Declaratory Statements - PT Scope of Service

1. 05.02.01 Utilization of FCE results to determine disability/ability to return to work - Is interpretation of the tests in a FCE within the scope and practice of a physical therapist? The reason I pose this question is that a local attorney in Shreveport is challenging a physical therapists legal authority to interpret the results of a FCE. He quotes a statement in the practice act that the interpretation of the results of a FCE to determine disability must be performed by a healthcare provider licensed to practice medicine. I believe this requires clarification because we do determine whether or not a person is capable (or disabled) form safely returning to their previous occupation. You can not separate ability form disability in a thorough FCE intended to answer the question of whether or not the patient can return to their job.

   It is the Boards opinion that it is within the scope of practice for a Physical Therapist to utilize FCE results to make recommendations for Physical Therapy treatment or return to work status. When a Physical Therapist is trained to translate FCE results to a disability rating, then those findings must be reviewed by the physician for final disability determination.

2. 04.10.02 Balanced Suspension Skeletal Traction - Petition: Is it within our scope of practice as Physical Therapists to set-up "Balanced Suspension Skeletal Traction", and does the orthopedists have to be present to do so?

   Physical therapy education includes the physics, mechanics, indications, and contra-indications of traction. Primarily, physical therapy set up mechanical traction for cervical and pelvic distraction. Physical therapists also perform manual traction for spinal and peripheral joints.

   The Board understands ýBalance Suspension Skeletal Tractioný requires that the Orthopedic Surgeon has surgically implanted skeletal pins; and determined the line of pull and traction force. In most cases, the orthopedist either sets up the traction himself or trains someone to perform this task.

   The Board feels that a physical therapist may set up the Skeletal Traction as long as the orthopedist has trained the physical therapist; and there is documentation of the training and competency. If the physician has observed the therapistsý competent performance of traction set-up on a number of occasions and is satisfied with his skill and safety, and in the future writes an order specifying the type of set up and force he desires, he does not need to be present during the physical therapistýs performance of the task.

3. Acupuncture - Is Acupuncture within the physical therapy scope of practice?

   Acupuncture is not within the scope of physical therapy since it is considered an invasive procedure. If you are aware of any Physical Therapist in Louisiana that is performing acupuncture, please provide information to the Board so that we can investigate.

4. ADL/PT Question A - Can PT staff assist nursing with patient personal care and transfer of patients even though they are not the PTs caseload nor have at any time been evaluated by PT?

   It is the Board's understanding from review of the question that the inquiry focuses on physical therapy staff being asked to assist nursing to provide better service to the patients. Therefore, to assist nursing with patient care and transfer patients who are not physical therapy patients, and such ADL components are not referred to as nor billed as physical therapy, would not be considered in and of itself a violation of the Physical Therapy Practice Act or Rules and Regulations of the Board. For the activities to be within the scope of physical therapy practice, it would be necessary to have a physician's order and an established treatment plan with therapeutic goals.

5. ADL/PT Question B - What are the legal consequences if a PT did assist nursing in transfer of a patient and the patient were to sustain an injury during this time?

   Please refer to the Board's response to Question No. 1. It appears that your question more appropriately addresses the issue of civil liability. The Board does not give legal opinions with regards to civil liability and it is recommended that you contact an attorney who specializes in the civil practice of law to respond to any inquiries you may have in this area.

6. ADL/PT Question C - Is a PT "covered" by the hospitals liability insurance?

   Please refer to the Board's response to Question No. 2 and it is recommended that the hospital liability insurance policy be reviewed by your civil attorney in order to respond to any questions you may have.

7. ADL/PT Question D - Is a PTs license in jeopardy in the above situation and could we be personally sued?

   Again, the question with regards to being ?personally sued" involves the civil arena and is not within the province of the Board's jurisdiction. Please refer to the Board's response to Question No. 1.

   Your license could be sanctioned if you are practicing physical therapy without a physician's order or without an established treatment plan with therapeutic goals.

8. ADL/PT Question E - Since the PT is responsible for the actions of the PTA and the PT technician, if a tech is asked to assist nursing, is the PT still responsible?

   Please refer to the Board's response to Question No. 1. If the tech is performing as a "nursing technician", and the services are not referred to as physical therapy nor billed as such, then the Board would consider such actions within the jurisdiction of the Louisiana State Board of Nursing.

9. Appropriateness for Short Term Rehab-Quad patient - Can a quadriplegia patient be appropriate for short term rehab if the only reason for admittance is for UTI? The FIMS are 6 & 7 and from week to week don't change.

   No. In order to qualify for inpatient rehab, a patient must require three (3) hours of skilled therapy per day. In the patient scenario you describe, the patient would probably not have functional goals nor meet the three (3) hour criteria.

10. Assisting an MD in Surgery - Question by an insurance company Account Manager - "Is it within the scope of practice of a physical therapist to assist an MD in surgery?"

    There are certain physical therapy treatments which a physical therapist can perform in connection with surgery. Such acceptable physical therapy services are: joint mobilization, casting, application of TENS unit or CPM devices, application of post-operative bracing, pre- and post-operative positioning of limbs, assisting the physician with the set up of traction post-operative and other types of services. Additionally, some physicians send their patients directly to the physical therapy department after surgery or the physical therapist is sent to the patient's room immediately after the surgical procedure.

11. Buck's and Russell's Traction - Is it within the scope of practice for a physical therapist to set up traction for a lower extremity fracture, namely: Buck's traction and Russell's traction? Additionally, can a physical therapist touch a patient without a physical therapy order?

    The Board carefully reviewed your inquiry at its August 26, 1999 meeting and has directed me to respond accordingly. In response to your first question, it is within the scope of the practice of physical therapy for a physical therapist to set up traction for lower extremity fracture namely- Bucks' traction and Russell's traction. It is recommended that the physical therapist have documented training in the application of traction set-ups that would reflect competency in this procedure. Additionally, you are correct in your understanding that while a physical therapist may evaluate a patient to determine the need for physical therapy, it is necessary to have a physician?s order to be able to lawfully implement treatment such as traction.

    Furthermore, your letter addresses a hypothetical doctor's order which states "Buck?s traction, left lower extremity-five (5) pounds." The wording of this physician's order is proper to allow you to evaluate and implement traction pursuant to the Physical Therapy Practice Act and the Rules and Regulations promulgated by the Board.

12. Cold Laser for smoking cessation - May a PT use infrared therapy such as Cold Laser in a ýWellnessý Program? Cold lasers are currently being used to help ease withdrawal symptoms of smoking.

    It is the opinion of the Board that the use of infrared therapy would be considered treatment, and therefore not appropriate for use in a wellness setting.

13. Collection of Urine in Home Health Setting - Is it within the scope of practice for a physical therapist in a home health setting to collect urine samples?

    Urine collection is not within the scope of practice of Physical Therapy, however, it would be a decision made between the Physical Therapist and the Home Health Agency. The determining factors would be: Is the P.T. willing to do this? Is the Home Health agency able to train the Physical Therapist and document competencies in the procedure? Does this meet your licensing/certification requirements?

14. Computerized FCE - In the state of Louisiana, can a licensed physical therapist who is performing a computerized functional capacity evaluation utilize an extender with direct supervision to assist him or her with data collection?

    A physical therapist can utilize physical therapy supportive personnel under direct supervision when performing a functional capacity evaluation to assist with data collection. The physical therapist is solely responsible for the interpretation of any data collected and for making any recommendations to the physician, insurance company, etc.

15. Clinical Trial - Cipro - Can a PT participate in a clinical trial for Cipro, a drug used to treat urinary tract infections? The physical therapist will be examining joints for signs of inflammation, performing goniometry and observing gait. The result will be documented on forms provided by the drug company and the patients will not be billed for physical therapy.

    In answer to your first question, you do not need to obtain a prescription from a physician to complete your part of the study. The Board considers your participation in such a program to be part of the research study. Additionally, in answer to your supplemental question, the Board does not require you to prepare a medical record; however, it is required that you keep a research record with regards to your participation in the study. It is the Boards understanding that the original form for recording your range of motion, joint assessment and gait findings will become part of your research records.

16. Clipping or Trimming Toe Nails - The question specifically addressed whether or not the "clipping or trimming of toe nails" for a diabetic patient or a patient with other diagnosis is within the scope of practice for a physical therapist in Louisiana.

    Our practice act does not prohibit a physical therapist licensed in Louisiana from providing this service. The board does view this as a form of "sharp debridement" and therefore must only be done by the physical therapist and not the physical therapist assistant. This service can only be performed after receiving a referral from a physician and can be performed as part of a general order for "diabetic foot care". Please remember that this Board is only authorized to govern the practice of physical therapy in Louisiana. We therefore, suggest that you contact other regulatory boards, such as the Podiatry Board, to see if this practice is in violation of their practice act.

17. Craniosacral Therapy - I have received information regarding the denial of a complaint's treatment of Craniosacral Therapy as experimental. I am asking for an opinion from the Louisiana Board of Physical Therapy Examiners as to whether they consider this treatment to be experimental?

    The Louisiana State Board of Physical Therapy Examiners must respond that though research literature exists, it is not within the role of the Louisiana State Board of Physical Therapy Examiners to determine if Craniosacral Therapy is experimental or evidence based. Through its law, Rules and Regulations, the Louisiana State Board of Physical Therapy Examiners determines the scope of practice of Physical Therapy. The Board can report that there are components of Craniosacral Therapy, such as soft tissue mobilization and massage, which are within the scope of practice of physical therapy.

18. Diagnostic Testing - EMG - Is it within the scope of practice for a physical therapist to perform a surface EMG?

    Yes, a physical therapist may perform a surface EMG as part of an initial evaluatoin without a physicians referral. If a physical therapist is going to utilize the findings of the evaluation to implement a treatment plan, then the physical therapist shall obtain a referral for physical therapy prior to initiation of treatment. The physical therapist shall also report the results of the initial physidal therapy evaluation to the referring physicain, dentist, chiropractor, or podiatrist.

19. Dictation - Can a physical therapist dictate an evaluation or progress note and, thereafter someone hand write the dictation with the physical therapist signing the handwritten document?

    The Board is of the opinion that the law very clearly states that for all documentation that the physical therapist must write and sign such documentation. However, the physical therapist can dictate and it can be transcribed or typed on a computer and then signed by the physical therapist. It is the Boards intent for the physical therapist to compose, proof and sign the documentation. In no event, can a third party compose or rewrite the documentation. For the rule to be otherwise, subjects the documentation requirement to potential serious abuse.

20. Education of patients regarding diagnostic testing - Is it within our scope of practice to use diagnostic results to educate a patient on their condition when the patient was already given the results by their physician? Quite often patients do not understand, or may be confused about what the doctor has told them regarding test results. It could be due to a number of factors, but the botton line is that most of the time we use this educational tool to enhance their understanding for prevention, better self-management and compliance with home programs.

    While your points regarding patient education are certainly valid, it is the Boardýs opinion that the discussion of physician ordered diagnostic testing with the patient should be approached with great caution. Diagnostic tests, both laboratory and radiological, are ordered by the patientýs physician as part of the diagnostic process. The results of these tests are subject to wide interpretation by the ordering physician, based on their experience with the particular lab, radiologist, pathologist, etc.. The final opinion of the physician is established by utilizing all of this data to reach a diagnosis. In many cases, the physicianýs final diagnosis may not be what is printed on an MRI report or other diagnostic test report. Any discussion of these individual parts of the diagnostic process with the patient that occurs without the physicianýs knowledge and concurrence has the potential to create conflict with the patient regarding their final diagnosis. It would be more appropriate to discuss the results and the final diagnosis with the physician, and then utilize this insight to provide more directed and appropriate care to your patient. Specific questions regarding misunderstandings and interpretations of diagnostic testing should be referred back to the treating physician for clarification, as further interpretation would be beyond the physical therapistýs scope of practice.

21. Educational Seminars - Two (2) PTs will be establishing educational seminars, including golf/tennis, preventive stretching and wellness education. A concern exists which may occur during the seminar which would involve a request to initiate physical therapy treatment secondary to possible preexisting injury. More particularly, the inquiry addresses two (2) issues.

    First, the question is whether it is permissible under the Physical Therapy Practice Act and the Board's Rules for you to conduct an initial physical therapy evaluation on an individual to determine the need for physical therapy at an education seminar. The Board is of the opinion that this may be done during an educational seminar. However, please understand that pursuant to current law, it is necessary to obtain a physician's order prior to the initiation of physical therapy treatment. However, the scenario proposed is not in violation of the Physical Therapy Practice Act and the Board's Rules regarding this issue.

    Second, you address the issue of establishing physical therapy treatment in a fitness setting if an order for physical therapy is received from a physician. Again, you can implement physical therapy treatment to a patient in any given setting as long as you comply with the requirements of the Physical Therapy Practice Act and the Board's Rules. As you have appropriately pointed out, to implement physical therapy treatment it is necessary to have a physician's order.

22. Evaluating and Treating Iontophoresis - Does a doctor's order stating "evaluate and treat" encompass iontophoresis? Does the term "modalities" in an order also allow iontophoresis? Does the administration of iontophoresis require an order specific for it because it involves administering medication?

    A doctor's orders stating "evaluate and treat" does encompass iontophoresis. The term "modalities" in an order does allow iontophoresis. If the physician orders "evaluate and treat," then the physical therapist has the discretion to decide the plan of care after performing an initial evaluation. However, if the order is specific as to the medication, then the physical therapist must get approval from the physician should the physical therapist recommend something different than what is specified in the order.

23. FCE - Extender Assistance - Can a licensed physical therapist who is performing a computerized functional capacity evaluation utilize an extender with direct supervision to assist him with data collection?

    A physical therapist can utilize physical therapy supportive personnel under direct supervision when performing a FCE to assist with data collection. The physical therapist is solely responsible for the interpretation of any data collected and for making any recommendations to the physician, Insurance Company, etc.

    At the outset, a physical therapist must be actively and directly involved in the performance of any evaluation, which includes an FCE. A physical therapist can not delegate any part of an evaluation to a tech. The tech may assist in patient set-up, positioning and recording data; however, a tech is prohibited from collecting data.

    During the collection of data, the physical therapist must be continuously observing the patient's performance and continuously interpreting the patient's behavior, body mechanics, limiting motion and monitoring safety concerns. Rule 305C promulgated by the Board states that it is prohibited for physical therapy supportive personnel to perform evaluations.

    Pursuant to Rule 305 there are two (2) types of supportive personnel, i.e., a physical therapist assistant and a tech. A tech is not legally permitted to do measurements. A physical therapist assistant may be able to do certain measurements as delegated by, the physical therapist. The physical therapist assistant may assist in the testing if he has documented training and skills in goniometry and muscle testing, however, he also can not perform the entire data collection. It was not the Board's intent for its June 1, 2001 response to be interpreted to mean that an extender with direct supervision may perform the entirety of the data collection during the concept of "assisting a physical therapist while under direct supervision." Therefore, supportive personnel, such as a physical therapist assistant or tech. can not lawfully perform the entire computerized portion of an FCE. In comparison, support personnel may press the keyboard as the physical therapist is actually present, performing, and evaluating the patient's performance and efforts/body mechanics and physiologic responses.

    Therefore, in summary, a physical therapist cannot delegate to supportive personnel the "data collection and performance testing" which requires ongoing observation, the performance assessment of a patient's physiologic responses, efforts, consistency and clinical decision making. It is also the Board's opinion that supportive personnel may not sign the FCE document and/or summary report as an evaluator.

    In the event supportive personnel and/or a supervising physical therapist is performing or allowing FCEs to be performed in a manner which is inconsistent with this letter, such would be a violation of the Physical Therapy Practice Act and the Board's Rules. However, at the present time, this letter is being forwarded to New Day Rehabilitation and you so as to place you on notice of the Board's supplementation of its earlier declaratory statement.

24. FCE Without a Physician's Referral - May a PT legally perform an FCE without a physician's referral?

    The Board is of the opinion that no prescription or referral from a person licensed to practice medicine, surgery, dentistry, or podiatry is needed to perform a functional capacity evaluation with regards to eligibility for workers' compensation benefits and/or social security benefits; however, the interpretation of results of a functional capacity evaluation to determine a disability rating must be performed by a health care provider licensed to practice medicine. Additionally, no prescription or referral is needed from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractor for the physical therapist to perform a functional capacity evaluation to determine the need for physical therapy, however, to implement a physical therapy treatment program is necessary for the physical therapist to obtain a prescription from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractor.

25. FMP - I work at a LTAC facility in Shreveport. I emailed a question late last year regarding a' Functional Maintenance Program that my hospital was starting. According to your response, such a program should not be associated with therapy at all. My supervisors are asking the therapists to: assess pts for FMP (don't we need a clearly defined order in the chart?); assign FMP pts to rehab techs (techs that work in the OT and PT dept). I interpreted your answer to my last inquiry to mean that once a pt is discharged from therapy, any maintenance program should be carried out entirely by nursing staff. My supervisor maintains that rehab techs can carry out an FMP program (ROM, OOB) because they would be under the supervision of nursing at that time. How can this be delineated? It seems to me that either their job description would need to be changed, or the person carrying out the FMP should be a designated member of the nursing staff. Could you please clarify the role of PT's AND rehab techs, in a Functional Maintenance Program?

    The Board would like to inform you that you may screen a patient for the need for physical therapy, however, any recommendations that require the establishment of goals and treatment plans would constitute physical therapy treatment or services. A PT may evaluate a patient to establish a Functional Maintenance Program as PT intervention, which would include an evaluation, establishment of goals, and a treatment plan. As such, a specific order would be required in order for the therapist to establish the goals and treatment plan (s), and to provide supervision and reassess the appropriateness of the FMP for the patient. Once the FMP is established and the program can be provided strictly for maintenance, the patient should be discharged from physical therapy. If the PT has determined as results of an evaluation or screening that the patient would not benefit from PT intervention, then an order would not be required. The provision of maintenance services for patients no longer requires skilled physical therapy intervention and would be provided by non-therapy personnel.

    The Board has no recommendations for the delineation of the rehab techs roles between therapy service and nursing service. This delineation should be outlined in personnel policy and procedure. However, it is imperative that a FMP which is no longer a Physical Therapy intervention be clearly identified as such including that personnel assigned to and or supervised by Physical Therapist not perform the FMP.

26. Full Contact Casts - Can a PT Nurse put on a full contact cast and bill for it?

    The Board has the jurisdiction in Louisiana to regulate the practice of physical therapy. Pursuant to State law, the Board licenses PTs and PTAs who have satisfied the requirements for licensure. Pursuant to Louisiana law, there is no such legal being as a "PT nurse."

    Pursuant to the Physical Therapy Practice Act of Louisiana, a PT may perform an evaluation or consultation to determine the need for physical therapy treatment and to establish a plan of care. However, to implement treatment, a PT must obtain a prescription or referral from a person licensed as a physician, surgeon, dentist, chiropractor or podiatrist. Therefore, the PT must first evaluate the patient and establish a plan of care. When a full contact cast is removed, a PT must again evaluate the patient to determine whether there is a continued need for physical therapy treatment. If so, the treatment plan will be modified by the PT accordingly.

    Furthermore, in Louisiana, a PT can delegate certain tasks to a PTA. PTAs may perform only those functions for which he has documented training and skills. Additionally, the level of responsibility delegated is at the discretion of the PT, who is ultimately responsible for the acts or omissions for the PTA. I would like to point out that pursuant to Louisiana law; a PTA may not perform evaluations or adjust treatment programs.

27. Initial Physical Therapy Evaluation/Advertisement - Pursuant to the Physical Therapy Practice Act, more particularly LSA R.S. 37:2401 A, and the Board's Rules, an initial physical therapy evaluation may be conducted by a physical therapist prior to a doctor's order. However, it is necessary under the current law to obtain a doctor's order prior to initiating physical therapy treatment?

    The board is of the opinion that to advertise the provision of this physical therapy service is not a violation of the Physical Therapy Practice Act or the Board's Rules. Please be advised that such advertisement must not be deceptive or misleading. You are encouraged to discuss with your private counsel this issue in more detail with regards to any other lawful requirements regarding advertisement.

28. Information Released Over the Phone - What information can be released via telephone to an insurance case manager and can an out-of-state insurance management firm dictate P.T. treatment?

    In response to the first question, no information can be released without the written consent of the patient or as authorized by law. The Board feels it would be prudent to require written authorization with specifics from the party requesting the authorization. In answer to the second question, physical therapy services rendered can not be changed without the written prescription of a physician who is licensed. No authorized source outside the State of Louisiana has any right to make any prescription change whether that be an out-of-state physician or case manager. The attending Louisiana physician is in the best position to determine the need for a prescription chance.

29. Integumentary System - Does the Physical Therapy Practice Act allow a clinical examination of the integumentary system?

    The law specifically requires that a physical therapy initial evaluation be performed before a treatment can be initiated. Our definition of physical therapy evaluation, which can be found in 305A. specifically states:

    Physical Therapy Evaluation - means the evaluation of a patient by the use of physical and mental findings, objective tests and measurements, patient history and their interpretation, to determine musculoskeletal and biomechanical limitations, to determine his suitability for and the potential efficacy of physical therapy and the establishment or modification of treatment goals and a physical therapy treatment program.

    The Rules and Regulations also define wound care and debridement, which includes sharps debridement. Therefore, the Board is of the opinion that all the evaluative, and objective measurements described are definitely within the scope of practice for a PT licensed in the state of Louisiana.

30. IVIVI - I would like to ask about whether a Physical Therapist can perform the application of "IVIVI" (a device that uses electromagnetic pulse to stimulate wound healing) The protocol is: IVIVI is applied to a dressed/ wrapped wound for 30 min BID. This is a new device and we would like to try it out in our facility since we deal with a lot of wounds (LTAC). I wonder if this is similar to using ESTIM on a wound and can be performed by a PT and charge for it? Please let me know if this is under our scope of practice and if you have an idea on what charge code it would be under.

    The board reviewed documentation and additional web information and determined this procedure would be within the scope of practice for a physical therapist. The board suggests you contact the product company and request information regarding billing.

31. JACHO standards for weekend care - According to JACHO accreditation standards how many PT treatments are patients required to get on Saturday and Sunday (if any) in the following settings: Acute care hospital patients, Skilled nursing beds in hospital (SNF), and nursing home residents?

    Inquiries regarding JACHO are more appropriately addressed to that entity. It is not within the board's jurisdiction to answer these issues. However, it is required by the Board as per the Practice Act and its Rules and Regulations that the plan of care must be established by the physical therapist and it is necessary that he follow through with such plan.

32. Legend Drugs - DEA Cert - We were told that a DEA Certificate would be required for us to purchase supplies from a surgical supply company. In the past we had provided a copy of our PT license. The representative of the supply company was told by the I State Board of Wholesale Pharmacies that a DEA certificate would be required and that this had been discussed at the Physical Therapy Board meeting. Have you heard anything about this? The supplies purchased state that they can not be dispensed without a prescription.

    The Board is not aware of any "DEA Certificate" requirements for a physical therapist to purchase supplies. In July 2000, the Physical Therapy Practice Act was amended to prohibit a physical therapist from copying their license. You can no longer provide the distributor with a copy of your license.

    In January 2002, the Board was in contact with the Louisiana State Board of Wholesale Drug Distributors (The "WDD Board''). Pursuant to the WDD Boards law, a customer of a wholesale drug distributor must possess a license/permit as authorized by law to procure or possess a legend drug. Section 3462 (4) of the Wholesale Drug Distributors Act defines "legend drug" to mean "any drug intended for use by humans that carries on its label the statement: 'Warning Federal law prohibits dispensing without a prescription!' The prescription must be from an authorized practitioner such as a physician, surgeon, podiatrist, dentist as well as physician?s assistant and advanced practice registered nurse. The Physical Therapy Practice Act does not in and of itself authorize Physical Therapists to procure or possess legend drugs. A legend drug can only be procured by an authorized practitioner.

    It is the Board's recommendation that in an outpatient setting you obtain a prescription from the patient's doctor for any legend drugs you plan to use in your treatment program. These would include the iontophoresis drugs of dexamethasone or lidocaine. If your outpatient facility had a medical director, you may also use this provider to obtain these drugs.

    In a hospital setting the medications will be under the auspices of the referring physician who will be ultimately responsible for ordering the treatment that involves the legend drug.

33. Low Laser Therapy - Is the use of low level laser therapy or cold laser in our scope of practice?

    Further research was necessary for the Board to adequately answer your question. Research found that cold laser is taught within physical therapy curriculums. The Board reviewed the information during the regularly held meeting in July of 2004 and concluded that the use of low laser therapy or cold laser therapy is within the scope of practice of Physical Therapist in the State of Louisiana.

    http://www.wholehealthmd.com/refshelf/substance view/0,1525,713 MO,00.html Cold laser therapy. Also known as soft or low-level laser therapy, this type of light therapy focuses a beam of low-intensity laser light at a particular area of the body. The treatment is thought to initiate a series of enzymatic reactions and bioelectric events, which stimulate the natural healing process at the cellular level. Supporters suggest that cold laser therapy is useful for relieving pain, reducing inflammation, and helping to heal wounds, however there has been no scientific proof of this. http://www.downstate.edu/CHRP/PT1/paqes/pt2.htm

    PHTH 4009

    Electrodiagnosis and Electrotherapy

    The use of high- and low-voltage electrical currents for diagnosis and treatment in physical therapy. The physical characteristics and physiological basis for the use of low voltage AC/DC, high volt and interferential currents are discussed. Special applications in transcutaneous electrical nerve stimulation, functional electrical stimulation, biofeedback, iontophoresis, cold laser, and EMG/NCV measurements are taught for safe and effective diagnosis and treatment of physical dysfunction.

    CHAPTER 29. PHYSICAL THERAPISTS

    2401. Definitions The following words and phrases, when used in this Chapter. shall have the meaning ascribed to them in this Section unless the conte:\.1 clearly indicates a different meaning: (l)(a) "Practice of physical therapy" is the health care profession practiced by a physical therapist licensed under this Chapter and means the holding out of one's self to the public as a physical therapist and as being engaged in the business of, or the actual engagement in. the evaluation and treatment of any physical or medical condition to restore normal function of the neuro-muscular and skeletal system, relieve pain, or prevent disability by use of physical or mechanical means, including therapeutic exercise, mobilization, passive manipulation, therapeutic modalities, and activities or devices for preventative. Therapeutic, or medical purposes, and further shall include physical therapy evaluation, treatment planning, instruction, consultative services, and the supervision of physical therapy supportive personnel, including physical therapist assistants. (b) The under the terms "physical therapy" as used in this Chapter and a license issued pursuant to this Chapter does not authorize the diagnosis of disease or treatment, without the prescription or referral of a person licensed in this state to practice medicine, surgery, dentistry, or podiatry.

34. Low Vision Rehab - Can a PT offer low vision therapy to homebound patients who are unable to perform and manage daily living activities?

    The Boardýs opinion is that it is within the scope of physical therapy practice for a physical therapist to do low vision therapy. As required by the La Physical Therapy Practice Act, the physical therapist is required to have a referral and a diagnosis from a physician and should be trained in the area of low vision therapy. You may want to review the applicable statute which is L.R.S. 37:2401(1)(a).

35. Mobility Training for the blind - One of our staff physical therapist is interested in working with individuals with blindness to address skills related to mobility and training the individual in using a white walking cane. Are there licensing/legal issues that prohibit her from doing this? We have found that a certification exists for mobility training with a cane. However, it is unclear if the training is required. Also, we are unclear if this falls within the practice of physical therapy

    Gait training for patients and/or their families is within the scope of practice for a physical therapist. The rules do not address specific training for the physical therapist regarding certification for mobility training with a cane. While certification is available, it is not required. There is a program available for Orientation and Mobility Training.

36. Neurobiofeedback/EEG - Is legal for a licensed physical therapist to utilize neurobiofeedback/EEG feedback in his/her practice if he/she has been trained for its use through continuing education. It can be utilized to treat chronic pain syndrome symptoms, fibromyalgia symptoms, headache symptoms, anxiety symptoms, PMS symptoms, etc. which would apply to our profession. It only involves electrodes which are placed on the skin. Invasive electrodes which are defined as needle/subdural electrodes are NOT utilized with neurofeedback techniques.

    The board determined that the use of neurobiofeedback iis appropriate for utilization by a physical therapist in their practice.

37. NCV testing - Is it within the scope of practice for a physical therapist to conduct NCV testing with invasive electrodes?

    In regards to the use of NCV testing by physical therapists, it is considered within the scope of practice when using surface electrodes, but not with the use of needle or invasive electrodes. It should be noted that needle EMG testing is considered beyond the scope of practice of physical therapists. It is considered a dynamic diagnostic test that requires ongoing diagnostic skills that may modify the course of the exam.

38. Ortho Tech/Debridement Issues 1 - If an ortho tech (who is under physical therapy cost center) performs crutch training on a patient and has been competency tested by a physical therapist to perform such a task, is the physical therapist liable if any unfavorable circumstances occur (In this instance, there has been no physical therapy consult, no physical therapy charge, no physical therapy documentation, no physical therapy interaction whatsoever with the patient).

    In response to your question, the board is of the opinion the title of an individual is not necessarily reflective of his function. Therefore, the board's opinion is not affected by the title you give to the tech. The patient is being provided services under physical therapy pursuant to your scenario. Therefore, the physical therapist must evaluate and is ultimately responsible for the treatment. As you are aware, the physical therapist must have a standing order as protocol or a physician's order. Additionally, the physical therapist must document.

39. Ortho Tech/Debridement Issues 2 - What is the board's stance on physical therapists debriding full thickness wounds and/or wounds extending into subcutaneous tissue (muscle and bone) and the use of 11000 codes specifically 11041 to 110144 to charge for these services?

    In response to question #2, the board is of the opinion that a physical therapist can debride the full thickness of wounds and/or wounds extending into subcutaneous tissue (muscle and bone). A physical therapist can use codes to charge for such services, however, it is the board's understanding that Medicare has a new code, G0169, for a physical therapist to bill for any type of debridement. It is believed that such code does not involve a timed unit, but rather a procedure unit. It is recommended that you review the new code and its applicability with the appropriate governmental agency which regulate such issue for Medicare.

40. Over the Counter Drugs - Is it within the Physical Therapy Practice Act and Rules and Regulations of the Board to sell vitamins, minerals and/or food supplements to patients in your clinic? It is the Board's understanding from the letter that the availability of such products in the facility would be a convenience to patients.

    The Board has carefully reviewed the inquiry as well as the Physical Therapy, Practice Act and Rules and Regulations promulgated by the Board and is of the opinion that the sale of these products is not within the scope of practice of physical therapy. However, such provision or promotion of these products may be in violation of other applicable laws and rules and regulations concerning "over the counter" drugs, including natural products or herbs. It is strongly recommended that you contact the Louisiana Board of Pharmacy and possibly any applicable federal agencies, such as the FDA, with regards to your inquiry and any requirements or prohibitions concerning the provision or promotion of such products.

41. Parental Permission - Problem: One parish's Special Education Department was requiring that a treating physical therapist must obtain parental permission prior to communication with the referring physician and that some parents refused to sign the release giving the P.T. permission to contact the physician.

    The Board attorney discussed this issue with the Acting Director of Special Education whose position was that the requirement of the "right to fair notice" between the P.T. and parents of the child must be complied with. While it is not disputed that there should be open communication between the attending physical therapist and the parents of the child, pursuant to the Physical Therapy Practice Act of Louisiana, more particularly LSA R.S. 37:2410, as a licensed physical therapist you are required by law to communicate with the referring physician regarding physical therapy evaluation and treatment procedures. To do otherwise would, of course, potentially subject your license to sanction as provided by law. Additionally, in reviewing the law regarding Education of Exceptional Children, more particularly LSA R.S. 17:1955(4) regarding Confidentiality of Information, the statute provides that "information contained in the individual education plan or evaluation shall not be available to the public and shall be available to the professionals in need of such information in connection with the educational program and evaluation of the child subject to existing federal and state laws governing such information." It is not disputed that Section 506 of the Regulations implemented by the Office of Special Educational Services regarding confidentiality of information requires open communication between the health care providers and the parents of the children. However, there is no requirement in the regulations and/or the law mandating that the physical therapist obtain approval from the parents in order to communicate with the referring physician regarding medical treatment. Based upon the foregoing, it is the Board's opinion that the physical therapist has the obligation to communicate with the referring physician regarding the medical condition and treatment of the patient. Additionally, it is the obligation of the treating physical therapist to comply with the requirements of the law and regulations concerning the education of exceptional children, more particularly in the present matter to maintain open communication between the physical therapist and the parents of the child.

42. Patient Abandonment - If a therapist is not being compensated for patient care does a departure from the facility constitute patient abandonment?

    Without becoming involved in the employer/employee relationship, the Board takes the position that your departure with reasonable notice is acceptable if it is not detrimental to the health of the patients which you treat. The Board does not require a physical therapist to work without compensation, however, it is mandated by law to protect the recipients of such services. Therefore, whether a physical therapist's termination of personally rendering services is detrimental to the health of the patient is a situation which must be reviewed by the Board on a case by case basis. There are no rules and regulations promulgated by the Board with regards to a "time line" regarding notice and the termination of the provision of services by a particular physical therapist. In conclusion, there is no magic answer or time line within which a physical therapist must comply regarding his termination of services rendered to patients due to his departure from employment. Please understand that the standard by which the Board uses to determine patient abandonment is whether or not the termination of patient treatment is detrimental to the health of the patient.

43. Physical Therapy Diagnosis - What does the statute/Practice Act say about physical therapists working for me giving a patient a diagnosis? The patient in question had seen a physician, and been given a diagnosis that was different than what the therapist determined was the problem following her extensive evaluation.

    It is within the scope of practice for a physical therapist to make a physical therapy diagnosis as a result of the extensive evaluation. The physical therapy diagnosis can be different from the physicianýs diagnosis. The physical therapist diagnosis is then reportable to the treating physician.

44. Physical Therapy Services/Nursing Home - Is it acceptable for a patient's therapy treatment (i.e. occupational therapy, physical therapy, or speech therapy) to be missed due to a holiday?

    At the outset, the Board is mandated with the authority to regulate the practice of physical therapy and, as such, cannot comment on occupational therapy and/or speech therapy. It is suggested that you contact the regulatory authorities which govern these particular therapy services. However, with regard to the practice of physical therapy, it is acceptable for a patient's physical therapy treatment to be missed due to a holiday if it is not detrimental to the health of the patient. It is the board's understanding that most facilities do not treat patients on holidays, however, there are exceptions such as a burn patient. It must also be stated that a physical therapist cannot abandon his patient and must get coverage if an otherwise missed treatment would be detrimental to the health of the patient.

45. Physical Therapist Supervision - If a physical therapist assistant (PTA) is working 8 hours a day, can the physical therapy (PT) supervision be supplied two hours in the a.m. and two hours in the p.m., or, is the P.T. supervision mandated to be four hours consecutively?

    In response to your question, the Board is of the opinion that Rule 321A1 does not require the supervision to be four (4) consecutive hours.

46. Pilates - Question 1: Are there any rules that would prevent a physical therapist, who is also a certified pilates instructor, from working in a pilates studio as an instructor? Question 2: I have an additional question with regard to therapists working as pilates trainers in a studio setting. Do the same rules apply for a therapist who is not licensed in Louisiana?

    Your questions are addressed by the Practice Act (La.R.S. 37: 2401-2421), specifically:

    2410. Practice A. A physical therapist licensed under this Chapter is fully authorized to practice therapy as defined in this Chapter. A person licensed under this Chapter may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy without referral or prescription, but implementation of a physical therapy treatment to individuals for their specific condition or conditions shall be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic.

    D. A physical therapist licensed under this Chapter shall not perform physical therapy services without prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.

    The Rules and Regulations further explain the practice of physical therapy in the above section of the Practice Act:

    305. Special Definition: Practice of Physical Therapy Preventative Services ? the use of physical therapy knowledge and skills by a physical therapist to provide education or activities in a wellness setting for the purpose of injury prevention, reduction of stress and/or the promotion of fitness, but does not include the administrations of physical therapy treatment and, therefore, can be performed without referral or prescription.

    306 Physical Therapy Services Without Prescription or Referral C. As used in connection with providing the services referred to in LSA-R.S. 37:2410 D. (4): (1) The word "client" shall mean an individual seeking or receiving information, education and/or recommended activities concerning wellness and preventative services, including conditioning, injury prevention, reduction of stress or promotion of fitness. (2) Prior to providing services, the physical therapist shall: (a) perform an initial screening to determine whether treatment or wellness/preventative services are indicated. The therapist shall inform the individual of screening results and make recommendations for follow-up with the appropriate health care provider if needed. (b) assess the client?s wellness/preventative services needs, and, should wellness/preventative services be indicated and desired, develop a written plan, which describes the wellness/preventative services to be rendered to the client.

    Given the Practice Act and Rules/Regulations, a physical therapist must exercise caution while functioning as a pilates instructor. Specific precaution should be taken in regards to individuals "seeking and receiving information, education and/or recommended activities concerning wellness and preventative services, including conditioning, injury prevention, reduction of stress or promotion of fitness." When a participant of such an exercise class seeks or receives individualized information as outlined in the Rules/Regulations, then the physical therapist must fulfill the requirements of 306, C.(2) (a) and (b). Otherwise, the P.T. is functioning only in the role of teaching a Pilates group exercise class.

47. PTA - Stable Extractor - What is the role of the PTA in staple Extraction?

    The Board is of the opinion that staple extractor is not considered a sharp debridement instrument and can be performed by a physical therapist assistant if there is a physician?s order and the physical therapist has assessed the patient prior to the use of the staple extractor. Additionally, the Board refers you to Rule 305 with regards to the level of responsibility which may be assigned to supportive personnel, including a physical therapist assistant, by a physical therapist.

48. Pulse Oxymeters - Are physical therapists able to legally use pulse oxymeters as an integral part of their practice, regardless of the setting, and are they able to document that use?

    Yes. The Board feels that it is appropriate to use vital signs to monitor patient response to treatment. The use of pulse oxymeters is one way to monitor vital sips. If a physical therapist has documented evidence that they have been trained in the use of these devices, then they should use them as appropriate. The responsible way to treat patients with COPD, cardiac and/or multiple medical problems would be to monitor vital signs prior to, during, and post treatment. The setting in which this is done should not matter. The therapist should absolutely document the use of these devices in the note for that day, just as would be done with blood pressure, heart and respiration rate measurements.

49. Respiratory Skills - Our rehabilitation facility is undergoing respiratory skills competencies. The question has been raised regarding the legality of PTs providing endotracheal auctioning if trained by a respiratory therapist Please advise us if this is acceptable.

    Historically speaking, respiratory care has always been a part of the scope of practice of physical therapy. However, through the passage of time, and with the creation of the respiratory therapy profession, the need for a PT's day to day involvement with respiratory techniques has been reduced. Please be advised that a PT is still trained in respiratory techniques such as endotracheal suctioning and generally performs such services in emergency situations. Therefore, in response, the Board is of the opinion that it is acceptable and within the scope of the practice of physical therapy for a PT to provide endotracheal suctioning with proper training and verification of competencies by a respiratory therapist, a registered nurse, or a physical therapist competent in the provision of such procedure.

50. Restraint Reduction Programs - The proposed restraint reduction program is to be a service to your customers in nursing homes. As stated, a nurse would first give a resident's name to the physical therapist to conduct what you refer to as a "screen". It is the understanding that such a screen would determine whether the resident would benefit from a full physical therapy evaluation and, if not, the physical therapist would look specifically at the current restraint to determine whether it appears effective or not. If such restraint for the resident is not appropriate/effective then the physical therapist may make a recommendation for a more appropriate/effective restraint/non-restraint. The physical therapist screen would be presented to the Care Plan Team which would make the final decision with regards to the recommendation.

    At the outset, what is referred to as a physical therapist "screen" is a physical therapy consultation as defined in the Physical Therapy Practice Act and the Board's Rules. A physical therapist is allowed by law to conduct a consultation of a screening nature to determine the need for physical therapy. Such consultation does not require a physician's order. As you are aware, pursuant to the Physical Therapy Practice Act, more particularly LSA R.S.37:2410 A, you may not begin physical therapy treatment without a physician's order.

    The proposed program is not a violation of the Physical Therapy Practice Act or the Board's Rules. However, it is highly suggested that you develop "high risk" criteria for the nurses to use to determine if the patients fall within such category which would necessitate the use of the physical therapist consultation. Additionally, the whole protocol should be approved by the medical director of the facility.

51. Reimbursement/Wound Care - Is a PT allowed to treat Stage 2, 3, and 4 wounds?

    First, PTs in Louisiana are allowed to treat Stage 2, 3, and 4 wounds with blunt debridement, various dressing changes, ultrasound, e-stim and sharp debridement. Additionally, it is required that you have a physician's order to perform these physical therapy modalities. It is necessary to further comply with the Physical Therapy Practice Act and the Board's Rules and Regulations with regards to evaluation, plan of care, documentation, etc. Also, please be advised that PTAs are not allowed to do sharp debridement. Secondly, the Board regulates the practice of physical therapy and does not have jurisdiction to address reimbursement questions. It is recommended that you contact medicare and other payors with regards to reimbursement issues. It is the Board's understanding that JCAHO and CARF are accrediting bodies and as such do not reimburse for treatment. You may wish to address this issue with JCAHO and CARF in order to verify whether or not these entities have rules regarding reimbursement.

52. Silver Nitrate Stick - I work for an LTAC unit, where I do almost all of our wound care. In situations where I am removing wound vacs, doing sharp debridement, etc., I have some patients that are bleeding, and I am unable to stop it for long periods even with constant pressure etc. I was wondering if it is allowed under our laws, if a PT can use silver nitrate. My company would like an answer from the board before we make any decisions on our end. Just to let you know, we do not always have a doctor on the grounds of the hospital to assist.

    It is within the scope of practice for a physical therapist to apply the silver nitrate to a specific area of a wound after an evaluation of the wound to determine exactly where the agent should be used. Since the condition of a wound frequently changes from visit to visit this patient would require more frequent evaluations and reassessments. This mean that the patient would have to be reassessed at every visit to determine if the patientýs wound required continuation of the application of the silver nitrate.

53. Splinting - Osteopenia - 1) Are we allowed to apply splints for the purpose of stabilizing a fracture if ordered by a Orthopedist? 2) Would is be appropriate splinting a baby with a diagnosis of osteopenia? 3) Can a splint be removed and reapplied by the nursing staff?

    1) It is the opinion of the Board that it is within the scope of practice for a physical therapist to fabricate and apply splints for fracture stabilization if ordered by an Orthopedist.

    2) If the diagnosis, osteopenia, or any other diagnosis is appropriate for splinting for boney or soft tissue structure support, then this is within our scope of practice.

    3) If you have in-serviced and documented training for donning and doffing a splint to the nursing staff and you as the physical therapist feels that the procedure can be safely performed by nursing staff, then it could be appropriately delegated.

54. Standing Frames and Gait Trainers - 1) Are these pieces of equipment (standing frames and gait trainers) "medical equipment" that should be used only under the direct supervision of a doctor and private therapist in a rehab setting? 2) Do these pieces of equipment (standing frames and gait trainers) require the expertise of a private PT every time the child is using it, due to daily changes in the child's medical status (for example, increased tone, hip subluxation, hip dislocation, blood pressure differences, ankle instability, knee instability, broken/fractured bones, etc.)? 3) Should a lay person (teacher or classroom aide) who has no training in the medical profession be using this equipment (standing frames and gait trainers) at all? 4) Can a PT train a teacher or classroom aide to use this equipment (standing frames and gait trainers) in the classroom and allow them to use it daily without a PT on the premises or without a PT first assessing the patient's status (every time, everyday)? 5) Are there any definite delineations between types of adaptive equipment that can be used by lay persons or that must be used by a PT? Or at what point can it change from being only used by PT to okay to be used by lay person? For example, how proficient must the child be? How much risk of injury? How much medical training must the person using it have (PT license, PTA, some medical training, no medical training, etc.)? How much documented training from a PT should they have? 6) Is a standing frame in the same category as a tilt table (done in rehab therapy under direct supervision of a doctor and PT)? Both are used as a device to increase a person?s tolerance to weight bearing and standing. 7) Is a gait trainer in the same category as parallel bars (done in rehab therapy under direct supervision of a doctor and PT)? Both are used as a pre-gait device before progressing to a walker. A gait trainer just allows the therapist's hands to be free to facilitate the pelvis for gait training and does not have the restraints of a 115-20 foot path like parallel bars. 8) Are any other pieces of equipment listed NOT okay to be used by a teacher/aide after training by PT/OT? 9) I know that in the State of Louisiana, there are a good number of PTs that are currently working in the school systems. Have there been any other similar concerns by other PTs? Are you aware of anything they are doing differently? For example, one parish I am told is still using the standing frame and gait trainers, although they agree they are rehab, but to abide by the PT Practice Act, are having the PTs do the actual therapy. That means that for one child, the PT is traveling daily to that school and putting him in, watching him stand for 20-30 minutes, and then taking him out of the standing frame. This in my opinion is rehab, definitely not cost effective for the school system, and not within the federal, state, and parish guidelines for PT in the school system. 10) Is there any written information/articles regarding the difference between a "gait trainer" and a "regular walker?" A child with only some head control can be fully supported by a "gait trainer" including sitting and having very limited weight-bearing through their lower extremities. Is this considered walking? Can a "gait trainer" ever be considered a "regular walker?"

    1) These pieces of equipment are purchased by school systems, nursing homes, and privately as well as by MD referral. They are used in all these settings as well as at home by parents.

    2) If a child's medical status changes daily, then this would be within the discretion of the therapist to decide whether it should be assigned to another to perform. If the child's medical status is very fragile, the physical therapist should exercise her discretion and not assign the task to another.

    3) As you are aware, patients use this equipment frequently. Good documentation by the physical therapist is needed as to proper instruction to the caregiver. The teacher or classroom aides are not considered physical therapy supportive personnel since the use of this equipment would set up similar to a home exercise program.

    4) Please refer to the Board's Response to Question 3. Again, good documentation by the physical therapist is needed as to proper instruction to the caregiver.

    5) You question is not one that generally falls within the regulatory authority of the Board to respond to. "Adaptive equipment" by its very nature is used for life by the patient and no skill level is required. The use of this equipment is also similar to a home exercise program. Good documentation by the physical therapist is needed as to proper instruction to the care giver.

    6) Your question is not one that generally falls within the regulatory authority of the Board to respond to. A standing frame as stated in Response #5 is adaptive equipment. It can also be used in a rehab setting as per a therapist or physician's determination.

    7) Your question is not one that generally falls within the regulatory authority of the Board to respond to. Please refer to the Board's responses set forth.

    8) No. Proper training and documentation are required.

    9) After carefully reviewing this question, the Board is of the opinion that your inquiry should be submitted to the school system for a response. The Physical Therapy Practice Act or the Board's Rules do not state that a physical therapist has to be present to observe a home exercise program. Programs assigned to school personnel should be documented and instructed as a home exercise program. Please refer to the Board's Response to Question 3.

    10) The Board is not in the position to adequately respond to your question. It is suggested that you contact the manufacturing company of the equipment with your inquiry.

    Second, the physical therapy documentation which includes instructions signed by the physical therapist supercedes the IEP documentation. The physical therapist should not be held accountable as long as her documentation clearly shows that she trained the caregiver and that the child will be attended to by the caregiver.

55. Staples - Stitches - In homecare, are physical therapists able to pull staples or stitches?

    Pursuant to the Physical Therapy Practice Act, LSA R.S. 37:2410 et seq., and the Board's Rules, it is within the scope of practice of physical therapy for a PT to pull staples or stitches. A PT may perform an initial evaluation or consultation to determine need for physical therapy and to establish a physical therapy treatment plan, however, the implementation of physical therapy treatment to a patient for his specific condition shall be based on the prescriptions or referral of the appropriate licensed healthcare provider. Therefore, the removal of staples and/or stitches by a PT can be done pursuant to a prescription or referral from a person licensed to practice medicine, surgery, dentistry or podiatry.

56. Supervision and Related Issues 3 - To perform an inpatient initial PT evaluation does the physician's orders have to read "PT to evaluate and treat" or will "PT consult" suffice as an appropriate order? Also, if a physician gives an order of "PT to perform ROM and Gait BID" does this order need to be rewritten to "PT evaluate and perform ROM and Gait BID" in order for a therapist to perform an initial evaluation?

    No matter what type of order the physician writes, when he consults with a physical therapist for "Evaluation and treatment, or for any specific treatment such as to perform ROM and Gait BID," the physical therapist by law must first evaluate the patient, establish a treatment plan and then he may begin treatment. It is not necessary for the physician to specifically direct you to evaluate the patient.

57. Therapeutic Procedure/CPT 2000 Manual - The specific question is whether or not a technician can render a massage and then the therapist bill for that service.

    Pursuant to the Physical Therapy Practice Act, LSA R.S. 37:2401 et seq., and the Board's Rules, more particularly Rule 305 Subsection c of Physical Therapy Supportive Personnel, a physical therapist has the discretion to assign the level of responsibility to physical therapy supportive personnel (aide/technician and/or physical therapist assistant). The physical therapist is ultimately responsible for the acts or omissions of these individuals. Furthermore, Rule 305 provides as follows: Supportive personnel may perform only those functions for which they have documented training and skills. The prohibitions for physical therapy supportive personnel shall include, but not be limited to, interpretation of referrals; performance of evaluations; initiation or adjustment of treatment programs; assumption of the responsibility for planning patient care; or any other matters as determined by the Board. The physical therapist shall only delegate portions of the treatment session to an aide/technician only after the therapist has assessed the patient's status. As prescribed by law every patient must be initially evaluated by the physical therapist who must identify problems, establish goals and create a physical therapy treatment plan. On each visit, the physical therapist must reassess the patient's status. The physical therapist then provides the treatment, however, he may delegate portions of the treatment to qualified supportive personnel, such as an aide/technician, or he may delegate the entire treatment session to a physical therapist assistant. Therefore, pursuant to the Practice Act and the Board's Rules, a physical therapist may delegate the provision of massage to an aide/technician or physical therapist assistant who has documented training and skills. Such delegation may only occur after the physical therapist has assessed the patient's status and the massage is part of the active skilled physical therapy treatment program prescribed for the patient. Furthermore, with regards to the supervision of supportive personnel such as aide or technician, the supervising physical therapist must be continuously, on the premises during the provision of such services by the aide or technician. The supervision requirement is also defined in Rule 305. With regards to billing for physical therapy services, the Practice Act and the Board's Rules do not prohibit the physical therapist from billing for the services provided by him or under his supervision as long as he complies with these laws. However, the Physical Therapy Practice Act and Board Rules do not supersede the CPT Codes drafted by the American Medical Association nor Medicare reimbursement guidelines with regards to whether payment will be make pursuant to these guidelines for the services rendered. Review of the CPT 2000 Manual which references "Therapeutic Procedures" more particularly, the reference under Therapeutic Procedures which state that a "physician or physical therapist required to have direct (one on one)patient contact. --97124 massage." The Board is of the opinion that Rule 305 is not in conflict with the CPT 2000 Manual cite you provided. Again, Rule 305 requires that the "Physical therapist shall only delegate portions of the treatment sessions to an aide/technician only after the therapist has assessed the patient's status." Furthermore, Rule 305 further states that the aide/technician may only perform those functions for which he has documented training skills. The Board also wishes to direct your attention to Section 2210 et seq. regarding Payable Physical Therapy as set forth in HCPCS 2000 Level II codes, appendix B: Medicare Carriers Manual References. In reviewing such provisions it is apparent that physical therapy treatment is to be performed by the physical therapist or under his supervision in accordance with applicable law. In concluding, please understand what the Physical Therapy Practice Act, and the Board's Rules, allow regarding the provision of physical therapy services and by whom, these laws do not dictate nor control what Medicare or a third party payor will have to pay for pursuant to their established Rules or legal guidelines.

58. Tracheal Suctioning - May a physical therapist perform tracheal suctioning of a patient? Example: I am treating a patient on ventilator support and notice increased sound of secretions in his/her airway. The patient lets me know that they need to be suctioned before we begin activity. Am I allowed to suction this patient?

    The physical therapist must first accept the responsibility for performing the tracheal suction you described, however, only after the clinical training and documented competence for such a skill. In addition, the facility should have policies and procedures in place which would define and outline the educational training and documentation of clinical competence required.

59. Walk-to-Dine Program - When a patient is discharged from physical therapy can the physical therapists assist in ambulating the patient in the walk-to-dine program in a nursing home environment?

    Once the patient is discharged then the Board does not consider the ambulation to be physical therapy, nor should it be billed as physical therapy. Therefore, if the patient is discharged and the physical therapist is not performing physical therapy nor billing for physical therapy, the Physical Therapy Practice Act and the Board's Rules and Regulations are not applicable. Please be advised that this opinion is limited to a response to the question concerning violations of the Physical Therapy Practice Act and/ or the Board's Rules and Regulations. This opinion does not intend, nor does it address, the issue of liability in a civil court with regards to fault on the part of the therapist whereby the patient is injured in the Walk-to-Dine Program.

60. Wound Care Plans and Intervention - Is it within the scope of practice for a physical therapist to measure and stage wounds?

    It is written within the scope of Physical Therapy for a physical therapist to measure and stage wounds and decide upon a plan of care for Physical Therapy Services. The direction of wound care plans and interventions should follow the laws that govern practice, and the rules and regulations that govern supervision and documentation, as stated in the Physical Therapy Practice Act LRS 37:2401-37:2422, and LAC Title 46.

61. Wound Care - Short Term Rehab - Is wound care alone reason to keep a patient in a short term rehab? FIMs, again 6 & 7, never changing by status of wound.

    A patient could be a candidate for long-term care or acute care based upon a status of wound. However, a patient requiring only wound care with FIM scores of 6-7 in other functional activities would not qualify to be kept in short term rehab.

62. Wound Debridement - Can a PTA do wound debridement with sharp instrumentation?

    It is not within the scope of practice for a Physical Therapist Assistant to do sharp wound debridement with instrumentation such as the use of tweezers, scalpels, scissors or Norsen debriders. However, it is within the scope and practice for the Physical Therapist Assistant to assist the therapist in wound care with dressing changes and in performing soft debridement of superficial necrotic tissue using techniques such as wiping with gauze or sponge and irrigation with pulsed lavage systems or bulb syringes.

63. Wound Debridement Scope of PT or Surgical Procedure - A question asked of the P.T. Board by a hospital P.T. and the Board of Medical Examiners as to whether wound debridement is within the scope of practice of a physical therapist or is it a surgical procedure constituting the practice of medicine.

    Hydrotherapy and wound debridement are within the professional education or training of physical therapists in all American Physical Therapy Association accredited programs, and are generally accepted treatment procedures within the scope of practice of a physical therapist in all 50 states including Louisiana. The requirements in Louisiana for such treatment of course, begin with physician's orders. LSA R.S. 37:2401A provides, in pertinent part that "no person licensed as a physical therapist shall practice physical therapy or act as a physical therapist, except upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry." Secondly, the distinction between debridement in physical therapy and surgical procedures performed by physicians can be made in the following ways: a) Physical therapists debride non-Viable tissue and exudate; b)Physical therapists can not use anesthesia nor cut into viable tissue; and c) Physical therapists can not use sutures, pins,The goal of wound care and debridement in physical therapy, whether through whirlpool or mechanical devices, is to remove necrotic tissue and debris in order to gradually expose healthy tissue, and promote epithelialization. Physical therapy debridement must be considered cleaning rather than surgical in nature. There is, no doubt, overlap in treatment procedures performed by numerous medical professionals, as there is in this case. The key to drawing the line as to the extent of debridement that a physical therapist does, is with the ordering physician. Physical therapists and physicians working closely together form bonds of respect and trust. The referring physician must make the ultimate decision as to how much responsibility will be given to the physical therapist. The title of the clinic is of little significance if the above guidelines are followed. Medicare and insurance companies accept and pay for the physical therapy treatment for wound care such as whirlpool and debridement.

64. Work Hardening Programs - Does a work hardening program require to be performed at a specialized clinic? Is a clinic required to be accredited to perform a work hardening program? What can one do to become accredited for this type of program?

    The Board has no requirement for accreditation of work hardening programs; however, some third party payors have required accreditation in order to pay for services.

    We are only aware of accreditation through CARF (Commission of Accreditation of Rehab Facilities), for work hardening programs; however, there may be others that also accredit these specialty programs.

    In the Board's role as a state agency whose function is public protection, we would require that any clinician have the knowledge and skills to perform any procedure with a patient. So, you must be able to demonstrate competence to do work hardening and have the equipment in your clinic that is adequate to do work conditioning and work stimulation. If you are unable to meet these requirements, you should refer the patients to a clinic that has the equipment and expertise in this area of practice.