A also addresses supporting organizations to meet health needs. In terms of supporting organizations, the principle does not specify the type of support that is required. Physical therapists may express support through

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volunteerism, financial contributions, advocacy, education, or simply promoting their work in conversations with colleagues. Issued by the Ethics and Judicial Committee American Physical Therapy Association October 1981 Last Amended November 2010 Last Updated: 11/30/10 Contact: [email protected]

7th Edition MPA Appendix C 1

Appendix C: Standards of Ethical Conduct for the Physical Therapist Assistant & Guide for Conduct

Standards of Ethical Conduct for the Physical Therapist Assistant HOD S06-09-20-18 [Amended HOD S06-00-13-24; HOD 06-91-06-07; Initial HOD 06-82-04-08] [Standard] Preamble The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association (APTA). The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Physical therapist assistants are guided by a set of core values (accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility). Throughout the document the primary core values that support specific principles are indicated in parenthesis. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence,health and wellness, and enhanced quality of life. No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.The APTA Guide for Conduct of the Physical Therapist Assistant and Core Values for the Physical Therapist and Physical Therapist Assistant provide additional guidance. Standards Standard #1: Physical therapist assistants shall respect the inherent dignity, and rights, of all individuals. (Core Values: Compassion and Caring, Integrity) 1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapist assistants shall recognize their personal biases and shall not discriminate against others in the provision of physical therapy services. Standard #2: Physical therapist assistants shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Collaboration, Comopassion and Caring, Duty) 2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist assistant. 2B. Physical therapist assistants shall provide physical therapy interventions with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients. 2C. Physical therapist assistants shall provide patients/clients with information regarding the interventions they provide. 2D. Physical therapist assistants shall protect confidential patient and client information and, in collaboration with the physical therapist, may disclose confidential information to appropriate authorities only when allowed or as required by law. Standard #3: Physical therapist assistants shall make sound decisions in collaboration with the physical therapist and within the boundaries established by laws and regulations. (Core Values: Collaboration, Duty, Excellence, Integrity) 3A. Physical therapist assistants shall make objective decisions in the patient’s or client’s best interest in all practice settings.

7th Edition MPA Appendix C 2

3B. Physical therapist assistants shall be guided by information about best practice regarding physical therapist interventions. 3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient and client values. 3D. Physical therapist assistants shall not engage in conflicts of interest that interfere with making sound decisions. 3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient or client status requires modifications to the established plan of care. Standard #4: Physical therapist assistants shall demonstrate integrity in their relationships with patients/ clients, families, colleagues, students, other health care providers, employers, payers, and the public. (Core Value: Integrity) 4A. Physical therapist assistants shall provide truthful, accurate, and relevant information and shall not make

misleading representations. 4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other

authority (eg, patients and clients, students, supervisees, research participants, or employees). 4C. Physical therapist assistants shall not engage in any sexual relationship with any of their patients and clients,

supervisees, or students. 4D. Physical therapist assistants shall not harass anyone verbally, physically, emotionally, or sexually. 4E. Physical therapist assistants shall discourage misconduct by physical therapists, physical therapist assistants,

and other health care professionals and, when appropriate, report illegal or unethical acts, including verbal, physical, emotional, or sexual harassment, to an appropriate authority with jurisdiction over the conduct.

4F. Physical therapist assistants shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law.

Standard #5: Physical therapist assistants shall fulfill their legal and ethical obligations. (Core Values: Accountability, Duty, Social Responsibility) 5A. Physical therapist assistants shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapist assistants shall support the supervisory roleof the physical therapist to ensure quality care and promote patient and client safety. 5C. Physical therapist assistants involved in research shall abide by accepted standards governing protection of research participants. 5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapist assistants who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. Standard #6: Physical therapist assistants shall enhance their competence through the lifelong acquisition and refinement of knowledge, skills, and abilities. (Core Value: Excellence) 6A. Physical therapist assistants shall achieve and maintain clinicalcompetence. 6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy. 6C. Physical therapist assistants shall support practice environments that support career development and lifelong learning. Standard #7: Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society. (core Values: Integrity, Accountability)

7th Edition MPA Appendix C 3

7A. Physical therapist assistants shall promote work environments that support ethical and accountable decision- making. 7B. Physical therapist assistants shall not accept gifts or other considerations that influence or give an appearance of influencing their decisions. 7C. Physical therapist assistants shall fully disclose any financial interest they have in products or services that they recommend to patients/clients. 7D. Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided. 7E. Physical therapist assistants shall refrain from employment arrangements, or other arrangements, that prevent physical therapist assistants from fulfilling ethical obligations to patients/clients Standard #8: Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Value: Social Responsibility) 8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapist assistants shall advocate for people with impairments, activity limitations, participation restrictions, and disabilities in order to promote their participation in community and society. 8C. Physical therapist assistants shall be responsible stewards of health care resources by collaborating with physical therapists in order to avoid overutilization or underutilization of physical therapy services. 8D. Physical therapist assistants shall educate members of the public about the benefits of physical therapy.

APTA Guide for Conduct of the Physical Therapist Assistant

Purpose This Guide for Conduct of the Physical Therapist Assistant (Guide) is intended to serve physical therapist assistants in interpreting the Standards of Ethical Conduct for the Physical Therapist Assistant (Standards) of the American Physical Therapy Association (APTA). The APTA House of Delegates in June of 2009 adopted the revised Standards, which became effective on July 1, 2010. The Guide provides a framework by which physical therapist assistants may determine the propriety of their conduct. It is also intended to guide the development of physical therapist assistant students. The Standards and the Guide apply to all physical therapist assistants. These guidelines are subject to change as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public. Interpreting Ethical Standards The interpretations expressed in this Guide reflect the opinions, decisions, and advice of the Ethics and Judicial Committee (EJC). The interpretations are set forth according to topic. These interpretations are intended to assist a physical therapist assistant in applying general ethical standards to specific situations. They address some but not all topics addressed in the Standards and should not be considered inclusive of all situations that could evolve. This Guide is subject to change, and the Ethics and Judicial Committee will monitor and timely revise the Guide to address additional topics and Standards when necessary and as needed. Preamble to the Standards The Preamble states as follows: The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American

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Physical Therapy Association (APTA). The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health and wellness, and enhanced quality of life. No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive. Interpretation: Upon the Standards of Ethical Conduct for the Physical Therapist Assistant being amended effective July 1, 2010, all the lettered standards contain the word “shall” and are mandatory ethical obligations. The language contained in the Standards is intended to better explain and further clarify existing ethical obligations. These ethical obligations predate the revised Standards. Although various words have changed, many of the obligations are the same. Consequently, the addition of the word “shall” serves to reinforce and clarify existing ethical obligations. A significant reason that the Standards were revised was to provide physical therapist assistants with a document that was clear enough such that they can read it standing alone without the need to seek extensive additional interpretation. The Preamble states that “[n]o document that delineates ethical standards can address every situation.” The Preamble also states that physical therapist assistants “are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.” Potential sources for advice or counsel include third parties and the myriad resources available on the APTA Web site. Inherent in a physical therapist assistant’s ethical decision-making process is the examination of his or her unique set of facts relative to the Standards. Standards Respect Standard 1A states as follows: 1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. Interpretation: Standard 1A addresses the display of respect toward others. Unfortunately, there is no universal consensus about what respect looks like in every situation. For example, direct eye contact is viewed as respectful and courteous in some cultures and inappropriate in others. It is up to the individual to assess the appropriateness of behavior in various situations.3 Altruism Standard 2A states as follows: 2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist assistant. Interpretation: Standard 2A addresses acting in the best interest of patients/clients over the interests of the physical therapist assistant. Often this is done without thought, but sometimes, especially at the end of the day when the clinician is fatigued and ready to go home, it is a conscious decision. For example, the physical therapist assistant may need to make a decision between leaving on time and staying at work longer to see a patient who was 15 minutes late for an appointment. Sound Decisions Standard 3C states as follows: 3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient and client values. Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge,

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there may be areas of physical therapy interventions in which he or she displays advanced skills. At the same time, other previously gained knowledge and skill may be lost due to lack of use. To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence. Supervision Standard 3E states as follows: 3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient and client status requires modifications to the established plan of care. Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient and client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient and client status indicate that modifications to the plan of care may be needed. Further information on supervision via APTA policies and resources is available on the APTA Web site. Integrity in Relationships Standard 4 states as follows: 4: Physical therapist assistants shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, other health care providers, employers, payers, and the public. Interpretation: Standard 4 addresses the need for integrity in relationships. This is not limited to relationships with patients/clients, but includes everyone physical therapist assistants come into contact with in the normal provision of physical therapy services. For example, demonstrating integrity could encompass working collaboratively with the health care team and taking responsibility for one’s role as a member of that team. Reporting Standard 4C states as follows: 4C. Physical therapist assistants shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate. Interpretation: When considering the application of “when appropriate” under Standard 4C, keep in mind that not all allegedly illegal or unethical acts should be reported immediately to an agency/authority. The determination of when to do so depends upon each situation’s unique set of facts, applicable laws, regulations, and policies. Depending upon those facts, it might be appropriate to communicate with the individuals involved. Consider whether the action has been corrected, and in that case, not reporting may be the most appropriate action. Note, however, that when an agency/authority does examine a potential ethical issue, fact finding will be its first step. The determination of ethicality requires an understanding of all of the relevant facts, but may still be subject to interpretation. The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Exploitation Standard 4E states as follows: 4E. Physical therapist assistants shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students. Interpretation: The statement is fairly clear – sexual relationships with their patients/clients, supervisees or students are prohibited. This component of Standard 4 is consistent with Standard 4B, which states:

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4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees). Next, consider this excerpt from the EJC Opinion titled Topic: Sexual Relationships With Patients/Former Patients (modified for physical therapist assistants): A physical therapist [assistant] stands in a relationship of trust to each patient and has an ethical obligation to act in the patient's best interest and to avoid any exploitation or abuse of the patient. Thus, if a physical therapist [assistant] has natural feelings of attraction toward a patient, he/she must sublimate those feelings in order to avoid sexual exploitation of the patient. One’s ethical decision making process should focus on whether the patient and client, supervisee or student is being exploited. In this context, questions have been asked about whether one can have a sexual relationship once the patient and client relationship ends. To this question, the EJC has opined as follows: The Committee does not believe it feasible to establish any bright-line rule for when, if ever, initiation of a romantic/sexual relationship with a former patient would be ethically permissible. The Committee imagines that in some cases a romantic/sexual relationship would not offend … if initiated with a former patient soon after the termination of treatment, while in others such a relationship might never be appropriate. Colleague Impairment Standard 5D and 5E state as follows: 5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapist assistants who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. Interpretation: The central tenet of Standard 5D and 5E is that inaction is not an option for a physical therapist assistant when faced with the circumstances described. Standard 5D states that a physical therapist assistant shall encourage colleagues to seek assistance or counsel while Standard 5E addresses reporting information to the appropriate authority. 5D and 5E both require a factual determination on the physical therapist assistant’s part. This may be challenging in the sense that you might not know or it might be difficult for you to determine whether someone in fact has a physical, psychological, or substance-related impairment. In addition, it might be difficult to determine whether such impairment may be adversely affecting someone’s work responsibilities. Moreover, once you do make these determinations, the obligation under 5D centers not on reporting, but on encouraging the colleague to seek assistance. However, the obligation under 5E does focus on reporting. But note that 5E discusses reporting when a colleague is unable to perform, whereas 5D discusses encouraging colleagues to seek assistance when the impairment may adversely affect his or her professional responsibilities. So, 5D discusses something that may be affecting performance, whereas 5E addresses a situation in which someone is clearly unable to perform. The 2 situations are distinct. In addition, it is important to note that 5E does not mandate to whom you report; it gives you discretion to determine the appropriate authority. The EJC Opinion titled Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Clinical Competence Standard 6A states as follows: 6A. Physical therapist assistants shall achieve and maintain clinical competence. Interpretation: 6A should cause physical therapist assistants to reflect on their current level of clinical competence, to identify and address gaps in clinical competence, and to commit to the maintenance of clinical

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competence throughout their career. The supervising physical therapist can be a valuable partner in identifying areas of knowledge and skill that the physical therapist assistant needs for clinical competence and to meet the needs of the individual physical therapist, which may vary according to areas of interest and expertise. Further, the physical therapist assistant may request that the physical therapist serve as a mentor to assist him or her in acquiring the needed knowledge and skills. Additional resources on Continuing Competence are available on the APTA Web site. Lifelong Learning Standard 6C states as follows: 6C. Physical therapist assistants shall support practice environments that support career development and lifelong learning. Interpretation: 6C points out the physical therapist assistant’s obligation to support an environment conducive to career development and learning. The essential idea here is that the physical therapist assistant encourage and contribute to the career development and lifelong learning of himself or herself and others, whether or not the employer provides support. Organizational and Business Practices Standard 7 states as follows: 7. Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society. Interpretation: Standard 7 reflects a shift in the Standards. One criticism of the former version was that it addressed primarily face-to-face clinical practice settings. Accordingly, Standard 7 addresses ethical obligations in organizational and business practices on a patient and client and societal level. Documenting Interventions Standard 7D states as follows: 7D. Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided. Interpretation: 7D addresses the need for physical therapist assistants to make sure that they thoroughly and accurately document the interventions they provide to patients/clients and document related data collected from the patient and client. The focus of this Standard is on ensuring documentation of the services rendered, including the nature and extent of such services. Support – Health Needs Standard 8A states as follows: 8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. Interpretation: 8A addresses the issue of support for those least likely to be able to afford physical therapy services. The Standard does not specify the type of support that is required. Physical therapist assistants may express support through volunteerism, financial contributions, advocacy, education, or simply promoting their work in conversations with colleagues. When providing such services, including pro bono services, physical therapist assistants must comply with applicable laws, and as such work under the direction and supervision of a physical therapist. Additional resources on pro bono physical therapy services are available on the APTA Web site. Issued by the Ethics and Judicial Committee American Physical Therapy Association October 1981 Last Amended November 2010 Last Updated: 11/30/10