40 Tex. Admin. Code § 372.1 - Provision of Services
(a) Medical
Conditions.
(1) Occupational therapists may
evaluate the client to determine the need for occupational therapy services
without a referral. However, a referral must be requested at any time during
the evaluation process when necessary to ensure the safety and welfare of the
client.
(2) Intervention for a
medical condition by an occupational therapy practitioner requires a referral
from a licensed referral source.
(b) Non-Medical Conditions. The evaluation or
intervention for a non-medical condition does not require a referral. However,
a referral must be requested at any time during the evaluation or intervention
process when necessary to ensure the safety and welfare of the
client.
(c) Methods of Referral.
The referral must be from a licensed referral source in accordance with the
Occupational Therapy Practice Act §454.213 (relating to Accepted Practice;
Practitioner's Referral) and may be transmitted in the following ways:
(1) by a written document, including paper or
electronic information/communications technologies;
(2) verbally, either in person or by
electronic information/communications technologies. If a referral is
transmitted verbally, it must be documented by the authorized personnel who
receives the referral. In this subsection, "authorized personnel" means staff
members authorized by the employer or occupational therapist to receive
referrals transmitted verbally; or
(3) by an occupational therapy plan of care,
developed according to the requirements of this section, that is signed by the
licensed referral source.
(d) Screening, Consultation, and Monitored
Services. A screening, consultation, or monitored services may be performed by
an occupational therapy practitioner without a referral.
(e) Evaluation.
(1) The occupational therapist is responsible
for determining whether an evaluation is needed and if a referral is required
for an occupational therapy evaluation.
(2) Only an occupational therapist may
perform an initial evaluation or any re-evaluations.
(3) An occupational therapy plan of care must
be based on an occupational therapy evaluation.
(4) The occupational therapist is responsible
for determining whether any aspect of the evaluation may be conducted via
telehealth or must be conducted in person.
(5) The occupational therapist must have
contact with the client during the evaluation. The contact must be synchronous
audio and synchronous visual contact that is in person, via telehealth, or via
a combination of in-person contact and telehealth. Other telecommunications or
information technology may be used to aid in the evaluation but may not be the
primary means of contact or communication.
(6) The occupational therapist may delegate
to an occupational therapy assistant the collection of data for the evaluation.
The occupational therapist is responsible for the accuracy of the data
collected by the occupational therapy assistant.
(f) Plan of Care.
(1) Only an occupational therapist may
initiate, develop, modify, or complete an occupational therapy plan of care. It
is a violation of the Occupational Therapy Practice Act for anyone other than
the occupational therapist to dictate, or attempt to dictate, when occupational
therapy services should or should not be provided, the nature and frequency of
services that are provided, when the client should be discharged, or any other
aspect of the provision of occupational therapy as set out in the Occupational
Therapy Practice Act and Rules.
(2)
Modifications to the plan of care must be documented.
(3) An occupational therapy plan of care may
be integrated into an interdisciplinary plan of care, but the occupational
therapy goals or objectives must be easily identifiable in the plan of
care.
(4) Only occupational therapy
practitioners may implement the written plan of care once it is completed by
the occupational therapist.
(5)
Only the occupational therapy practitioner may train non-licensed personnel or
family members to carry out specific tasks that support the occupational
therapy plan of care.
(6) The
occupational therapist is responsible for determining whether intervention is
needed and if a referral is required for occupational therapy
intervention.
(7) Except where
otherwise restricted by rule, the occupational therapy practitioner is
responsible for determining whether any aspect of the intervention session may
be conducted via telehealth or must be conducted in person.
(8) The occupational therapy practitioner
must have contact with the client during the intervention session.
(A) The contact must be either:
(i) synchronous audio and synchronous visual
contact that is in person, via telehealth, or via a combination of in-person
contact and telehealth; or
(ii)
synchronous audio contact, provided that the occupational therapy practitioner
makes use of store-and-forward technology in preparation for or during the
intervention session. The synchronous audio contact may be in person and/or via
telehealth. In this subsection, "store-and-forward technology" means technology
that stores and transmits or grants access to a client's clinical information
for review by an occupational therapy practitioner at a different physical
location than the client.
(B) Other telecommunications or information
technology may be used to aid in the intervention session but may not be the
primary means of contact or communication.
(9) Except where otherwise restricted by
rule, the supervising occupational therapist may only delegate to an
occupational therapy assistant tasks that they both agree are within the
competency level of that occupational therapy assistant.
(g) Documentation.
(1) The client's records include the medical
referral, if required; the initial evaluation; the plan of care, including the
goals and any updates or change of the goals; the documentation of each
intervention session by the OT or OTA providing the service; progress notes and
any re-evaluations, if required; any patient related documents; and the
discharge or discontinuation of occupational therapy services
documentation.
(2) The licensee
providing occupational therapy services must document for each intervention
session. The documentation must accurately reflect the intervention, decline of
intervention, and modalities provided.
(3) In each intervention note, the
occupational therapy assistant must include the name of an occupational
therapist who is readily available to answer questions about the client's
intervention at the time of the provision of services. The occupational
therapist in the intervention note may be different from the occupational
therapist who wrote the plan of care. The occupational therapy assistant may
not provide services unless this requirement is met.
(h) Discharge or Discontinuation of
Occupational Therapy Services.
(1) Only an
occupational therapist has the authority to discharge clients from occupational
therapy services. The discharge or discontinuation of occupational therapy
services is based on whether the client has achieved predetermined goals, has
achieved maximum benefit from occupational therapy services, or when other
circumstances warrant discontinuation of occupational therapy
services.
(2) The occupational
therapist must review any information from the occupational therapy
assistant(s), determine if goals were met or not, complete and sign the
discharge or discontinuation of occupational therapy services documentation,
and/or make recommendations for any further needs of the client in another
continuum of care.
Notes
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No prior version found.