Ethics and Jurisprudence for the Physical Therapy Professional Licensed in Tennessee

Learning Outcomes

After this course, participants will be able to:

• List basic principles of ethics and their application to rehabilitation and physical therapy.
• Identify codes of ethics that govern discipline-specific therapy practice.
• Analyze ethical dilemmas through case scenarios to illustrate how to apply a Code of Ethics to real-world issues.
• Identify ethical issues commonly experienced in healthcare settings.
• Identify 3-4 sources of rules and laws governing physical therapy practice in Tennessee. 
• Explain how to access the most recent Tennessee Physical Therapy Practice Act and apply the clinical scope of practice in Tennessee.
• List the key supervision requirements for physical therapist assistants and physical therapy aides.
• Examine the Tennessee Practice Act to determine requirements for physical therapists and physical therapist assistants to maintain and renew their licenses, including continuing competence requirements.  

Introduction

What is jurisprudence exactly?  Jurisprudence is the philosophical study of law, encompassing its nature, origins, interpretation, and application within society.  Jurisprudence requirements for physical therapists vary across states in the United States, with each state's physical therapy licensing board or regulatory agency establishing its own rules and regulations, including any jurisprudence requirements. Jurisprudence courses and/or exams assess therapists' knowledge of the laws and regulations governing physical therapy in a specific state. 

You may ask why jurisprudence?  Why do I need to take a course on this each renewal period?   

Therapists must stay informed about and adhere to their practice acts for several reasons:

1. Legal and Ethical Compliance: Understanding and following the regulations outlined in practice acts ensures therapists comply with legal and ethical standards, maintaining a high standard of professional conduct.

2. Patient Safety and Quality of Care: Practice acts often include guidelines and standards to protect patients' well-being and safety.  Staying updated on these regulations enables therapists to implement best practices for their patients' safety.

3. Professional Accountability: Adhering to the Practice Act demonstrates professional accountability, ensuring therapists can be held responsible for maintaining the highest standards of care through their actions and decisions.

4. Licensing and Certification Requirements: Practice acts govern licensing and certification requirements. To maintain professional credentials, therapists must be aware of continuing education, renewal, and other requirements specific to the state or states practicing in.

5. Professional Development: Staying current with the practice act allows therapists to engage in ongoing professional development, attending conferences or training sessions to enhance their skills and knowledge for optimal client care.

6. Adaptation to Changes: Practice acts may undergo updates or changes over time. Staying informed about these changes enables therapists to adapt their practices, incorporating new evidence-based practices and aligning with evolving standards.

Today, we will go through the jurisprudence and the ethical aspects of physical therapy practice in Illinois. 

Physical Therapy and the Law

The rules governing physical therapy practice are embedded within the State Practice Act. Additionally, the legal landscape incorporates common law, also known as case law, originating from judicial decisions and encompassing aspects like malpractice cases.

Establishing physical therapy practice guidelines in each state rests upon the State Practice Act, a legislative creation that reflects administrative insights from the state board. These boards, responsible for interpreting and upholding the State Practice Act, oversee physical therapy practice within their jurisdiction. Given the diversity of state regulations, all 50 states possess distinct practice acts shaping the scope of physical therapy within their borders. 

Licensed professionals in Tennessee are held accountable by the Tennessee Board of Physical Therapy and the Division of Health Related Boards (Division of Health Licensure and Regulation). The Board of Physical Therapy is responsible for safeguarding Tennesseans' health, safety, and welfare by ensuring that all physical therapists practicing in the state are qualified. The Board interprets laws, rules, and regulations to establish appropriate standards of practice, ensuring the highest level of professional conduct. It also investigates alleged violations of the Practice Act and its rules and disciplines licensees who are found guilty of such violations.

Licensure is the primary regulatory mechanism within the domain of physical therapy. It mandates that individuals cannot identify as physical therapists, physical therapist assistants or offer physical therapy services without a valid physical therapy license. Each jurisdiction's state practice act in the United States outlines the prerequisites for obtaining and retaining a license. Every person licensed to practice any branch of the healing arts in Tennessee is required to apply to the division of the healing arts for a certificate of registration.

For instance, in states like Tennessee, acquiring a license typically necessitates completing a licensing examination. Although many states, including Tennessee, opt for the licensing examination provided by the Federation of State Boards of Physical Therapy, this remains a discretionary decision. Presently, licensure remains contingent on adherence to individual state regulations. Reciprocity, whereby a license in one state permits practice in another, isn't guaranteed. 

Statutes

A statute formally expresses the legislative body's will, written according to the necessary procedures to constitute the state's law. 

The Tennessee State General Assembly (Legislature) proposes and enacts statutes into law. The Board adopts rules, following specific notice requirements and hearings. Both statutes and rules have the force of law and can be used to regulate a profession. The statutes relevant to this Board are in T.C.A. 63-1 (Division of Health Related Boards) and T.C.A. 63-13 (Physical Therapy).

Federal Laws

The realm of physical therapy practice is also influenced by federal laws, which emanate from the central government in Washington, DC. Notably, these federal laws possess jurisdictional impact across all states. Several prominent federal laws are of relevance within clinical practice, including:

1. Health Insurance Portability and Accountability Act (HIPAA): HIPAA is a pivotal confidentiality law. It establishes guidelines for safeguarding patient medical information and personal data. Accompanying HITECH, it ensures the confidentiality of electronic health records.

2. HITECH (Health Information Technology for Economic and Clinical Health Act): This law complements HIPAA by addressing technology-related confidentiality concerns. It supports the secure exchange of electronic health information while upholding patient privacy.

3. Medicare Rules and Regulations: Guidelines established by the Centers for Medicare & Medicaid Services (CMS) that dictate reimbursement policies, documentation requirements, and standards of care for physical therapy services provided to Medicare beneficiaries.

4. Americans with Disabilities Act (ADA): This law protects individuals with disabilities against discrimination in various spheres, including employment and access to public service, healthcare services, and facilities.

5. IDEA (Individuals with Disabilities Education Act). IDEA is a federal law that governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. IDEA covers early intervention services for infants and toddlers with developmental delays or disabilities and their families. Children with disabilities must be educated with non-disabled children to the maximum extent possible. Parents must be included in the IEP process, and older students are also involved in developing their educational plans. The main purposes of IDEA are to ensure all children with disabilities have access to a free and appropriate public education, protect their rights, and provide early intervention services.

6. Stark Law: Prohibits physicians from referring Medicare patients to entities with which they have a financial relationship, which can impact physical therapists who have referral relationships with physicians.

7. Anti-Kickback Statute: Prohibits the exchange of remuneration in exchange for referrals for services reimbursed by federal healthcare programs, which can affect relationships between physical therapists and other healthcare providers.

These federal laws extend their influence beyond state boundaries, making it imperative for physical therapists to comprehend and adhere to their provisions.

HIPAA

In 1996, HIPAA was introduced as a crucial confidentiality law with the central aim of safeguarding patient identifiers and protected health information (PHI). Protected health information encompasses any data that could potentially identify an individual, including details like name, address, social security number, and diagnosis. Even defining characteristics, like in the case of a high-profile patient, can be considered within the scope of PHI. The primary focus of HIPAA revolves around the secure transmission of information and the methods by which such information is shared.

Protected Health Information (PHI) encompasses any information related to a patient's past, present, or future physical and/or mental health or condition, regardless of its form, including written (such as documentation, electronic communication), spoken (like hallway discussions), or even notes left for colleagues. However, spoken and electronic texts are particularly prone to causing issues.

For example, consider a scenario where individuals in a public setting, clearly from the healthcare field, inadvertently disclose patient information in conversation, potentially breaching confidentiality. Similarly, online forums, including social media groups, can inadvertently expose PHI when discussing cases. Physical therapists must remain vigilant across all communication channels, ensuring confidentiality and avoiding HIPAA violations.

PHI Identifiers

There are 18 specific identifiers.  Those identifiers include: 

• Name
• Address
• All elements (except years) of dates related to an individual
• Telephone numbers
• Fax number
• Email address
• Social Security Number
• Medical record number
• Health plan beneficiary number
• Account number
• Certificate or license number
• Any vehicle or device serial number
• Web URL
• IP Address
• Finger or voice print
• Photographic images
• Any other characteristic that could uniquely identify the individual ie. tattoo   

How Can We Use and Share Patient Information? 

We can use it for treatment, payment, or operations.

Treatment (T)

Physicians, nurses, therapists, and other providers may access a patient’s record for treatment.  Health information may also be shared with other healthcare providers outside of the facility  to decide on the best treatment or to coordinate care.   

Payment (P)

Health information is shared with Medicare, Medicaid, insurance plans, and other payers to determine claims payments and benefits. 

Operations (O)

Health information is used for quality assurance, training, and audit purposes.  This would include working in an organization where they have a quality assurance committee or performance improvement plans that utilize training, and internally auditing chart reviews. 

For purposes Other than TPO

Unless required or permitted by law, you must obtain written authorization from the patient to use, disclose, or access patient information. Where I see us get into trouble sometimes with this is related to research first and foremost, as well as marketing.

Even positive stories about patient outcomes or new equipment require authorization to be shared publicly, as they are not considered treatment, payment, or healthcare operations. Well-intentioned aggregated data could still indirectly identify individuals, so caution is needed. Sales and marketing teams may propose ideas that breach TPO, requiring therapists to ensure proper protections remain in place. The minimum necessary standard also applies - only essential PHI should be used or disclosed. Openly discussing patients without a job-related purpose violates HIPAA, even if de-identified. When unsure if PHI use aligns with TPO, consult compliance staff rather than risk violations. Their guidance helps therapists avoid missteps while still being able to appropriately leverage data or stories in practice enhancement or referral development. The key is obtaining patient consent and limiting PHI outside immediate care team needs.

Except for Treatment, the Minimum Necessary Standard Applies

For patient care and treatment, HIPAA does not restrict healthcare providers' use and disclosure of PHI. Exceptions: psychotherapy information, HIV test results, and substance abuse information.

For everything else, HIPAA requires users to access the “minimum necessary” amount of information necessary to perform their duties and only disclose it to those who have a need to know. 

You may not discuss any patient information with anyone unless required for your job.

Keep Health Information Secure is Part of Your Job

This includes: 

• Secure Faxing
• Safe Emailing
• No texting of PHI
• Safe Internet use
• Password Protection
• Conversations-Conversations are to be held in a private place
• Department Security
• Social Media
• Discarding Papers
• Computer Security
• Know where you left your paperwork. Check your printers, fax machines, copiers, etc. Make sure that soft charts are brought back to the appropriate area if you do have them.
• Removal of Records- We don't remove records from our facilities for any reason unless required or requested by a government agency, an intermediary, or a carrier.
• Storage of Records-Store records in a secure location that is not available for public view or access.
• Building Access- How many times have you used your swipe card to go into a facility and somebody comes behind you? If you don't know that individual, don't allow him or her to enter a secure facility if they're not authorized to do so.
• Verification of Requests- Ensure you know your policy on verifying those requests. Don't disclose PHI unless you have the written authorization to do so
• Sharing PHI
• Disclosure of PHI

Several excellent points for therapists to ensure HIPAA compliance and safeguard protected health information:

• Avoid transmitting PHI via unsecured methods like plain email/text
• Use strong passwords, never share credentials, and properly secure computers
• Have private conversations away from public areas
• Shred documents and utilize locked cabinets/rooms to limit exposure
• Log off computers when stepping away and confirm printer/fax documents aren't left out
• Do not post any patient details or photos on social media
• Verify identity and authorization before releasing records. Make sure you know your policy for figuring out how to verify those requests. We don't disclose PHI unless we have written authorization to do so.
• Do not allow building access to unknown people
• Check state privacy laws, as penalties for violations are substantial

Even when communicating with a patient's friends or family, the patient must have the capacity to consent to disclosing their protected health information. Therapists cannot share details with loved ones without the patient's explicit authorization, even if they intend to keep them informed. It's an important distinction, as family dynamics can make assumptions of implied permission risky. As you noted, HIPAA violations carry substantial penalties, so obtaining express patient consent before any PHI disclosure is essential to avoiding hefty fines or potential legal consequences.

Internet is an Electronic Billboard

You may expect electronic messages to remain private, but once you send or post them, you lose all control over them. 

Deleting an electronic message does not make it invisible or undiscoverable.

NO Social media! Do not post patient-related or sensitive information on a website or social networking site.

Online communications like texts, emails, and social media posts are discoverable even after "deletion." While encrypted networks provide some protection, the best practice is to avoid any patient-related information online. Therapists should assume that anything posted could potentially become public, regardless of privacy settings or quick retractions. Violating patient privacy through digital channels can generate HIPAA violations and legal consequences. 

Texting

When is texting appropriate at work?

If your message is urgent or short & sweet:

• “Call Me”
• Say, “I just sent you an email and need a response.”
• Logistical communications: Travel information, dates, times, and locations of meetings are okay (if no names are provided). However, do not include protected health information in a text.

Voice Mail 

Don't leave a detailed voicemail unless absolutely necessary.  Never leave substantive patient-related messages on unfamiliar phone numbers.  Instead, say, "Hey, this is Kathleen from therapy. I need to speak with you. Call me at your earliest convenience. 

Do not use a speaker phone unless privacy is assured.  When using your phone through the car's Bluetooth system, the audio can be heard by people outside of the car. It's important to be mindful of this, especially when parked. To maintain privacy, it's a good practice to use earphones or AirPods if you need to have a private conversation or maintain discretion.

Don't forget that voice mails are easily forwarded, passed along, and otherwise shared. 

Best Practices for Voice Communication

Do not give PHI over the phone unless you confirm the listener's identity and authority to receive PHI.  

Be aware of your surroundings and who is around to hear any discussions concerning PHI.     

Refrain from discussing PHI in public areas such as coffee shops, airports, elevators, restrooms, and reception areas. 

Recommendations for Email

Email PHI only to a known party (e.g., patient, health care provider).

Do not email PHI to a group distribution list unless individuals have consented to such a method of communication.

In the subject heading, do not use patient names, identifiers, or other specifics; consider the use of a “confidential” subject line.

Again, I don't put any PHI into my emails. I would say, "Please contact me. I need to speak with you." Oftentimes, I do this within my own organization. If I need to speak with somebody about something that could be compliance-related, I'll email, "Hey, I have that information; I'm following up. Can you give me a shout?" And that's kind of my code to say, I need to talk to you, but I'm not putting that in writing. Always consider what you put in writing.

Medicare Rules and Regulations

Distinguishing between resources for healthcare providers and consumers, inquiries from professionals are directed to the cms.gov website, while patient queries are referred to the medicare.gov website.

Medicare, originally comprised of Parts A and B denoting inpatient and outpatient categories, has expanded to encompass Parts C and D. Part C represents a new version of Medicare resembling an HMO or PPO, and Part D pertains to pharmaceutical coverage. The distinctions among these parts can significantly influence coverage and care. Unlike Medicaid, which is managed at the state level, Medicare is federally funded and administered. The funds originate from federal taxes and are distributed nationwide from Washington, DC.

The American Physical Therapy Association (APTA) is a valuable and comprehensive resource for navigating Medicare rules and regulations. APTA also provides advocacy resources for private practice owners, aiding in optimizing reimbursement. The significance of Medicare regulations on physical therapy practice cannot be overstated. Since many patients treated fall under Medicare, understanding reimbursement policies is pivotal for financial sustainability.

Furthermore, Medicare policies often set the precedent for other third-party payers. For example, the concept of direct access, allowing patients to seek physical therapy without a physician referral, has varying degrees of acceptance by third-party payers. Medicare's stance on reimbursement influences the decisions of these payers. If Medicare were to support reimbursement for direct access care, other payers would likely follow suit, enhancing the financial feasibility of direct access care within the physical therapy practice.

Americans with Disabilities Act

The impact of federal laws on our clinical practice extends to ensuring accessibility for all individuals. Common inquiries arise regarding accommodations for patients with specific needs. While the answers might seem straightforward, local and state regulations often influence them. Consider these examples:

1. Accommodations for Deaf Patients: Providing a sign language interpreter is a common accommodation for deaf individuals. While using a family member might not always be ideal, seeking a professional translator is preferable.

2. Service Animals in Clinics: Determining which service animals to permit in outpatient clinics can be challenging due to the absence of clear guidelines. Developing well-defined clinic policies and procedures becomes crucial. Generally, service animals should be accommodated with appropriate documentation from a medical professional.

3. Wheelchair Accessibility in Clinics: While promoting wheelchair accessibility aligns with the principles of physical therapy, the financial feasibility is considered. While full accessibility is ideal if implementing it poses a significant financial burden, complete wheelchair accessibility might not be mandated.

Viewing the Americans with Disabilities Act (ADA) from the perspective of PTs and PTAs involves more than meeting legal requirements. It also serves as a tool for patient advocacy. Our responsibility extends beyond compliance; it's about empowering patients to live life fully in their most accessible communities. By adhering to ADA standards, we ensure legal compliance and champion our patients' rights and inclusivity.

Physical Therapy Practice in Tennessee

Let's delve into the specifics of physical therapy practice in Tennessee and the relevant laws governing it.  In addition to the federal laws discussed prior, the following are specific to Tennessee. 

In Tennessee, physical therapists and physical therapist assistants must be licensed. Licensing these health professionals protects the public by ensuring that they meet a minimum level of competence.

To obtain a license as a physical therapist or physical therapist assistant in Tennessee, individuals must complete specialized education and pass an examination. Alternatively, Illinois may grant licensure through credential acceptance from another state where the individual has already been licensed. This process helps maintain high standards in the practice of physical therapy, safeguarding the health and well-being of the community.

It's imperative to stress that, as a professional, you have a duty to be well-informed about the rules and regulations to practice as a physical therapist or physical therapist assistant. Keeping up-to-date with the Practice Act and the Rules of the Tennessee Board of Physical Therapy ensures legal compliance and safe and effective patient care. In Illinois, a review of all professions occurs every ten years, with the last review in 2016.  

Tennessee Practice Act- This act governs the practice of physical therapy in the state of Tennessee.

Rules of the Tennessee Board of Physical Therapy- (General Rules Governing The Practice of Physical Therapy)

Child Abuse Mandatory Reporting- In Tennessee, everyone is a mandated reporter under state law (Tennessee Code Annotated 37-1-403(I)). Anyone who has reasonable cause to believe that a child is being abused or neglected is legally required to immediately report it to the Tennessee Department of Children’s Services or local law enforcement. The reporter has the option to remain anonymous.

Duty to Report Abuse, Neglect or Exploitation – T.C.A. 71-6-103(b)- Any person, including but not limited to a physician, nurse, social worker, department personnel, coroner, medical examiner, alternate care facility employee, or caretaker, who has reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, is required to report or ensure that a report is made in accordance with this part. The responsibility to report remains even if the adult has died, and it includes reporting the circumstances surrounding the death.

Sexual Harassment (State and Federal)- Laws prohibiting sexual harassment in the workplace, both at the state and federal levels.

Discrimination (State and Federal)-Laws prohibiting discrimination based on race, gender, age, disability, or other protected characteristics.

Background Checks Required to Provide Patient Care- Before hiring any person who will provide direct patient care and has not undergone a background check, healthcare facilities, emergency medical services, and individual health professionals are legally required to conduct background checks. These checks must include the state sex offender registry, the state abuse registry, and the abuse registries for states where the prospective employee has lived in the past seven years, as mandated by Public Chapter 1084.

Changing Your Name on Your License 

If you have changed your name due to marriage, divorce, or any other reason, you must fill out a form and submit a copy of the legal document that changes your name, such as a marriage certificate, divorce decree, or court order, and mail or email it within 30 days of the change. The addresses are on the form. Make sure if you use email, you send it to the correct email for PT/PTA.  

Please note, APTA and TPTA members, that updating your name on your license does not automatically update your name in your APTA/TPTA membership records. To change your name on your APTA/TPTA membership, contact APTA Membership Services at 800-999-2782. Notifying TPTA separately is unnecessary, as APTA and TPTA share information.

Changing Your Address on Your License 

If you hold a license in Tennessee, Tennessee law mandates that you keep the Division of Health Licensure and Regulation informed of your current address within 30 days of the change. You can update your address on your license online. Failing to update your address after moving may result in not receiving your license renewal information promptly. For changes to your address, email, or telephone, click here.  

Please note, APTA and TPTA members, that updating your name on your license does not automatically update your name in your APTA/TPTA membership records. To change your name on your APTA/TPTA membership, contact APTA Membership Services at 800-999-2782. Notifying TPTA separately is unnecessary, as APTA and TPTA share information.

Tennesee Physical Therapy Practice Act

The Tennessee Physical Therapy Practice Act is found in Title 63, Chapter 13, Parts 1, 3, and 4 of the Tennessee Code Annotated. This chapter is known as the Occupational and Physical Therapy Practice Act. Initially, this title included both the Occupational and Physical Therapy Practice Acts, resulting in some overlap. However, under Public Chapter 115 of the Public Acts of 2007, the Board of Occupational Therapy and Physical Therapy Examiners, along with its two Committees (Occupational Therapy and Physical Therapy), was replaced by the separate Boards of Occupational Therapy and Physical Therapy.

The latest edition is available from the Tennessee Board of Physical Therapy here.  As noted, the board may adopt new rules or amend existing ones between complete editions, and if so, it will also list those on its website.

The legislative purpose and intent of the Practice Act are "to protect public health, safety, and welfare, and to provide state administrative control and supervision over the practice of physical therapy."

Physical Therapy Practice Act 

Definitions give us a common framework for discussing a particular topic or issue.  These definitions are found in Title 63, Chapter 13, Part 1 (General Provisions) of the Tennessee Code.

Practice of Physical Therapy/Scope of Practice 63-13-303 (What we can do): 

The practice of physical therapy means providing physical therapy services, whether through an in-person encounter or via telehealth, telemedicine, or provider-based telemedicine, and may include:

• Examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments, functional limitations and disabilities, or other health and movement-related conditions to determine a physical therapy treatment, diagnosis, prognosis, a plan of therapeutic intervention, and to assess the ongoing effect of an intervention.
• Alleviating impairments and functional limitations by designing, implementing, and modifying therapeutic interventions that include, but are not limited to, therapeutic exercise, functional training, manual therapy, therapeutic massage, assistive and adaptive orthotic, prosthetic, protective and supportive equipment, airway clearance techniques, debridement and wound care, physical agents or modalities, dry needling, mechanical and electrotherapeutic modalities, and patient-related instruction.
• Reducing the risk of injury, impairments, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in all age populations
• Engaging in administration, consultation, education, and research.

Direct Access (What we can do with some limitations noted)

The practice of physical therapy generally requires a written or oral referral from a referring practitioner (63-13-104): 

• Doctor of medicine, chiropractic, dentistry, podiatry, or osteopathy.
• Nurse practitioner or physician assistant

. However, a licensed physical therapist may (63-13-303):

• Conduct an initial patient visit without a referral.

• Provide physical assessments or exercise recommendations to an asymptomatic person without a referral.

• In emergency situations where emergency medical care is necessary, including minor emergencies, assist a person to the best of their ability without a referral. After providing assistance, the physical therapist must refer the person to the appropriate healthcare practitioner as needed.

• Treat a patient without a referral, within the scope of physical therapy, if the following conditions are met:

  • The physical therapist has notified the patient's physician.

  • If no progress is made within 30 days of the initial visit, the physical therapist must stop treatment and refer the patient to a qualified healthcare practitioner.

  • The physical therapist must consult the patient's healthcare practitioner if treatment continues beyond 90 days.

  • If the patient was previously diagnosed with chronic, neuromuscular, or developmental conditions, and the treatment is for symptoms related to those conditions, the 30-day and 90-day rules do not apply.

  • A physical therapist must refer patients to appropriate healthcare practitioners if symptoms or conditions arise that require services beyond the physical therapist's scope of practice, if progress is not being made, or if physical therapy treatment is contraindicated.

It is unprofessional conduct for a physical therapist to initiate physical therapy services to a patient that violates the above. 

Exclusions from Physical Therapy Scope (63-13-104)

Physical therapy does not include the following practices:

• Medicine
• Osteopathy
• Podiatry
• Chiropractic
• Nursing

Additional Definitions

• Physical Therapist: The definition of a "physical therapist" or "physiotherapist"  is a person who is licensed, according to Title 63, Chapter 13, to practice physical therapy.

• Physical Therapist Assistant: A physical therapist assistant (PTA) is a person who meets the requirements of this chapter for licensure and performs physical therapy procedures and related tasks that have been selected and delegated only by the supervising physical therapist.

• Physical Therapy: Physical therapy comprises treatment furnished by or under the direction and supervision of a licensed physical therapist.

• Physical Therapy Assistive Personnel: 

  • Other Assistive Personnel refers to healthcare workers who aren't specifically defined elsewhere but have been trained to carry out certain tasks related to physical therapy. They work under the supervision of a physical therapist. Depending on their training and qualifications, and as long as it's allowed by law, they may be given a job title that matches their specific training.

  • Physical Therapy Aide (also called "aide," "technician," or "transporter") refers to a person trained by a physical therapist to perform routine tasks in physical therapy, always under the therapist’s supervision.

• Restricted Physical Therapist Assistant License: A license that has limitations placed on it by the committee due to actions they have taken.

• Restricted Physical Therapy License:  A license with specific limitations or conditions set by the committee. These can include restrictions on what the therapist can do, where they can work, how they are supervised, how long the license is valid, or the types of patients they can treat.

• Supervision ( of the physical therapist assistant): The supervising physical therapist must be easily accessible to the assistant. If the assistant works at a different location, the physical therapist must be available by phone or other communication methods. Regular patient meetings will be scheduled and documented, and supervisory visits will follow the rules and regulations.

• Onsite Supervision: The supervising physical therapist or physical therapist assistant must:

  • Be continuously present in the department or facility where the assistive personnel are working.

  • Be immediately available to help the person being supervised with the tasks they are performing.

  • Stay actively involved in the relevant parts of each treatment session, where a portion of the treatment is assigned to assistive personnel.

Supervision of Students and Assistive Personnel (63-13-311)

The supervision of PTAs and assistive personnel is an important section for us.  Many issues that go before the board pertain to supervision or the lack thereof.

Physical therapists are responsible for the patient care provided by physical therapist assistants, assistive personnel, and students on clinical affiliations under their supervision. They can delegate specific tasks or procedures to these individuals as long as they are within the scope of their education or training.

Physical therapist assistants must always be supervised by a licensed physical therapist.

Physical therapy aides, other assistive personnel, and clinical students must always perform patient care activities under the onsite supervision of a licensed physical therapist or physical therapist assistant.

Physical therapist students and physical therapist assistant students must always be supervised by a physical therapist.

Board of Physical Therapy (63-13-318)

The board consists of five (5) members, all appointed by the governor and residents of Tennessee:

• Three (3) members must be licensed physical therapists with at least five (5) years of experience in practicing or teaching physical therapy before their appointment.
• One (1) member must be a licensed physical therapist assistant with at least five (5) years of experience in performing physical therapy tasks or teaching a physical therapist assistant program.
• One (1) member must not be involved in physical therapy or the healthcare industry.

• The governor can choose physical therapists and assistant members from a list of nominees provided by physical therapy groups, like the Tennessee Physical Therapy Association.

• The board meets every year to select a chair and a secretary, and they hold meetings as needed.

• For the board to make decisions, at least three (3) members must be present (this is called a quorum).

• The board receives administrative, investigative, and clerical support from the division.

• Board members are reimbursed for any expenses they incur while performing their duties and receive $100 for each day they conduct board business. Travel expenses are reimbursed according to state guidelines.

• Regular appointments to the board last three (3) years, and members continue to serve until a new appointment is made. If a position becomes vacant, the governor will appoint someone to fill the remainder of that term.

• If the board requests it, the governor can remove a board member for misconduct, incompetence, or neglect of duty.

• When making appointments, the governor aims to ensure:

  • At least one (1) member is 55 years or older.
  • At least one (1) member is a racial minority.
  • The gender balance of the board reflects the gender balance of the state's population.

Board Powers (63-13-304)

The Board of Physical Therapy has the power and authority to:

• Evaluate the qualifications of applicants for licensure and provide for the examination of physical therapists and physical therapist assistants.

• Set passing scores for the examination.

• Issue licenses to those who meet the qualifications outlined in this chapter.

• Regulate the practice of physical therapy by interpreting and enforcing this chapter, including taking disciplinary action.

• Adopt and revise rules as necessary and appropriate, consistent with this chapter, to fulfill its obligations. Once lawfully adopted, these rules have the effect of law.

• Establish requirements for assessing the continuing competence of licensees.

• Set all license and registration fees.

The Board of Physical Therapy shall establish minimum competency requirements that a physical therapist must demonstrate in order to practice dry needling.

Applications, Examinations, Initial Licensure (63-13-306)

To apply for a physical therapist or physical therapist assistant license, you must submit an application as required by the board. A non-refundable application fee and the examination cost must be included with your completed written or online application. Fees are set by the board's rules.

When the board receives your completed application for initial licensure, they will:

• Make a decision on your application within 60 days, or
• Notify you if you need to appear before the board.

After the application process has been completed, the applicant (PT or PTA applicant) will take the examination for the appropriate licensure.  The board determines when and where the exams are available within the state, and the board sets the passing score.

If you do not pass the exam on your first attempt, you can retake it again without reapplying for licensure, up to six attempts. Your application will remain active for 12 months. After 12 months, you must submit a new application with all applicable fees if you wish to continue the process.

Exemptions From Licensure (63-13-305)

The following persons are exempt from licensure as a physical therapist or physical therapist assistant under this chapter:

• A person pursuing a degree in physical therapy or as a physical therapist assistant in a board-approved education program, fulfilling supervised clinical education requirements.

• A physical therapist or physical therapist assistant practicing in the United States Armed Services, United States Public Health Service, or Veterans Administration, as per federal regulations for state licensure of healthcare providers.

• A physical therapist or physical therapist assistant licensed in another U.S. jurisdiction, or a foreign-educated or internationally trained physical therapist credentialed in another country who is performing physical therapy as part of teaching or participating in an educational seminar for up to 60 days in a calendar year.

• A physical therapist or physical therapist assistant licensed in another U.S. jurisdiction temporarily performs physical therapy for members of established athletic teams, athletic corporations, or performing arts companies that are training, competing, or performing in Tennessee. The person must agree to use the secretary of state for service of process as per Title 20, chapter 2, part 2.

• The practice of dry needling by a licensed physical therapist does not constitute the practice of acupuncture.

• Nothing in this chapter restricts persons licensed under any other state law from performing physical agent modalities for which they have received education and training.

Qualifications of Applicants, Reciprocity (63-13-307)

Qualifications for Licensure as a Physical Therapist

• Be of good moral character.
• Complete the application process.
• Graduate from a professional physical therapy program accredited by a national accreditation agency recognized by the U.S. Department of Education and the Board of Physical Therapy.
• Successfully pass an examination approved by the board.

Qualifications for Licensure as a Physical Therapist Assistant

• Be of good moral character.
• Complete the application process.
• Graduate from a physical therapist assistant education program accredited by an agency approved by the board.
• Successfully pass an examination approved by the board.

Licensure for Applicants from Other U.S. Jurisdictions

• The board will issue a license to a physical therapist or assistant who has a valid, unrestricted license from another U.S. jurisdiction, provided they met all the requirements listed above when they were first licensed.
• When the board receives a completed application from an applicant licensed in another state or territory, they must:
  • Make a decision on the application within 60 days, or
  • Inform the applicant if they need to appear before the board.

Licensure for Foreign-Educated Physical Therapists

• Be of good moral character.
• Complete the application process.
• Provide evidence that their education is equivalent to that of U.S.-educated physical therapists. If not, they may need to complete additional coursework.
• Provide proof that their physical therapy education is recognized by their country’s ministry of education.
• Provide proof that they are authorized to practice as a physical therapist in the country where they were educated.
• Provide proof of legal authorization to live and work in the U.S. or its territories.
• Have their educational credentials evaluated by a board-approved credential evaluation agency.
• Pass board-approved English proficiency exams if their native language is not English.
• Complete an interim supervised clinical practice period before licensure.
• Successfully pass the board-approved examination.
• Note: If the foreign-educated applicant graduated from a program accredited by an agency approved by the board, certain requirements (such as proving education equivalency, school recognition, and completing a supervised clinical period) may be waived.

Board Decision-Making:

• A majority vote of the Board of Physical Therapy is required to determine an applicant’s qualifications for licensure as a physical therapist or physical therapist assistant.

License Renewal/Retirement/Inactive Status and Exemption from Continuing Education Requirements (63-13-308)

• Tennessee-licensed physical therapists (PTs) and physical therapist assistants (PTAs) must renew their licenses as specified by the regulations to practice in Tennessee. Failure to renew by the expiration date will result in losing the privilege to practice in the state.

• A physical therapist or PTA licensed in another jurisdiction that is a Physical Therapy Licensure Compact member can apply for compact privileges in Tennessee, provided they meet the requirements outlined in § 63-13-402, which will be discussed later in the course.

• Retired licensees are not required to register as long as they file an affidavit, provided by the board, stating the retirement date and any other necessary information. If a retired person wishes to return to practice, they must apply for licensure again and meet the continuing education requirements set by the board unless exceptions are granted for good and sufficient reasons as determined by the board.

• A licensee can place their license in inactive status by submitting the appropriate forms and paying a biennial fee. To return to active practice, they must apply for re-licensure and fulfill the continuing education requirements set by the board, with potential exceptions as determined by the board.

Reinstatement of License, Failure to Renew License (63-13-309)

Reinstatement of a Lapsed License

If you miss the renewal deadline, you must pay the renewal fee, a late renewal penalty fee, and a reinstatement fee as set by the board’s rules.

Reinstatement After More Than Three Years

If your license has lapsed for more than three (3) consecutive years, you must reapply for a new license and pay the required fees.

You must also demonstrate your competency in physical therapy, which may involve:

• Serving an internship under a restricted license,
• Taking remedial courses,
• Or a combination of these, as determined by the board.
• The board may also require you to take an examination.

Administrative Revocation for Failure to Renew

If you fail to renew your license and pay the biennial renewal fee within sixty (60) days after it’s due, your license will be administratively revoked without further notice or hearing.

If your license is administratively revoked, you can apply in writing to the board for reinstatement. If you show good cause, the board may reinstate your license upon payment of all required fees.

Denial, Suspension, or Revocation of Licenses (63-13-312)

The board has the authority to deny, suspend, or revoke the license of a licensee who is guilty of violating any provisions of this practice act or is guilty of the following acts or offenses:

• Practicing physical therapy in violation of the laws or board rules.
• Practicing beyond the scope of physical therapy.
• Making false or misleading statements or being guilty of fraud in obtaining a license or practice.
• Providing substandard care due to ignorance, incompetence, or negligence, whether or not the patient was harmed.
• Providing substandard care as a physical therapist assistant, including performing tasks that go beyond what the supervising physical therapist has assigned, even if no actual harm to the patient occurs.
• Failing to properly supervise or delegate duties that exceed the scope of practice for assistive personnel.
• Being convicted of a felony or any crime involving moral turpitude, including a guilty verdict or a plea of no contest.
• Practicing under the influence of controlled substances, drugs, chemicals, or alcohol.
• Facing disciplinary action in another state or territory for acts that would be grounds for discipline in this state.
• Engaging in sexual misconduct, including:
  • Having or soliciting sexual relationships with patients.
  • Making sexual advances or engaging in sexual conduct with patients.
  • Intentionally viewing a disrobed patient inappropriately during treatment.
• Participating in or accepting unearned fees or commissions for services not provided.
• Failing to adhere to professional ethics.
• Charging unreasonable or fraudulent fees for services.
• Making deceptive or fraudulent representations in the practice of physical therapy.
• Being judged mentally incompetent by a court.
• Aiding or abetting an unlicensed person in performing activities requiring a license.
• Failing to report violations of the chapter by other licensees or individuals.
• Interfering with or refusing to cooperate in an investigation or disciplinary proceeding, including threatening or harassing patients or witnesses.
• Failing to maintain patient confidentiality without prior written consent unless required by law.
• Failing to maintain adequate patient records, including evaluation, diagnosis, treatment plan, and discharge plan.
• Promoting unnecessary devices or treatments for financial gain.
• Providing unwarranted treatment or continuing treatment beyond the point of reasonable benefit.
• Violating or attempting to violate any provisions of the chapter, board orders, or any criminal statute.
• Engaging in fee-splitting or paying commissions for referrals.
• Acting inconsistently with generally accepted standards of physical therapy practice.
• Practicing with a mental or physical condition that impairs the ability to practice safely and skillfully.

Disciplinary Actions of the Board (3-13-313)

The board has the authority to take the following disciplinary actions, either individually or in combination, upon proof of any violation of this chapter:

• Deny an application for a license, whether the application is made through reciprocity or otherwise.
• Permanently or temporarily withhold the issuance of a license.
• Suspend, limit, or restrict a previously issued license for a duration and in a manner determined by the board.
• Issue a letter of reprimand.
• Reprimand or discipline an applicant or licensee in other ways, including informal settlements and letters of warning, as the board deems appropriate.
• Revoke a license.
• Refuse to issue or renew a license.
• Impose civil penalties for violations of this chapter. Additionally, the board may assess and collect reasonable costs incurred during a disciplinary hearing when action is taken against a person's license.

Administrative Procedure of Disciplinary Actions (63-13-314)

• Disciplinary Proceedings: Any disciplinary action against a licensee will follow the procedures outlined in the Uniform Administrative Procedures Act, found in Title 4, Chapter 5.

• Board’s Jurisdiction: The board has the authority to modify or refuse to modify any of its orders related to disciplinary actions if requested by any party involved.

Penalties (63-13-315)

Class B Misdemeanor

A person commits a Class B misdemeanor if they engage in an activity that requires a physical therapy license without obtaining the required license, violate any provision of this chapter, or use words, titles, or representations that imply they are licensed to practice physical therapy. This includes using any title or description incorporating terms or abbreviations restricted under §§ 63-13-103 and 63-13-310.

Investigation 

The board can authorize an investigation to determine if someone is unlawfully practicing physical therapy.

• Injunctive Relief: The board, through the attorney general's office, can seek a court order to stop anyone from violating this chapter. This legal action is in addition to any other penalties and remedies this chapter provides.

• Civil Penalty: A person who helps or requires someone else to violate this chapter or its rules, allows their license to be used by someone else, or acts with the intent to violate or evade this chapter or rules can be fined up to $1,000 for each violation.

Peer Assistance Program, Fees (63-13-316)

Instead of a disciplinary proceeding, the board may permit a licensee to actively participate in a board-approved peer assistance program.   This is more of a private way to address certain violations. 

Some of the circumstances that would qualify for a peer assistance program would be:

• The board has evidence that the licensee is impaired.
• The licensee has not been convicted of a felony relating to a controlled substance in the United States.
• The licensee enters into a written agreement with the board for a restricted license and complies with all the terms of the agreement, including making progress in the program and adhering to any limitations on the licensee's practice.
• The licensee signed a waiver allowing the peer assistance program to release information to the board if the licensee does not comply with the requirements of this section or is unable to practice with reasonable skill or safety.

The board will establish fees for this section.

Disclosures to Patient, Confidentiality, Complaints, and Display of Licensure (63-13-317)

The physical therapist must inform the patient of any financial arrangements connected to the referral process and disclose any financial interest in products endorsed and recommended to patients in writing. The licensee is also responsible for ensuring the patient is informed of freedom of choice in services and products.

Importantly, information relating to the physical therapist-patient relationship is confidential and may not be communicated to a third party not involved in that patient's care without the patient's prior written consent. Physical therapist-patient confidentiality does not extend to cases in which the physical therapist must report information as required by law.

Any person may submit a complaint regarding any licensee or anyone potentially violating this chapter. Confidentiality shall be maintained subject to the law.

The department is to keep all information relating to complaints filed against licensees confidential until the information becomes public record as required by law. 

Each licensee must display a copy of their license or current renewal verification in a location accessible to the public at their place of employment.

Unlawful Use of Titles or Designations Indicating Licensure (63-13-310)

A physical therapist shall use the letters "PT" or "DPT" in connection with their name to denote licensure.  

It is unlawful for any person or business to use the words "physical therapy," "physical therapist," "physiotherapy," "physiotherapist," "registered physical therapist," licensed physical therapist," "doctor of physical therapy," or the letters "PT," "LPT," "DPT," OR "RPT" or any other words or abbreviations indicating or implying that physical therapy is being provided or supplied including the billing of services labeled as physical therapy unless by or under the direction of the physical therapist.  

According to the statute, a physical therapist assistant shall use the letters "PTA" to denote licensure.  

No person shall use the title "physical therapist assistant" or the letters "PTA" in connection with the person's name or any other words or abbreviations implying that the person is a physical therapist assistant unless the person is licensed as a physical therapist assistant.  

Part 4 Physical Therapy Licensure Compact

Compact 

The state of Tennessee entered into the physical therapy licensure compact.  The purpose of the compact is to allow interstate physical therapy practice so that access to physical therapy services is improved.  The practice of physical therapy occurs in the state where the patient/client is located at the time of the service. The state's regulatory authority is preserved to protect public health and safety through the current state licensure process.  It will also encourage the cooperation of member states to this compact to regulate multi-state therapy practice.  It will support spouses of relocating military members and enhance the exchange of information among its members (licensure, investigative, and disciplinary information). 

The term "compact privilege" means a remote state has granted a license from another member state of the compact to practice as a PT or PTA in the remote state under its law 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.  

The compact requires many rules that the state must uphold to participate. You may find them in 63.13-402 Section 3.  

The compact member states established the Physical Therapy Commission.  Some of the commission's duties are establishing bylaws, establishing the fiscal year and maintaining financial records, create uniform rules to implement and administrate the Compact. The executive board has nine members. Seven are voting members, and two are non-voting members. The commission will meet at least once annually, prepare the budget, maintain financial records, monitor Compact compliance, establish committees if needed, and ensure Compact administration. Meetings are open to the public, and minutes are taken, while specific committees or the Executive Board may meet privately.   For further information on the Commission, please see 63-13-402 in its entirety.  

In April 2017, the PT Compact was officially enacted when ten states joined the PT Licensure Compact. To read this in its entirety, please click here.  Compact privilege was available in Tennessee beginning July 9, 2018.  As of September 2024, 39 states have joined the PT Licensure Compact. However, some won't become effective for a few years. Additional states have legislation introduced in their respective state.  To see those states and others working on joining with legislation in progress, please click here. To verify if a PT or PTA has a compact privilege to practice in Tennessee, visit the PT compact commission verification webpage here. 

Compact Privilege Requirements

For the licensee to participate in compact privilege, the licensee must hold a license in the home state and have no limitations placed on his/her license in any state.  The licensee must be eligible for a compact privilege in any member state with no prior disciplinary action against any license or compact privilege within the prior two years.  The licensee must notify the commission that he/she is seeking compact privilege within a remote state(s).  Any fees, including any state fee, are to be paid by the licensee.  The licensee must meet any jurisprudence requirements established by the remote state(s) the member is seeking compact privilege and let the commission know if an adverse action is taken on his/her license by a non-state of the compact within 30 days of the adverse action.  

The compact privilege is valid until the expiration date of the home license. To maintain compact privilege in the remote state, the licensee must abide by the requirements mentioned in the paragraph above.  

The licensee providing physical therapy in a remote state must abide by the laws and regulations of that state. The licensee is subject to that state's authority when practicing in that state, and the remote state may impose fines or take any necessary action to protect the health and safety of its citizens. Compact privilege is not allowed in any other state until removal action is satisfied by the state taking action on the license and all fines are paid.  

If a licensee's home state licensee is limited in any way by that board, compact privilege is lost in any remote state until the home state license is no longer limited and two years have elapsed from the date of the disciplinary action.  Once those requirements are satisfied, the licensee must meet the above compact privilege requirements to obtain compact privilege in a remote state.  

If a licensee's compact privilege in any remote state is removed, the licensee will lose compact privilege in any remote state until all fines are paid, the specific period for which the compact privilege was removed has ended, and two years have elapsed from the date of the disciplinary action.  Once those requirements are satisfied, the licensee must meet the above compact privilege requirements to obtain compact privilege in a remote state.  

Active Duty Military Personnel or Their Spouses 

A licensee who is active duty military or the spouse of someone who is active duty military can designate the home state as one of the following:

• Home of record,
• Permanent change of station (PCS), or
• State of current residence if it differs from the PCS state or home of record.   

Adverse Actions

• Home State Authority:

  • The home state has exclusive power to impose disciplinary actions (adverse actions) against a license issued by that state.
  • The home state can take adverse action based on investigation findings from a remote state as long as it follows its own procedures.
  • Participation in alternative programs (instead of disciplinary actions) by a licensee remains non-public if the state’s laws require it. Licensees in such programs cannot practice in another member state without prior authorization during the program.

• Remote State Authority:

  • A remote state can take disciplinary action against a licensee's compact privilege within that state.
  • Remote states can issue subpoenas for hearings and investigations, requiring witnesses and evidence. If a subpoena is for another state, it must be enforced by a court in that state. The issuing state covers associated costs like witness fees and travel expenses.
  • If allowed by state law, a remote state can recover the costs of investigations and case resolutions from the licensee.

• Joint Investigations:

  • Member states can collaborate on joint investigations of licensees.
  • Under the Compact, member states must share investigative, litigation, or compliance materials to support these joint or individual investigations.

Rules of the Tennessee Board of Physical Therapy Chapter: 1150-01 General Rules Governing the Practice of Physical Therapy

Regulations

The Board of Physical Therapy promulgates regulations that affect physical therapy. A regulation is simply a rule or order prescribed for management or government. It is a regulating principle issued by various governmental departments to carry out the intent of the law.

The general rules governing the practice of physical therapy in Tennessee are contained in Chapter 1150-01.  The original chapter was filed on June 6th, 1978.  The most recent version of the rules and regulations may be found here. 

Definitions (1150-01-.01)

The board defines certain language, and these rules are an additional definition to those definitions that are provided in the Physical Therapy Practice Act.  A complete list of definitions in Chapter 1150-01 can be found here.  A few highlighted definitions are as follows.  

• Continuing Competence: Refers to the ongoing application of professional knowledge, skills, and abilities relevant to your specific scope of practice and work setting. This is why you're participating in this course.

• Manual Therapy Techniques: Manual Therapy Techniques are passive interventions in which therapists use their hands to perform skilled movements. These techniques aim to manage pain, increase joint range of motion, reduce swelling or inflammation, improve tissue extensibility, and enhance various functions. The techniques involve applying graded forces that do not exceed the joint’s normal range of motion.

• Physical Therapy Aide: Also known as a technician or transporter, this person is trained by and works under the direction of a physical therapist to carry out supervised routine tasks.

• Other Assistive Personnel: Trained healthcare workers who perform designated tasks related to physical therapy under the supervision of a physical therapist. As long as no law prohibits it, they may use titles that reflect their specific education and credentials.

• Physical Therapy Treatment Diagnosis: The PT treatment diagnosis involves the process and the result of evaluating examination information. The physical therapist organizes this information into defined clusters, syndromes, or categories to determine the most appropriate intervention strategies.

• Department: Refers to the Tennessee Department of Health.

• Division: The Division of Health Related Boards within the Department of Health provides administrative support to the Board.

• Advertising: Includes any business solicitations—whether in print (like cards, signs, newspapers) or through media (like radio, internet, or TV)—designed to attract public attention.

• Board: Refers to the Board of Physical Therapy

Scope of Practice and Supervision (1150-01-.02)

Physical therapy typically requires a written or oral referral from a licensed doctor (medicine, chiropractic, dentistry, podiatry, osteopathy), nurse practitioner, or physician assistant. However, there are exceptions:

• Initial Visit: A licensed physical therapist can conduct an initial patient visit without a referral.

• Assessments and Exercise Recommendations: A licensed physical therapist can provide physical assessments or exercise recommendations to an asymptomatic person without a referral.

• Emergency Situations: A licensed physical therapist can assist without a referral in emergencies, including minor ones. After providing help, the therapist must refer the person to the appropriate healthcare practitioner if further care is needed.

• Treating Without a Referral: A licensed physical therapist can treat a patient without a referral if the following conditions are met:

  • The patient's physician, as defined by law, is notified by the physical therapist.

  • If no progress is made within 30 days, the therapist must stop treatment and refer the patient to a healthcare practitioner.

  • The therapist cannot continue treatment beyond 90 days without consulting the patient’s healthcare practitioner.

  • If the patient was previously diagnosed with chronic, neuromuscular, or developmental conditions, and the treatment is related to those conditions, the 30-day and 90-day rules do not apply.

• Referral to Other Practitioners: A physical therapist must refer patients to appropriate healthcare practitioners if they believe the patient’s symptoms or conditions require services beyond the scope of physical therapy, if therapeutic progress is not being made, or if physical therapy is not suitable.

• Emergency Definitions:

  • Emergency Circumstances: Situations where emergency medical care is needed.
  • Notified: Informing the patient's physician when the therapist treats a patient without a referral.
  • Emergency Medical Care: Genuine emergency services are needed after the sudden onset of a severe medical condition, where delaying treatment could result in serious health risks, impaired bodily functions, or dysfunction of any organ or body part.

Practice of Physical Therapy

The board has defined the rules of what the practice of physical therapy includes.  The practice of physical therapy in the state of Tennessee includes the following: 

Assessment and Diagnosis: Physical therapists examine, evaluate, and test individuals with mechanical, physiological, developmental impairments, functional limitations, disabilities, or other movement-related conditions. This process helps to determine a treatment diagnosis, prognosis, and plan of therapeutic intervention and to assess the ongoing effectiveness of the intervention.

Therapeutic Interventions: Physical therapists design, implement, and modify therapeutic interventions to alleviate impairments and functional limitations. These interventions include, but are not limited to:

• Therapeutic exercise and functional training
• Manual therapy and therapeutic massage
• Use of assistive and adaptive equipment, including orthotics and prosthetics
• Airway clearance techniques and wound care
• Application of physical agents, mechanical and electrotherapeutic modalities, and patient-related instruction
• Electrophysiologic studies (e.g., motor and sensory nerve conduction, somatosensory evoked potentials)

Injury Prevention and Health Promotion: Physical therapists work to reduce the risk of injury, impairments, functional limitations, and disabilities. They also promote and maintain fitness, health, and quality of life across all age groups.

Professional Roles: Physical therapists engage in administration, consultation, education, and research.

Manual Therapy Techniques: These are passive interventions where therapists use their hands to apply skilled movements designed to:

• Modulate pain
• Increase joint range of motion
• Reduce or eliminate swelling, inflammation, or soft tissue restrictions
• Induce relaxation
• Improve tissue extensibility and pulmonary function

These techniques involve applying graded forces without exceeding the joint’s normal range of motion and can be applied to all joints of the body as needed.

Special Electromyography Guidelines:

• Invasive Kinesiologic Electromyography: Can only be performed in a university academic setting as part of a research project approved by the educational institution’s Internal Review Board without a referral.
• Diagnostic Electromyography: Must be performed by a licensed physical therapist who meets specific requirements.
• Referral for Electromyography: Diagnostic and invasive electromyography can only be performed with a referral from:
  • An allopathic physician, osteopathic physician, dentist, podiatrist, nurse practitioner, or physician assistant licensed under the relevant Tennessee statutes.

Substandard Care

In the rules, there are definitions regarding what occurrences are automatically considered substandard care.  Substandard care includes: 

• Overutilization or Underutilization: Providing too much or too little physical therapy services.
• Unwarranted Treatment: Giving treatment that is unnecessary for the patient’s condition.
• Excessive Treatment: Continuing treatment beyond the point where it provides any reasonable benefit.
• Abandoning a Patient: Stopping care without informing the patient about their options for further care.
• Not Following Standards: Failing to practice according to the standards outlined in the "Guide to Physical Therapist Practice," (as required by the rules).

Supervision of the PTA  

Supervision is an area ripe for exposure to physical therapists from many different standpoints. In Tennessee, a licensed PTA must practice under the supervision of a licensed physical therapist. 

• Initial Evaluation: The licensed physical therapist must perform the initial evaluation of the patient and develop a written treatment plan, including therapeutic goals, frequency, and duration of services.

• Ongoing Re-evaluations: The licensed physical therapist must perform and document re-evaluations, assessments, and any necessary modifications to the treatment plan at least every 30 days.

• Inspection of Therapy Services: For patients receiving services for more than 60 days, the licensed physical therapist must inspect the therapy provided at least every 60 days.

• Proximity of Supervision: The licensed physical therapist cannot supervise a PTA delivering services at a location more than 60 miles away or more than one hour's travel time from the physical therapist. The supervising therapist must always be available to communicate by phone or other means when the PTA is providing services.

• Discharge Evaluation: The licensed physical therapist must perform the discharge evaluation and write the discharge summary. The licensed physical therapist and the PTA share equal responsibility and accountability for meeting these supervision requirements.

Supervision of the Physical Therapy Aide and Assistive Personnel, Including Supervision Ratio 

Physical Therapy Aides: Physical therapists can delegate tasks to physical therapy aides that do not require clinical decision-making or problem-solving. Aides must be directly supervised, meaning the supervising physical therapist or physical therapist assistant must be on-site and actively supervising.

Other Assistive Personnel: Physical therapists can use other assistive personnel (like certified exercise physiologists, athletic trainers, or massage therapists) for specific tasks that match their training and education. These personnel must also be directly supervised on-site by a physical therapist, who must co-sign all related documentation in patient records.

On-Site Supervision: The supervising physical therapist or physical therapist assistant must be continuously present in the facility where the assistive personnel is working, immediately available to assist with the services being performed and stay involved in the relevant aspects of each treatment session where tasks are delegated to assistive personnel.

Supervision Limits: A physical therapist can supervise up to three (3) full-time physical therapist assistants at once, two (2) full-time assistive personnel or physical therapy aides at once, and two (2) full-time physical therapy aides at once.

Volunteers: Physical therapists and physical therapist assistants must provide direct on-site supervision to volunteers. Volunteers are not allowed to provide physical therapy to patients.

Clinical Students: Physical therapists must provide on-site supervision to physical therapy clinical students at all times, following APTA guidelines, which recommend at least one (1) year of licensed clinical experience before becoming a clinical instructor. Physical therapist assistants must also provide on-site supervision to physical therapist assistant clinical students, following the same APTA guidelines for clinical education.

Necessity of Licensure (1150-01-.03)

A person must hold a license to practice in Tennessee.  It is unlawful for anyone not licensed in TN to hold himself/herself as a PT or PTA, including advertising on signs, mailboxes, addresses, plates, the internet, telephone listings, etc.  

Qualifications for Licensure (1150-01-.04)

The qualifications for licensure are the same as those outlined in The Physical Therapy Practice Act 63-13-307.

Diagnostic Electromyography: If you’re applying for licensure as a physical therapist and want to perform diagnostic electromyography (invasive needle studies of multiple muscles to diagnose muscle and nerve diseases), you must provide documented evidence of having current ECS (Electrophysiologic Clinical Specialist) certification from the American Board of Physical Therapy Specialties.

Surface Electrophysiological and Kinesiologic Studies: If you’re applying to conduct surface electrophysiological studies (like motor and sensory conduction, somatosensory evoked potentials) or kinesiologic studies (invasive needle studies to assess muscle function during movement), you must submit documented evidence that you have the necessary theoretical background and technical skills to perform these studies safely and competently.

Supervision: The supervision of physical therapists conducting diagnostic electromyography, surface electrophysiological studies, and kinesiologic studies must align with sound medical practices. This ensures that these procedures are conducted under proper guidance and standards.

Procedures for Licensure (1150-01-.05)

Procedures for licensure are articulated by the board.  To become a licensed physical therapist, one must comply with the following procedures and requirements: submit an application packet and respond truthfully and completely.  Applications can be accepted throughout the year, and the nonrefundable application fee must be paid.  You must submit a passport-style photograph, and you must disclose circumstances about a conviction of a crime, the denial of licensure by any other state or country, the loss or restriction of a license, or any kind of civil suit, judgment, or settlement.

The applicant must also request that the results from a criminal background check be submitted directly to the board from a vendor, as outlined in their application packet. Personal resumes are not accepted and will not be reviewed as part of the application. A license will be issued only after all requirements have been met. 

There are additional procedures for licensure by reciprocity.  The person seeking reciprocity must have passed the licensing examination according to Tennessee rules, and the applicant must request licensure status verification from all states in which he/she has been licensed to the Board's office. 

International educated applicants must pass the required exam, have his/her education evaluated and verified by an agency approved by the Board, submit proof of citizenship in the US or Canada or evidence of being able to live and work legally in the US, any current verification of license and current standing shall be sent to the Board.  All documents must be translated into English, and both original and translated certified versions must be submitted to the Board.   

Fees (1150-01-.06)

All fees are established, reviewed, and can be adjusted by the board.  The fee schedule is noted in rule 1150-01.-06.

Application Review, Approval, and Denial (1150-01-.07)

Applications for licensure are accepted year-round. The initial review of applications to check for completeness may be done by the Board's Unit Director. The licensure action taken by the Unit Director or a designated Board member will be ratified by the Board.

If an application is incomplete upon receipt at the Board's administrative office, the applicant will be notified of the deficiency. The individual will not be considered eligible to take the examination until the administrative office deems the application complete and accurate. The Board may delay making a decision on your exam eligibility if they need more information.

Denial of Application:

• The denial becomes final if your completed application is denied and the Board ratifies this decision.
• You’ll receive a denial notification by certified mail, including specific reasons for the denial and references to the laws or rules for the decision.
• The notification will explain your right to request a contested case hearing under the Tennessee Administrative Procedures Act if the denial was based on subjective or discretionary criteria. You might be granted a hearing if the denial was based on clear, objective criteria.
• To appeal the denial, you must submit a written request to the Board within 30 days of receiving the denial notice.

False Information: If you provide false information or omit important details in your application, you’ll be denied the chance to take the exam or, if already licensed, your license may be suspended or revoked.

Board Errors: If the Board mistakenly issues a license, they will notify you by certified mail of their intent to annul it. You’ll have 30 days to meet the licensure requirements.

Abandonment of Application:

• Your application will be considered abandoned and closed if:
  • You don’t complete it within 12 months after the initial review, or
  • You don’t take the written exam (if applicable) within six months of being notified of your eligibility.
• If your application is closed, you’ll be notified in writing, and you’ll need to submit a new application with all fees to be reconsidered for licensure.

Changing Application Type: To change your application type (e.g., from reciprocity to examination), you must submit a new application with supporting documents and pay an additional fee.

Recommendation Letter: You must submit an original letter of recommendation from a licensed physical therapist or physical therapist assistant in the U.S. that attests to your good moral character. The letter cannot be from a relative.

Examinations (1150-01-.08)

To obtain licensure, you must pass an examination. Most of those taking this course have already passed this exam.  However, as clinical instructors, it is nice to understand the current process for students.  The Board uses the National Physical Therapy Examinations (NPTE) endorsed by the Federation of State Boards of Physical Therapy (FSBPT).

Application Process:

You must apply for the examination directly through the FSBPT. Contact them at:

• Federation of State Boards of Physical Therapy
• 509 Wythe Street, Alexandria, VA 22314
• Phone: (703) 299-3100 | Fax: (703) 299-3110
• Website: www.fsbpt.org
• Applications and instructions are provided by the Board’s administrative office.
• All educational requirements must be completed before applying.

Eligibility Approval:

• Only those who have filed the required application, paid the fees, and been approved by the Board are eligible to take the exam.
• The FSBPT compiles an applicant list and sends it to the Board for approval. The Board notifies FSBPT of eligible candidates.
• The exam is only for those seeking initial licensure or those without a qualifying exam score in another jurisdiction.

Eligibility Notification:

• The FSBPT sends eligibility lists to the Computer Based Testing Provider.
• You will receive a letter with a toll-free number to schedule your exam.
• You must take the exam within 60 days of the eligibility letter. If you don't, you’ll be removed from the eligibility list and must start the application process again.
• You can reschedule the exam up to two working days before the test date without penalty. Failure to do so will result in forfeiting your exam fees and you’ll need to restart the application process.

Examination Administration:

• Arrive at the test site at least 15 minutes before your appointment.
• Bring government-issued photo identification (passport, driver’s license, etc.) and another ID with your signature.
• All candidates will be thumb-printed, photographed, and videotaped at the testing center.

Passing Score:

• To pass, you must achieve a scaled score of 600 on a scale of 200-800.

Exam Results:

• You won’t receive pass/fail information at the test site.
• Results are mailed to you within ten working days of receipt by the Board’s office. Scores are only provided in writing by mail.
• Hand scoring is available from the FSBPT upon request for a fee.

Retaking the Exam:

• If you fail, you can retake the exam. After two failed attempts, you must wait three months before reapplying.
• If you don’t pass the exam within 12 months of becoming eligible, your application will be denied, and your file will be closed. You’ll need to reapply if you wish to try again.
• Applicants who fail the exam two or more times must complete an additional 10 hours of clinical training and 10 hours of coursework before reapplying for another attempt. This requirement applies after each subsequent failure.

Renewal of a License (1150-01-.09)

Renewal Due Date

The renewal due date is the expiration date indicated on your renewal certificate.

Methods of Renewal

• Internet Renewals: You can renew your license and pay fees online here. 
• Paper Renewals: If you don’t renew online, a renewal application form will be mailed to the last address you provided to the Board. Not receiving this form doesn’t relieve you of the responsibility to meet renewal requirements.

Eligibility for Renewal

To be eligible for renewal, an individual must submit to the Division of Health-Related Boards a completed and signed renewal form, the applicable renewal fees, and a statement attesting to completing the continuing competency requirements.

Non-Compliance

If you fail to comply with the renewal rules or notifications about late renewal, your license will be processed according to Rule 1200-10-01-.10. Submitting false information on your renewal form can result in license denial or disciplinary action.

Reinstatement of an Expired License

An expired license can be reinstated after payment of a reinstatement fee, the renewal fee, and proof of completing continuing competence requirements.  

Provisional License (1150-01-.10)

A provisional license can be issued for internationally educated persons who have complied with the various license qualifications contained in these rules issued by the board except for the clinical practice period required. The provisional license can also be issued for a physical therapist or PTA whose license has been retired or expired for at least three years with no unresolved disciplinary actions.   

Provisional licenses for internationally educated applicants are valid for no fewer than 12 weeks and no more than 48 weeks.  For those whose licenses have been retired or expired for more than three years, provisional licenses are valid for a time period determined by the Board.  The provisional license may not be renewed. 

A physical therapist with a provisional license must work under the direct supervision of a licensed, on-site physical therapist with at least one year of licensed clinical experience. A PTA with a provisional license must work under the direct onsite supervision of a PT or PTA who is in good standing in TN and has at least one year of clinical experience. 

Retirement and Reactivation of a License (1150-01-.11)

A person with a current license who doesn't plan to practice as a physical therapist or physical therapist assistant in Tennessee can convert their active license to inactive ("retired") status. Here's how:

• Obtain an affidavit of retirement form from the Board's administrative office.
• Complete and submit the affidavit affirming that while in retired status, the licensee won't practice or indicate holding an active Tennessee license. This includes refraining from using any words, letters, titles, or figures in Tennessee that suggest being a licensed physical therapist or assistant.

Alternatively:

• Submit a signed and notarized letter requesting the license to be placed in retirement. The letter must state the understanding that the licensee cannot practice or imply holding an active Tennessee license or use related terms in the state.

Holding a retired license exempts the individual from paying renewal fees.

License holders looking to reactivate their retired licenses can follow these steps:

• Submit a written request for licensure reactivation to the Board’s administrative office. Include a statement describing all relevant experiences and education during retirement or inactivity.

• Pay the current licensure renewal fees and State regulatory fee.

• If retirement reactivation is requested within one year from the date of retirement, the Board will additionally require payment of the reinstatement fee. 

• Complete the continuing competence requirements.

Continuing Competence (1150-01-.12)

The board requires each licensed physical therapist or PTA to participate in a minimum number of experiences to promote continuing competency for the 24 months that precede the licensure renewal month. All applicants for licensure, renewal, reactivation, or reinstatement must demonstrate competency.

Physical therapists are required to have 30 hours every 24 months.  Twenty of those hours must be from Class I activities, and up to 10 hours can be acquired online.  

The definition of "online" courses may be found here, and it is important to know the difference.  If there is an interactive potential for the continued competence course and a quiz following the course, that course is not deemed "online."  Up to 10 of the 30 required may be from Class II activities. Effective June 29, 2016, and after, physical therapist assistants are required to have 30 hours every two years.  The licensee is limited to 10 hours of online instruction, counting toward the 30 total hours.  Up to 10 hours of the 30-hour requirement may be from Class II activities.  

Four hours of the continuing competency requirements must consist of ethics and jurisprudence education for PTs and PTAs. These four hours, generally, two hours for ethics and two for jurisprudence, are required every renewal cycle.  Jurisprudence is what we are covering today.  Passing the board examination for first-time applicants out of school is sufficient for the continuing competence requirement for the initial license period, except for the ethics and jurisprudence requirement.  

The ethics course must include the Code of Ethics, Guide for Professional Conduct, Standards of Ethical Conduct for the PTA, Guide for Conduct of the PTA, a model for ethical decision-making, and case analysis. Jurisprudence courses must include the PT Practice Act, General Rules (Chapter 1150-01), Board policy statements, licensure process and renewal, the scope of practice, offenses that lead to disciplinary action, and supervision. The Board has the ultimate authority in deciding what is approved for ethics and jurisprudence courses.  

Continuing competence coursework is defined as a planned learning experience that is at a level beyond the entry-level requirements for PTs and PTAs, and the content must relate to physical therapy.

Class 1 Courses

Class I acceptable continuing competence evidence includes:

• External peer review of practice with verification of acceptable practice by recognized entities (e.g., American Physical Therapy Association). Credit: 20 hours per review, max 1 review in 24 months.
• Internal peer review of practice with verification of acceptable practice. Credit: 2 hours per review, max two reviews in 24 months.
• Courses, seminars, workshops, and symposia that are pre-approved for CEUs by appropriate CEU granting agencies.
• Courses approved by other State Boards, accredited PT/PTA schools, or health-related nonprofit organizations. The board retains the right to determine compliance.
• Home study courses or electronic media courses approved by recognized organizations or accredited PT educational institutions.
• University credit courses. Credit: 12 hours per semester credit hour.
• Participation as a presenter in approved continuing education events. Credit: Based on contact hours, max 20 hours per topic.
• Authorship of presented scientific posters, platform presentations, or published articles undergoing peer review. Credit: 10 hours per event, max two events in 24 months.
• Teaching as an adjunct responsibility in PT or PTA credit courses. Credit: Based on contact hours, max 20 hours per course (counted once if taught multiple times).
• Certification of clinical specialization by ABPTS. Credit: 26 hours, recognized in the 24-month certification period.
• Certification by organizations other than ABPTS (e.g., McKenzie Institute, Neuro-Developmental Treatment Association, Ola Grimsby Institute). Credit: Up to 26 hours in a 24-month period, determined by the Board.
• Awarding of an advanced degree from an accredited University. Credit: 26 hours, recognized in the 24-month period of degree award.
• Participation in a clinical residency program. Credit: 5 hours per residency week, max 26 hours per program.

Class II Courses

Class II acceptable continuing competence evidence includes:

• Self-instruction from reading professional literature. Credit: Limited to a maximum of one (1) hour each twenty-four (24) month period.
• Attendance at a scientific poster session, lecture, panel, or symposium that does not meet the criteria for Class I. Credit: One (1) hour per hour of activity, with a maximum of two (2) hours credit each twenty-four (24) month period.
• Serving as a clinical instructor for an accredited physical therapist or physical therapist assistant educational program. Credit: One (1) hour per sixteen (16) contact hours with the student(s).
• Acting as a clinical instructor for a physical therapist participating in a residency program or as a mentor for a learner for a formal, nonacademic mentorship. Credit: One (1) hour per sixteen (16) contact hours.
• Participating in a physical therapy study group consisting of two (2) or more physical therapists or physical therapist assistants. Credit: Limited to a maximum of one (1) hour credit each twenty-four (24) month period.
• Attending and/or presenting in-service programs. Credit: One (1) hour per eight (8) contact hours, with a maximum of four (4) hours credit each twenty-four (24) month period.
• Serving the physical therapy profession as a delegate to the APTA House of Delegates, on a professional board, committee, or task force. Credit: Limited to a maximum of one (1) hour credit each twenty-four (24) month period.

Unacceptable Activities

Unacceptable activities for continuing competence include, but are not limited to:

• Attending courses regarding:

  1. Regulations of the United States Department of Labor’s Occupational Safety and Health Administration (OSHA);
  2. Regulations of the Tennessee Department of Labor and Workforce Development’s Division of Occupational Safety and Health (TOSHA);
  3. Cardiopulmonary resuscitation (CPR);
  4. Safety;

• Meetings for purposes of policy decisions;

• Non-educational meetings at the annual association, chapter, or organization meetings;

• Entertainment or recreational meetings or activities;

• Visiting exhibits.

Documentation  

All continuing competence activities must be documented and kept for five years from completion. 

If the Board requests, the licensee has thirty days to provide evidence of continuing competence.  If a licensee fails to complete the competency requirements or falsifies the documents in any way, the licensee is subject to disciplinary action.

Documentation includes a signed peer review report, an official program or outline of the course attended or taught, or a copy of the presentation showing the physical therapy-related content and objectives and the number of course hours. It should also include any responsibility in teaching/authoring.

Other documentation examples are a CEU certificate, completion verification of the home study program, a copy of the final grade report if a University credit course has been taken, a specialization certificate, or documentation of self-instruction from reading professional literature.

Reinstatement/Reactivation of an Expired or Retired Licensee 

Individuals whose licenses have expired or have been retired for three (3) years or less are eligible to seek reinstatement or reactivation. To initiate this process, they must complete the appropriate application and furnish documentation of continuing competence. The documentation should demonstrate ongoing competency and must have been initiated and completed within two (2) years before submitting the application for reinstatement or reactivation.

An individual whose license has expired or retired for more than three years must submit the application for reinstatement or reactivation with documentation of continued competence. This must also be initiated and completed within two years before the application is submitted. The only difference with having a license retired or expired over three years is that the board can require additional education, supervised clinical practice, successful completion of examinations, or issuing a provisional license.

Waive or Extend Continued Competence Requirements 

In situations of documented illness, disability, or other undue hardship, the Board has the authority to waive continuing competence requirements and/or extend the deadline for completing these requirements. Licensees seeking a waiver or an extension must submit a written request with supporting documentation before the conclusion of the twenty-four (24) month period in which the continuing competence requirements were not fulfilled.

Advertising (1150-01-.13)

Physical therapists must be careful to avoid misleading the public when advertising due to the public's lack of sophistication regarding physical therapy services. Advertising must be reliable and accurate to benefit the public, and reasonable regulation ensures the flow of useful information without deception.

Advertising Content

The following are considered unethical conduct and may result in disciplinary action:

• Claiming superiority in services, personnel, or equipment without substantiation.
• Using misleading degrees or credentials.
• Promoting services beyond the licensee's ability to perform.
• Using intimidating or undue pressure in communication.
• Appealing excessively to anxiety.
• Using unverifiable personal testimonials.
• Making unjustified predictions about treatment results.
• Misrepresenting or concealing material facts.
• Failing to disclose risks, benefits, and alternatives for procedures or products.
• Using "bait and switch" tactics.
• Misrepresenting credentials, training, or experience.
• Failing to include the licensee’s name, address, and phone number in advertisements.
• Not disclosing compensation for media coverage.
• Using the name of a former licensee more than 30 days after their departure without disclosure.
• Implying services are provided by a certain licensee when they are not.
• Offering or receiving fees for patient referrals.

Advertising Records and Responsibility

• Licensees who are principal partners or officers are responsible for the content of advertisements. All advertisements are presumed to be approved by the licensee named.
• A recording of electronic media ads and copies of print ads must be kept for two years and made available for the Board to review.
• The licensee must have evidence to substantiate the truthfulness of the claims made when placing an ad.

Code of Ethics (1150-01-.14)

The Board of Physical Therapy has adopted the current "Code of Ethics" for physical therapists as established by the American Physical Therapy Association (APTA). You can access this code on the APTA website.

Disciplinary Actions, Civil Penalties, Assessment of Costs, and Screening Panels (1150-01-.15)

Upon a finding by the Board that a physical therapist or PTA has violated any provision of the T.C.A. §§ 63-13-101, et seq., or the rules promulgated thereto, the Board may impose any of the following actions separately or in any combination deemed appropriate to the offense: advisory censure, formal censure, probation, licensure suspension, licensure revocation, or assessment of civil penalty.  Advisory censure is a written action to the PT or PTA for minor or near infractions. Advisory censure does not involve disciplinary action. Formal censure or reprimand is a written action to a PT or PTA for one-time and less severe violations.  It does require disciplinary action. Probation is a formal disciplinary action upon a PT or PTA.  It may require conditions to be met before the probation is lifted and/or restrict the individuals' activities during the probationary period. Licensure suspension is a formal disciplinary action that suspends practice for a period of time. Licensure revocation is a disciplinary action that terminates licensure.  After one year of a license being revoked, the board, at its discretion, reinstate a revoked license after conditions and a period of time that the board feels is appropriate.  Of the procedures that are used, the petitioner shall submit a written and signed petition for order modification to the board's administrative office. 

The petitioner would be the physical therapist.  The Board authorizes consultants and administrative staff to make an additional determination on any petition and take action.  The Board relies on various consultants when deciding on any type of proceeding.  The board can impose Type A civil penalties, which can range up to $1,000.00, Type B civil penalties, which can range up to $500.00, and Type C penalties, which range up to $100.00.

Reconsideration and stays deal with a contested case in which the therapist is opposing an action that the Board wishes to take.  The Board authorizes the member who chaired the Board for a contested case to be the agency member to make the decisions authorized according to rule 1360-04-01-.18 regarding petitions for reconsideration and stays in that case. 

Please refer to this Rule section for a complete outline of the disciplinary policies, as it is lengthy.

Duplicate (Replacement) License (1150-01-.16)

A license holder whose “artistically designed” license has been lost or destroyed, or a license holder whose renewal certificate license has been lost or destroyed, may be issued a new license upon receipt of a written request in the Board’s administrative office.  Such request shall be accompanied by an affidavit (signed and notarized) stating the facts concerning the loss or destruction of the original document, accompanied by a recent photograph, signed and notarized, and the required fee. 

Board Meetings, Officers, Consultants, Records, Complaints, and Declaratory Orders (1150-01-.19)

Purpose of the Board

The Board is responsible for regulating the practice of physical therapy.

Board Meetings

• Meeting Schedule: The Board decides when and where to meet, but at least one meeting is required annually.
• Special Meetings: Can be called by the Chair or at the request of two Board members, with adequate notification to all members.
• Quorum: Three members of the Board are needed to constitute a quorum.
• Public Access: All Board meetings are open to the public.
• Non-Board Members: Can address the Board only if recognized by the chairperson.

Board Officers

• Chair: Presides over all Board meetings.
• Secretary: Presides in the absence of the Chair and, along with the Board’s Unit Director, handles Board correspondence.

Responsibilities of the Board

• Adopting and revising rules and regulations.
• Adopting and administering examinations.
• Denying, withholding, or approving licenses and renewing them.
• Appointing designees to assist in duties.
• Conducting hearings.

Conflict of Interest

Any Board member with a personal, private, or financial interest in a matter before the Board must disclose it in writing and not vote on it.

Board Consultant

The Board can select a consultant to:

• Recommend disciplinary actions based on complaints or investigations.
• Recommend settlement terms for complaint cases, which the full Board must ratify.
• Undertake other tasks authorized by the Board.

Records and Complaints

• Communications: All communications and correspondence must be directed to the Board’s administrative office.
• Board Decisions: Requests needing a Board decision must be received 14 days before a scheduled meeting, or they will be deferred to the next meeting.
• Public Records: All records, except those confidential by law, are open for public inspection at the Board’s office, with copies available for a fee.
• Complaints: Complaints against a licensed practitioner become public once a notice of charges is filed.

Declaratory Orders

The Board follows Rule 1200-10-01-.11 regarding declaratory orders. Petitions involving statutes, rules, or orders within the Board's jurisdiction are addressed by the Board. Declaratory Order Petition forms are available from the Board’s administrative office.

Consumer Right-to-Know Requirements (1150-01-.20)

Malpractice

You are required to report any malpractice cases. However, if the payment amount from a malpractice judgment, award, or settlement is below $10,000, it does not need to be reported under the "Health Care Consumer Right-To-Know Act of 1998." If the amount exceeds $10,000, it must be reported to consumers.

Criminal Conviction Reporting Requirements

Any felony conviction must be reported. 

Any misdemeanor conviction involving the following elements must be reported:

• Sexual offenses
• Alcohol or drug-related offenses
• Physical injury or threats of injury to any person
• Abuse or neglect of a minor, spouse, or elderly person
• Fraud or theft

If a misdemeanor conviction that has been reported is later expunged, you must submit a copy of the expungement order signed by the judge to the Department. Only then will the conviction be removed from your profile.

Professional Peer Assistance (1150-01-.21)

As an alternative to disciplinary action or as part of disciplinary action, the Board may approve and utilize a professional assistance program for situations regarding licensee substance abuse, chemical abuse, or lapses in professional and/or ethical judgments. Information on those referred by the board and who are entering the program is confidential.

Dry Needling (1150-01-.22)

Physical therapists must complete all required educational instruction in person; online or video conferencing courses are unacceptable.

Mandatory Training Areas

• 50 hours of instruction in the following areas (usually covered during physical therapy school):
  • Musculoskeletal and Neuromuscular systems
  • Anatomical basis of pain mechanisms, chronic pain, and referred pain
  • Trigger Points
  • Universal Precautions
•  24 hours of specific dry needling instruction covering:
  • Dry needling technique
  • Dry needling indications and contraindications
  • Documentation of dry needling
  • Management of adverse effects
  • Practical psychomotor competency
  • OSHA’s Bloodborne Pathogens Protocol

Course Approval

Each instructional course must specify the anatomical regions covered and whether the course is introductory or advanced.

Courses must be pre-approved by the Board or its consultant, recognized health-related organizations, or accredited physical therapy educational institutions.

Newly Licensed Therapists

A newly licensed physical therapist cannot practice dry needling for at least one year after obtaining their license unless they can prove that their pre-licensure education meets the requirements.

Out-of-State Training

Physical therapists who completed the 24 hours of dry needling instruction in another state or country must submit documentation to the Board for approval before practicing dry needling in this state.

Delegation

Dry needling can only be performed by a licensed physical therapist and cannot be delegated to a physical therapist assistant or support personnel.

Documentation

Physical therapists must provide written documentation of their dry-needling training upon request by the Board.

Patient Information

Physical therapists must provide all patients receiving dry needling with information that includes a definition and description of the practice and the risks, benefits, and potential side effects of dry needling.

Policy Statements

The Board of Physical Therapy is also charged with the duty of issuing policy statements.  A policy statement is an authoritative guide to the meaning of an applicable guideline. There are many policies listed on the Board's website, some dating back more than 15 years.  Below is a sample of some of the policy statements relating to PT.  For an up-to-date list, click here.  

Direct Access Policy 2023

These recent changes were discussed in 63-13-303, which outlines exceptions for referrals and governs direct access to physical therapy services. An amendment on April 4, 2023, allows a physical therapist to treat a patient without a referral, adhering to the scope of practice of physical therapy and specific conditions. However, this condition was added: 

• If, based on clinical evidence, the physical therapist determines no progress in the patient's condition within thirty (30) days after the initial visit, the physical therapist discontinues services and refers the patient to a qualifying healthcare practitioner.

The Board of Physical Therapy emphasizes that according to 63-13-303, a physical therapist treating a patient without a referral must discontinue services and refer the patient to an appropriate healthcare practitioner after thirty (30) days if no progress is observed.

Approved and Pre-Approved Dry Needling Courses

All physical therapists in Tennessee who wish to practice dry needling must complete specific coursework that meets specific prerequisites. Those are further described in 1150-01-.22(b). Courses in dry needling must be approved by the Board. As mentioned earlier, they will be reauthorized every two years. Please refer to the Board for a list of the most up-to-date providers. 

Criminal Convictions 

Anyone applying for a license as a physical therapist or physical therapist assistant with one or more criminal convictions may be required to meet with the Board before a license is granted. The following individuals must appear before the Board prior to being issued a license:

1. Any applicant with a felony conviction.
2. Any applicant with multiple misdemeanor convictions.
3. Any applicant convicted of a Class A or B misdemeanor within five (5) years of the application date.

The following individuals do not need to appear before the Board before a license is issued:

1. Applicants convicted of nothing more serious than a Class C misdemeanor (or its equivalent in other states).
2. Applicants convicted of only one misdemeanor that occurred more than five (5) years before the application date.

The Board’s administrator, in consultation with a Board member, consultant, or attorney, can grant temporary authorization and decide if the applicant needs to appear before the Board. This policy was adopted by the Board of Physical Therapy on February 17, 2012.

Patient Referrals for Physical Therapy

The Tennessee Board of Physical Therapy has established the following policy regarding patient referrals for physical therapy:

Jointly developed protocols may include referring patients for physical therapy, provided the referrals are within the skill and competence of the physician assistant, orthopedic physician assistant, or advanced practice nurse and align with the supervising physician's usual scope of practice.

When physical therapy referrals are included in such protocols, any referrals made by a physician assistant, orthopedic physician assistant, or advanced practice nurse are considered to be referrals from the supervising physician. This complies with Tennessee Code Annotated Sections 63-13-109 and 63-13-303, which require that "The practice of physical therapy shall be under the written or oral referral of a licensed doctor of medicine or osteopathy."

Physical Therapy Discharge Evaluations/Plans/Summaries

Physical therapists often face situations where patients are discharged from a facility without prior notice to the physical therapy department. When a patient’s discharge is outside the physical therapist's control, completing a formal discharge evaluation may not be feasible, and producing a formal discharge summary can be logistically challenging.

However, to comply with TCA 63-13-312(20), the physical therapy section of the medical record must include the following:

• Patient identification
• Physical therapy evaluation
• Physical therapy treatment diagnosis
• Plan of care, including desired outcomes
• Treatment record
• Results of interventions
• Discharge plan

Despite challenges, a discharge evaluation, plan, or summary is required for every physical therapy record.

This policy was adopted by the Board of Physical Therapy on August 11, 2006, and amended and ratified on November 14, 2008.

Educational Equivalency for Foreign-Trained Therapists

This is addressed at length in Rule 1150-01-.04(3). 

The Tennessee Board of Physical Therapy has established guidelines for determining if foreign-trained Physical Therapists meet the necessary educational requirements to practice in Tennessee. These guidelines ensure that the applicant’s education is equivalent to a first professional degree from a CAPTE-approved Physical Therapy program in the U.S. However, the Board has the final say on whether the education is equivalent, even if a credentialing agency approves it. The Board also considers the standards set by the National Federation of State Boards of Physical Therapy.

Requirements for Foreign-Trained Physical Therapists:

1. English Proficiency: Proof of English proficiency by passing the TOEFL, TWE, or TSE exams as required by Rule 1150-1-.04.

2. Education Equivalency: Verification of the applicant’s education through one of the Board's approved credentialing agencies, meeting the following criteria:

   A) Minimum Education:

   • At least 150 semester hours.

   B) General Educational Requirements (60 semester hours minimum):

   • Courses required with a minimum grade of “C”:
     • Humanities: At least one course.
     • Physical Sciences: One course in Physics and one in Chemistry.
     • Biological Sciences: One-semester course.
     • Social Sciences: At least one course.
     • Behavioral Sciences: One-semester course in Psychology.
     • Mathematics: At least one course.

   C) Professional Educational Requirements (90 semester hours minimum):

   • Basic Sciences (must include courses in):
     • Human Anatomy and Physiology specific to physical therapy.
     • Neurological Sciences.
     • Kinesiology/Functional Anatomy.
     • Abnormal or Developmental Psychology.
     • Pathology.
   • Clinical Sciences (must include courses in):
     • Neurology, Orthopedics, Pediatrics, Geriatrics.
     • Integumentary, Musculoskeletal, Neuromuscular, Cardiopulmonary, and Metabolic Assessment and Treatment.
   • Clinical Education: Two clinical affiliations totaling a minimum of 800 hours.

   D) Related Professional Courses:

   • Content must include topics such as professional behaviors, administration, community health, research, medical terminology, communication, ethics and legal aspects, cultural competency, emergency procedures, and consultation.

   Note: CLEP credits will only be accepted for general education requirements.

These guidelines were originally adopted on November 6, 1998, ratified on November 14, 2008, and adopted by the Board on August 21, 2009.

Home Health Aides

Monitoring home health aides by physical therapy practitioners is not in itself a violation of the Physical Therapy Practice Act and Rules if no other ethical or practice violations are present. 

The Board of Occupational and Physical Therapy Examiners, Committee of Physical Therapy, adopted the following policy statement on February 11, 2005.

Multidisciplinary Health Screenings

The board has determined that conducting health screenings in areas outside of a licensed professional’s scope of practice poses a risk to public safety. Any licensee who performs such screenings may face disciplinary action by the board or be at risk of malpractice litigation.

This resolution was originally adopted by the Board of Occupational and Physical Therapy on September 14, 1998, and ratified by the Board of Physical Therapy on November 14, 2008

Called to Active Military Duty

The policy statement on active military duty was created to support licensed professionals serving in the military who may face challenges renewing their licenses or completing continuing education due to deployment. This policy ensures that military personnel are given flexibility and consideration when they are unable to meet these requirements on time because of their service. 

Procedures:

1. Any licensed professional who was actively licensed with Health Related Boards before being called to active duty and couldn’t renew their license due to military deployment must notify the appropriate board office in writing.
2. The licensee must submit a letter explaining that the reason for the late renewal was active duty service in the U.S. Military. This letter should include the dates of service and proof of active duty.
3. Once the board receives the notification and proof of service, the licensee will be allowed to renew their license without any late fees or penalties.
4. All documentation, including proof of active service, will be added to the licensee's permanent file.

Additional Points:

• If the license has expired for one year or less, the licensee will not be required to complete continuing education for renewal.
• If the license has expired for more than a year, the licensee must complete half of the required continuing education to renew it.

This ensures that military personnel have a fair and manageable process for maintaining their professional licenses during and after their service.

Continuing Competency

Physical Therapists and Physical Therapist Assistants in Tennessee must demonstrate continuing competence by earning a minimum of 30 hours of continuing education (CE) within the 24 months before their license renewal month. This applies to both Physical Therapists and Physical Therapist Assistants. Failure to meet this requirement may result in disciplinary action.

If a licensee falls short of the required CE hours, the Board will send a notification to the licensee's last known address, allowing 90 days to resolve the deficiency without penalty. If the issue is not resolved within this grace period, disciplinary measures will follow, depending on how many hours are missing:

• If at least 8 CE hours are completed:

  1. A civil penalty of $100 per missing hour must be paid within 30 days of notification.
  2. The licensee must complete and submit the missing hours with proof of attendance.

• If less than 8 CE hours are completed:

  1. A civil penalty of $100 per missing hour must be paid within 30 days of notification.
  2. The licensee must complete and submit the missing hours with proof of attendance.
  3. The license will be suspended for at least 45 days and remain suspended until all missing CE hours are submitted.

Licensees found non-compliant will face a follow-up audit and cannot count previously submitted hours towards future CE requirements. Ignoring Board requests for documentation or failing to resolve the deficiency may result in further disciplinary action.

This policy was amended and ratified by the Board of Physical Therapy on February 9, 2017.

Definition of "Online" courses under Continuing Competence Rule 

In Rule 1150-01-.12(3)(a)(1) and 1150-01-.12(3)(b)(1), "online" refers to courses or activities accessible via a computer, smartphone, tablet, or other internet-enabled devices. It does not include live, real-time courses. The Board may request proof of the interactive elements of any submitted continuing competence course.

This rule was amended on May 19, 2017, and revised on February 9, 2018.

Fingerstick Techniques

It is the policy of the Tennessee Board of Physical Therapy that performing fingerstick techniques (such as glucometer or coumadin readings) is within the scope of practice for licensed physical therapists and physical therapist assistants in Tennessee, as long as these activities are necessary during physical therapy treatment under Tennessee Code Annotated § 63-13-301.

However, this policy does not remove the responsibility to refer patients to the appropriate healthcare providers, as required by Tennessee Code Annotated § 63-13-302. This policy was adopted to protect patients, improve care, and guide licensees.

Adopted by the Board on August 20, 2010.

Lapsed License Policy

The Tennessee Board of Physical Therapy has established the following procedures for reinstating an expired license for Physical Therapists and Physical Therapist Assistants:

1. Cease Practice and Contact the Board:
   Upon realizing their license has expired, the individual must immediately stop practicing and contact the Board’s administrative office to request a reinstatement application.

2. Complete and Submit Application:
   The individual must complete the reinstatement application, provide a detailed work history since the license expired, sign, notarize, and return it to the Board’s administrative office along with the required documents and fees.

3. Reinstatement for Less Than 30 Days Expired:
   If the license has expired for less than 30 days, the Board’s administrator may reinstate it upon receiving the completed application, documentation (including continuing education proof), and fee payment. Preferential treatment will not be given; applications are reviewed in the order received.

4. Reinstatement for 30 Days to Less Than 6 Months Expired:
   If the individual has practiced for over 30 days but less than six months on an expired license, they will be presented with an Agreed Citation. This citation imposes a $250 fine for each month worked beyond the 30-day grace period. The license will only be reinstated once the citation is signed and the fine is paid.

   • The Agreed Citation will be reported on the Department of Health’s website, the monthly disciplinary action report, and to federal databanks like the National Practitioner Data Bank (NPDB).
   • This option is only available for licenses lapsed for less than six months.

5. Refusal or 6 Months or Longer Expired:
   If the licensee refuses to sign the citation or has practiced on an expired license for six months or longer, the matter will be referred to the Office of Investigations and Office of General Counsel for formal disciplinary action. If proven, the minimum penalties include:

   • A formal, reportable reprimand on the license.
   • Civil penalties exceeding $250 per month for each month worked beyond the 30-day grace period.
   • Payment of costs for investigation and prosecution.
   • Any other remedies deemed appropriate by the Board.

6. Reinstatement During Disciplinary Action:
   If the matter is referred for formal disciplinary action, the Board’s administrative office can reinstate the license upon receiving a completed reinstatement application, supporting documentation, and fee payment. Applications will be processed in the order they are received, without preferential treatment.

   For those who declined the Agreed Citation, their application will be considered received 60 days after the citation was initially sent.

This policy was amended and ratified by the Board of Physical Therapy on May 27, 2016.

 Release of Medical Records 

Effective June 18, 2005, the statute regarding the release of medical records (T.C.A. § 63-2-101) was amended to include requirements for releasing records to the TennCare Office of Inspector General and the Medicaid Fraud Control Unit. The new statutory provisions are as follows:

1. T.C.A. § 63-2-101 (i):
   Healthcare providers must make medical records available for inspection and copying by the Office of Inspector General and the Medicaid Fraud Control Unit upon request, no later than the close of business on the next business day. If records cannot be produced, the provider must provide a compelling reason. Records cannot be removed from the provider’s office without consent unless there is a reasonable belief that the records may be altered or destroyed.

2. T.C.A. § 63-2-101 (j):
   Upon the provider's request, an authorized agent of the requesting agency must sign a document acknowledging receipt of the records. Similarly, upon the agency's request, an authorized agent of the provider must sign a document acknowledging the return of specific records.

3. T.C.A. § 63-2-101 (k):
   Providers are protected from civil or criminal liability for releasing patient information in response to a request from the Office of Inspector General or the Medicaid Fraud Control Unit.

This amendment ensures compliance with investigations by the TennCare Office of Inspector General and the Medicaid Fraud Control Unit while protecting healthcare providers.

Attorney General 

In addition to the federal Attorney General, each state has an Attorney General. The Attorney General is the chief law officer of the state.  He or she gives advice and opinions to the governor and to the executive and administrative departments or agencies.  Those opinions are entitled to respectful consideration, but the Attorney General's opinions have no control over the state of the law discussed in the opinion. Opinions published before the year 2000 are not available for digital viewing.  Those in the year 2000 and later may be found here.  To request an opinion in its entirety, call (615) 741-2518.  I have placed a few that are applicable to therapists below, but I have found no recent ones in the past few years. 

Opinion 21-16 COVID-19 Vaccination as Condition of Employment Imposed by Private Employers 

The question for the Attorney General was if a private employer can require its employees to be vaccinated against COVID-19 as a condition of employment.  The opinion states that in Tennessee, private employers have the authority to mandate COVID-19 vaccination as a condition of employment. However, the ability to enforce such a requirement may be influenced by federal law, collective bargaining agreements, and other contractual obligations related to employment. It's essential to consider the specific details and circumstances of each private employment situation. Certain exceptions, such as those for medical reasons, may apply based on relevant legal and contractual considerations. Please see the entire opinion on the website for a full analysis.  

Opinion 83-172: Use of Electronic Muscle Exercisers

This first opinion was issued in 1983. It deals with rules and regulations regarding the operation of electronic muscle exercisers and the licensing requirements and qualifications of an operator of such equipment. There were no statute rules or regulations directly governing those requirements for those devices then, but under certain circumstances, the equipment must only be operated by a licensed physical therapist.

Opinion 95-033: Advertising and Treatment by Massage Therapists

The next opinion was issued in 1995, and the question presented to the Attorney General was, “May a massage therapist in Tennessee lawfully advertise that he or she ‘treats’ one or more conditions?”  The answer was no.  The Attorney General expressed an opinion that treating any condition through massage constitutes therapeutic massage, and only licensed physical therapists and certain other healthcare professionals may lawfully engage in therapeutic massage. 

Opinion 05-171: Physical and Occupational Therapy Reimbursements under the Medical Fee Schedule

This opinion is dated 2005.  The question was, "Does the method of reimbursing physical and occupational therapy facilities under the medical fee schedule as prescribed by the rules and regulations violate the equal protection provisions of the Tennessee Constitution?"  The Attorney General's answer was no, which was pursuant to various other rules and regulations cited in that opinion.

Opinion 07-55: Performance of Spinal Manipulation

In 2007, this landmark opinion was issued.  "Under current law, may physical therapists legally perform spinal manipulation as that term is defined in Tennessee code, annotated 63-43-101?"  The opinion said no.  No personal license under Title 63, including physical therapists, may perform spinal manipulation or spinal adjustment.  In this case, the chiropractors received an opinion that protected one of their practice techniques.

Opinion 12-27: Authority of Physical Therapy Board

In 2012, these questions were presented to the Attorney General regarding the Physical Therapy Board's ability to take action against chiropractors who offered “physical therapy” or used the term “physical therapy” in their practices.  This Attorney General opinion favored physical therapists, stating that the Board could file for injunctive relief and impose civil penalties. 

Tennessee Board of Physical Therapy Meetings 

Please refer to the Board meeting minutes for this discussion.

An administrative hearing is a proceeding before an administrative agency, which may consist of an argument, trial, or both.  The use of procedural rules is more relaxed than in a court hearing. If something occurs where you must go before the board, it may be in your best interest to seek legal counsel as you proceed.

The last posted meeting minutes at the time of this course update (August 2024) are from the May 10th, 2024, board meeting, which were ratified at the August 23, 2024, board meeting.  Once these minutes were approved by the board, they became public records.  Please know this is an example of what these proceedings look like and not a reflection of our feelings or opinions of this case.

On page one, there is a list of who is present and absent, as well as the notification of when the meeting was called to order with a quorum present.  On page two, there are no contested cases mentioned this month in the meeting minutes.  

On page two, two consent orders (orders agreed upon by all parties) approved by the Board were also discussed.   

On page two, the Office of General Counsel also reported that fourteen PTs are being monitored: four on probation, four on reprimand, four on suspension, and two revoked/surrendered. Thirteen Physical Therapist Assistants are being monitored: two on reprimand, six on probation, one on suspension, and four revoked/surrendered. 

On pages 3 and 4, the current fiscal report was discussed, and a motion to increase fees was made and carried.  Those increases are: Physical Therapist application fee will increase from $100 to $150; license fees will increase from $25 to $45; renewal fee will increase from $55 to $140. Physical Therapist Assistants application fee will increase from $90 to $140; license fees will increase from $25 to $45; renewal fee will increase from $45 to $130. 

Detailed information about disciplinary actions and general licensure verification may be found on the Tennessee Department of Health Website. The most recent list of violations for CE violations/lapsed licenses is on page 7 of the minutes, as well as on the Tennessee Department of Health website by month.  

Legislative Updates 

To stay updated on the latest legislative updates, please frequent this page.   

Public Chapter 551-This public chapter extends the Physical Therapy Licensure Compact to June 30, 2028, and took effect on March 19, 2020.

Public Chapter 594-This chapter was the Department of Health's Accountability Act.  It allows all health-related boards to take action against a licensee who has been disciplined by another state. It expands allowable actions beyond a summary suspension.  The act also states that notification of health practitioner law changes can be done by the online posting of those law changes by the respective boards. That notification must remain online for at least two years following the change of law.  This went into effect on March 20, 2020

Public Chapter 738- Chapter 738 states that before authorizing public records destruction, the public record request coordinator must be contacted to ensure those records are not subject to any pending public records request.  Therefore this act does not allow for any destruction of public records if it is known that those records are needed for a pending inquiry.  The regular schedule of records destruction can still occur as long as there is no knowledge by the records custodian of a pending request.  This went into effect on June 22, 2020

Public Chapter 790- This chapter makes several changes to the statutes regarding physical therapists.  The statute now includes the term "physiotherapist," and a definition of "competence" has been added.  The new statute makes it clear that a physical therapist will only be licensed under this chapter if he or she holds a degree from a physical therapy program accredited by a national accreditation agency recognized by the United States Department of Education and by the board.  The age requirement has been deleted. The statute also changed to allow a physical therapist to conduct an initial patient visit without a referral instead of just an initial evaluation.  The physical therapist now may treat a patient without a referral if it is within the scope of practice and the following occurs:  

• The patient's physician is notified.
• The physical therapist must refer the patient to a healthcare practitioner who qualifies as a referring practitioner if the physical therapist determines no progress has been made in regard to the patient's condition within 30 days after the initial visit.  
• Therapy services cannot continue beyond 90 days without the patient's healthcare practitioner being consulted.  
• The 30 and 90-day time frame windows do not apply if the patient was diagnosed by a licensed physician with chronic, neuromuscular, or developmental conditions and the treatment is for symptoms associated with those conditions.
• The physical therapist must refer the patient to an appropriate healthcare practitioner for the following reasons:  
  • Patient's symptoms or conditions beyond their scope of practice
  • Reasonable therapeutic progress is not being made
  • Physical therapy is contraindicated

It is considered unprofessional conduct to initiate physical therapy services in violation of the conditions discussed in this statute.   

Applications will be active for 12 months, and no more than six attempts can be made to pass the examination.  

A physical therapist (or PT assistant) licensed in a member state of the PT Licensure Compact is eligible to become a licensee for compact privileges in Tennessee.

Finally, additional grounds for license denial, suspension, revocation, and discipline were created.  Now included in the statute are: 

1. A licensee acting in a manner inconsistent with generally accepted standards of physical therapy practice
2. Practicing physical therapy with a mental or physical condition that impairs the ability of the licensee to practice with skill and safety. 

This went into effect on July 15, 2020

Public Chapter 4-Deals with telehealth and reimbursement. An amended Telehealth Statute 63-1-155 was enacted on August 20, 2020. 

This public chapter covers telehealth services and how they are reimbursed. Most of the legislation focuses on insurance and payment for these services. However, Section 9 of the chapter explains what telehealth means and which healthcare providers are allowed to offer it.

In Section 9, "telehealth," "telemedicine," and "provider-based telemedicine" are defined as the use of real-time audio, video, or other electronic tools that allow healthcare providers and patients to interact remotely for diagnosis, consultation, or treatment. This includes situations where there is no face-to-face meeting, as well as "store-and-forward" services, where medical information is sent electronically to be reviewed later.

Until April 1, 2022, all licensed healthcare providers under Title 63, licensed alcohol and drug counselors under Title 68, and crisis service providers working at licensed facilities under Title 33 are considered eligible to offer telehealth services. After April 1, 2022, this definition will only include individuals with a valid license under the same titles. Telehealth services cannot be used in pain management clinics or to treat chronic non-cancer-related pain. Veterinarians are also not allowed to use telehealth services.

A relationship between a patient and a provider through telehealth is established by mutual agreement and communication. Telehealth does not change the standard of care, meaning healthcare providers are held to the same expectations as if they were treating the patient in person. Lastly, the board cannot create stricter rules for telehealth than those already allowed by the provider's licensing regulations.

Board Updates on Legislative Changes

CE Broker Reminder

Since July 1, 2020, CE Broker has been the official CE tracking system. Licensees must report proof of completion of their CEs to CE Broker, including at the time of license renewal. The Board will periodically audit proof of completion of CE courses submitted to CE Broker to determine compliance with CE requirements. You must keep records of these hours for up to five years after completing them. The Board will only request proof of these hours if they make a specific request.

Frequently Asked Questions

The Board provides a frequently asked question page and recommends it as another resource for practicing PTs and PTAs in Tennessee.  You can access it here.  A few of the questions not already covered in this course to are included below:

Q: How to file a complaint against a physician: 

A: To file a complaint against a physician, follow these steps:

1. Contact the Health-Related Boards’ Office of Investigations:
   • Phone: Call 1-800-852-2187 to speak directly with the office and report the issue.
2. Submit an Allegation Report Form:
   • Visit the Office of Investigation webpage to access the Allegation Report form.
   • Fill out the form with the necessary details about your complaint.

Make sure to include all relevant information and documentation to support your complaint, such as medical records or witness statements, if applicable. Once submitted, the office will review the case and take appropriate action if necessary.

Q: How do I verify the status of a Tennessee license?

A: To verify the status of a Tennessee healthcare practitioner or facility license, you can use the following resources:

1. For Individuals:

   • Visit the Individual License Verification website.
   • Enter the required information to search for the healthcare practitioner’s license status.

2. For Facilities:

   • Go to the Facility License Verification page.
   • You can search for licensed healthcare facilities in Tennessee by entering the appropriate details.

These tools allow you to confirm the current licensure status, disciplinary actions, and any other relevant credentials of practitioners and facilities in Tennessee.

Principles of Ethics

Ethics are crucial in guiding our decisions about what is morally right and wrong, extending seamlessly from our personal lives into our professional conduct as physical therapists. Our choices in the professional realm are intricately tied to the unique context in which we practice. In this discussion, we will delve into fundamental principles of ethics. As we progress, we hope you will find alignment with these principles, affirming that your practices align seamlessly. However, you may also encounter ethical gray areas that prompt further consideration and reflection within your clinic or practice area.

Autonomy

Let's start with the basic ethical principles, starting with autonomy. Autonomy refers to the moral right to make choices about one's own actions—in other words, it's the right to self-determination. For practitioners, respecting autonomy means refraining from interfering with patients' choices. We allow and enable patients to make their own choices. That said, we can still educate patients about the risks, benefits, and consequences of choices without diminishing autonomy. 

In our approach to patient education, we prioritize providing information to empower individuals to make informed decisions regarding their therapy. However, it's essential to acknowledge that within the health and rehabilitation sector, our dedication to helping others can inadvertently overshadow the principle of respecting autonomy.

For instance, when a patient declines therapy, it's crucial to communicate the potential risks and benefits of their decision. However, persistent attempts to convince or pressure them could undermine their autonomy and demonstrate a lack of respect for their choices and preferences.

Maintaining a delicate balance between offering guidance and honoring an individual's autonomy is paramount. By providing comprehensive information and fostering open communication, we create an environment where patients can confidently exercise their autonomy in making choices about their care.

Nonmaleficence

This principle embraces the timeless guidance from the Hippocratic Oath - "do no harm." As healthcare practitioners, it reminds us that if we cannot provide direct assistance to our patients, we must, at the very least, ensure we do not cause harm or exacerbate their condition. When we examine harm, we must recognize its diverse manifestations, encompassing physical, psychological, social, mental, reputational, or even harm to one's liberty, property, and more.

The nuanced nature of harm leads us to question both the recipient and the nature of the harm, especially when working with patients who may lack decision-making capacity, such as those with advanced dementia. Understanding harm in this context requires a delicate approach, considering differing interpretations and perspectives on what constitutes harm.

Furthermore, it's vital to acknowledge that our perception of harm may diverge from the patient's own assessment. For instance, we may believe that non-participation in physical therapy could harm the patient, while the patient may not perceive it as detrimental. Hence, we must carefully consider whose perspective of harm we are referencing.

Beneficence

In alignment with nonmaleficence, we delve into the principle of beneficence, representing our duty to prevent harm and promote the greater good. This duty involves the act of removing harm and actively fostering positive outcomes. However, it's essential to recognize that this moral obligation has its limits, especially when our actions, aimed at benefitting the patient, may inadvertently cause harm to ourselves as healthcare providers. Balancing the pursuit of benefit with preserving our well-being is critical to this ethical consideration.

Beneficence in healthcare centers on promoting the patient's overall well-being. However, a crucial and complex aspect is navigating the potential disparity in perspectives regarding what constitutes the patient's "good" or best interest. As healthcare providers, we often have a professional understanding of what interventions may optimize a patient's health and quality of life.

Yet, it's paramount to acknowledge and respect each patient's individualized perspectives. What we might perceive as a beneficial treatment or intervention may be viewed differently by the patient based on their unique experiences, pain thresholds, fears, and personal circumstances. For instance, encouraging a patient to walk for their health may conflict with their personal experiences of pain and fear of falling, causing them to consider it against their best interest.

The essential approach lies in effective patient education, open dialogue, and collaborative decision-making. Providing comprehensive information about risks, benefits, and potential outcomes empowers patients to make informed choices aligned with their values and concerns. It's about balancing promoting the patient's well-being and respecting their autonomy and individual perceptions of what benefits them.

Justice

The principle of justice in healthcare is becoming increasingly significant as the demand for limited healthcare resources continues to rise. Justice emphasizes the fair distribution of both burdens and benefits in society, aiming to provide individuals with their rightful due. In healthcare decision-making, this principle is pivotal in determining who should receive essential resources, examining whether some individuals deserve these resources more than others, and identifying the stakeholders responsible for these allocation decisions.

However, achieving justice in healthcare is a complex challenge, as it involves addressing various contextual factors, including religious beliefs, professional ethics, legal frameworks, institutional policies, and more.

My mother's story highlights the importance of advocating for the fair and equitable distribution of healthcare resources, irrespective of personal connections or influential networks. My mother just recently had back-to-back emergency surgeries, and she's doing very well right now. She was in the intensive care unit, and we were trying to get her into an inpatient rehab facility as opposed to a skilled nursing facility. I knew the case manager at that particular large teaching hospital. I was able to ask her what she would be able to do to get my mom whatever she needed.  We got what we wanted, and we got what we asked for. Was that justice? No, not necessarily. I thought, how do we fairly and equitably distribute resources such as discharge location and therapy? It shouldn't be necessary to know someone to get what is needed.  I was a very strong advocate. What about those individuals who are receiving care who don't have advocates in their families like me? 

Healthcare professionals must uphold the principles of justice by advocating for all patients, particularly those without strong advocates. By doing so, we contribute to a system where healthcare decisions are made fairly and ethically, guided by the best interests of the patients and the community.

Informed consent

Informed consent is a fundamental ethical and legal principle in healthcare. It requires healthcare professionals to provide patients with comprehensive and easily understandable information about their proposed intervention strategies. This includes outlining the potential benefits, risks, potential risks, side effects, alternatives, and any other relevant details associated with the proposed course of action.

Informed consent is more than just a checkbox to complete a procedure or evaluation. It embodies a vital opportunity for genuine communication and understanding between healthcare providers and their patients. It's about engaging in a meaningful conversation, ensuring that patients fully comprehend the proposed evaluation or treatment, its potential benefits, risks, alternatives, and what is expected from them throughout the process.

This process of obtaining informed consent should be conducted with care, empathy, and a genuine concern for the patient's well-being and understanding. By explaining and addressing any concerns, questions, or uncertainties, we establish a foundation of trust and collaboration with the patient. This, in turn, enhances patient satisfaction, compliance, and overall outcomes.

Moreover, by approaching informed consent in this way, we uphold ethical principles, such as autonomy and beneficence, by respecting the patient's right to make informed decisions about their own healthcare. It's an opportunity to empower patients with knowledge and involve them in the decision-making process regarding their own health, promoting a sense of ownership and engagement in their care.

Veracity

Informed consent, an ethical cornerstone, hinges on the principle of veracity. Veracity dictates our duty to convey truth and integrity in all patient communications. Let me pause momentarily to clarify that I will use patient, resident, and individual client interchangeably. Now, diving deeper into veracity, its significance becomes apparent as we delve into case examples later.

Confidentiality

Confidentiality, deeply rooted in the Hippocratic Oath, is paramount. The oath asserts, "Anything I see or hear of the life of men, whether in a professional capacity or otherwise, which should not be passed on to others, I will hold as professional secrets and not divulge them." Hence, we possess a duty to restrict access to treatment-related information, maintaining a strict confidentiality boundary between us and our patients.

Yet, stepping back and acknowledging exceptions grounded in justice and beneficence is crucial. Certain laws mandate breaching confidentiality to protect citizens, such as reporting child abuse or elder abuse in specific states. We function as mandated reporters, adhering to distinct timeframes, notably in elder abuse cases. Nevertheless, upholding confidentiality remains vital.

Allow me to elaborate. In my role as an occupational therapist, patients often confide personal details during daily activities. Perhaps a past trauma or a family-related matter. If it doesn't necessitate reporting, I frequently express gratitude for their openness. I ask, "May I have your permission to share this with the healthcare team? It will aid in devising the best plan of care and course of action for you." While not obligatory, seeking this permission cultivates trust and reinforces the patient's faith in us as practitioners. Confidentiality, once again, emerges as an immensely significant principle.

Fidelity

Fidelity, closely intertwined with confidentiality, embodies our moral duty to uphold promises and fulfill commitments made to patients.

Patients rightly expect us to honor both explicit and implicit promises. The explicit promises, such as scheduled appointments like, "We'll meet you at 9:30 for your physical therapy session," are clear commitments. Simultaneously, implicit promises, rooted in regulations like HIPAA and confidentiality, assure patients that we will preserve the privacy of shared information and provide the services prescribed by the physician.

Continuing to explore fidelity, we recognize five crucial expectations patients reasonably hold regarding healthcare contexts. These expectations encompass:

1. Treating them with fundamental respect and dignity,
2. Demonstrating competence and capability in performing our professional duties (a topic we'll delve into shortly),
3. Adhering to a professional code of ethics,
4. Following organizational policies, procedures, applicable laws, and licensure regulations,
5. Honoring any agreements made with the patient or client.

Duty

This underscores the obligations we hold toward others within society. Often, these duties stem from the nature of relationships between parties. In the context of therapy, initiating a patient-therapist relationship entails specific duties toward the patient. These encompass obligations to deliver a defined standard of care and maintain confidentiality, among other responsibilities. Establishing and upholding these obligations forms the foundation of ethical practice and professional conduct within the healthcare domain.

Rights

We will now discuss rights to a certain extent. Rights pertain to the ability to exercise a moral entitlement to either perform an action or refrain from doing so. In the realm of healthcare, a variety of rights come into play. The Patient's Bill of Rights, introduced some time ago, is a fundamental document. Additionally, individual healthcare facilities or communities may adopt their own Bill of Rights, outlining specific rights within their organizational context.

These rights encompass various aspects, including the right to health insurance irrespective of preexisting conditions—an evolving right. Federal statutes also delineate specific patient rights concerning privacy, such as the Health Insurance Portability and Accountability Act (HIPAA). Moreover, different states may have their unique Bill of Rights. Hence, we must understand and adhere to these rights as mandated by our respective organizations and regions of practice.

Paternalism

While not a distinct ethical principle, paternalism is a significant concept to address. Paternalism occurs when an individual, often a healthcare provider, disregards a person's autonomy and substitutes their own beliefs, opinions, or judgments for the judgment of the individual involved, typically a patient. They may act without obtaining informed consent or going against the patient's wishes under the pretext of seeking to benefit the patient.

In cases of paternalism, individuals rationalize their actions by asserting that they acted in the person's best interest. This often happens when someone believes they know better or what's best for the person in question without adequately considering the desires and wishes of the patient. Paternalism is sometimes observed in healthcare, particularly when dealing with families, such as in end-of-life care, where family members may have differing opinions on the care plan compared to the patient. In long-term care settings, involving the family in decision-making instead of the patient can also be a form of paternalism, especially in cases of dementia where the patient's capacity to make decisions may be intact.

Recognizing and addressing paternalism is crucial in promoting patient-centered care and upholding the principle of autonomy. Respecting and honoring patients' wishes and involving them in decision-making processes is essential to providing care that aligns with their values, preferences, and autonomy. 

Physical Therapy Ethics

Professional Ethics

Professional ethics incorporates values, principles, and morals into professional decision-making within our respective professions. Without this guidance, we risk falling into pitfalls that can harm ourselves, others, and society at large.

An insightful perspective shared by a friend emphasizes the importance of intuition, that gut feeling, as a guide for ethical decisions. However, it's crucial to recognize that not everyone possesses the same intuition or gut instincts. Therefore, relying solely on individual feelings may not always lead to universally ethical decisions.

We often witness the consequences of ethical lapses within our professional circles—colleagues facing sanctions or making headlines in the newspaper or online social networks for the wrong reasons. It makes you cringe.  How did that person allow that to happen? Why did they do that? These instances remind us of the critical need for a strong ethical foundation. Professional ethics act as a safeguard against such missteps, aiming to prevent these issues from occurring in the first place.

In our professional roles, we must tap into our training, knowledge, and ethical obligations. These resources guide our actions and behaviors, helping us make informed and morally sound decisions in our respective fields.

Code of Ethics

Our code of ethics incorporates a set of rules or principles intended to express the values of the profession as a whole.

Licensing boards/credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. This ethical framework isn't confined to association membership; it universally applies to all practitioners within the field. Whether at the state or national level, adherence to the strictest code of ethics should be a priority, ensuring you maintain a strong ethical foundation in your practice.  It may mean, for example, using evidence-based practice or a certain quality measure or maybe incorporating something very specific into our rules. 

The code of ethics plays a pivotal role in promoting the basic tenets of the profession. It codifies our fundamental beliefs of the professions and the common moral values the profession chooses to protect patients and clients from harm. It gives meaning to the distinctiveness of your role as a physical therapist or physical therapist assistant. It serves as a unifying bond between professionals, fostering a common standard and shaping the very essence of being a practitioner in this field. These values become integral to your moral and behavioral repertoire, akin to how you integrate social, cultural, and other personal values.

Furthermore, courts reference the code of ethics to gauge appropriate professional behavior and as a component of the standard of care expected from practitioners. In legal scenarios, the code of ethics can significantly impact the outcome, acting as a measuring stick for proper conduct.

It's important to acknowledge that the code of ethics isn't a comprehensive guide that dictates behavior or decision-making with absolute certainty. Rather, it's a foundational starting point, reference point, and aspiration to steer professional practice. While it offers invaluable guidance, gray areas may still necessitate careful consideration and ethical discernment.

Unethical Practice

Unethical practice in healthcare refers to actions that deviate from established professional standards. This deviation spans from unreasonable, unjustified, or ineffective practices to those that are outright immoral, harmful, or knowingly wrong. Evaluating ethicality often involves a litmus test, a gut check, where practitioners assess their discomfort or unease with a certain practice.

Ethical analysis is multifaceted and influenced by various perspectives, including social, religious, and cultural viewpoints. It's important to acknowledge that not everyone will share the same ethical analysis, and disagreements are part of the ethical discourse. Often, as practitioners, we arrive at our ethical analysis from many different views, and not everybody will agree with our analysis, and that's okay.

We have to recognize what we will or won't do. Sometimes, it's a matter of discussing it with your supervisor or somebody on your compliance team. Unethical practice has a profound impact, primarily on the patient, but it also extends to the practitioner, the employing organization, insurers, society, and more. Instances of unethical behavior can lead to loss of professional license and credibility, highlighting the substantial risk unethical practices pose to one's professional investment and the credibility of the healthcare system at large.

Considering the investment of time, effort, and resources put into acquiring professional qualifications, it becomes imperative to safeguard one's ethical standing and uphold the profession's integrity. Maintaining ethical practice is not only a moral duty but also a strategic decision safeguarding the individual practitioner and the healthcare system. Somebody said to me one day, and it just resonated with me: Gosh, I spent so much money and time to get through school; why would I place that at risk to do anything that I would consider unethical? So, I think of it in that regard as well.

Core Values for the Physical Therapist and Physical Therapist Assistant

The core values of physical therapy form the foundation for high-quality care and professional conduct. These principles guide physical therapists and their assistants in all aspects of practice, ensuring that patient needs remain at the forefront. Physical therapists bear ultimate responsibility for delivering safe, accessible, cost-effective, and evidence-based services, while physical therapist assistants provide crucial support under their direction and supervision.

When examining the code of ethics in-depth, it's structured around the five fundamental roles of a physical therapist: patient management, consultation, education, research, and administration. This ethical framework revolves around the core values that underpin the profession, navigating the intricate landscape of ethical action across multiple realms. 

In physical therapy, practice is fundamentally shaped by seven core values, each playing a significant role in guiding practitioners' actions and decisions. These core values form the ethical compass of the profession, anchoring the practice within a strong ethical foundation and ensuring the delivery of patient-centric, responsible, and morally sound care.

Those core values are:

1. Accountability
2. Altruism
3. Compassion or caring
4. Excellence
5. Integrity
6. Professional duty
7. Social responsibility

Central to these values is accountability, which involves embracing responsibility for one's professional roles and actions. This includes self-regulation and behaviors that positively impact patients, the profession, and society's health needs. Altruism emphasizes putting patients' interests first above personal concerns. Collaboration entails working effectively with patients, families, communities, and other health professionals to achieve common goals. Collaboration in the physical therapy team means leveraging each member's strengths to optimize patient outcomes.

Compassion and caring are intertwined values that involve empathizing with patients' experiences and considering their needs and values. Duty reflects a commitment to providing effective services, advancing the profession, and contributing to societal health. Excellence in physical therapy requires consistent application of current knowledge and skills, recognition of personal limitations, integration of patient perspectives, embracing progress, and striving for continuous improvement.

Inclusion is vital in creating a welcoming environment for all. It involves providing safe spaces, amplifying diverse voices, acknowledging personal biases, and actively opposing discrimination. Integrity underpins all these values, demanding adherence to high ethical standards, honesty, fairness, and transparency in professional actions and decision-making.

Social responsibility extends these principles beyond individual patient care. It involves fostering mutual trust between the profession and the broader community by actively addressing societal health and wellness needs. This value underscores the profession's commitment to public health, preventive care, and community engagement.

These core values shape a framework for physical therapy practice that prioritizes patient well-being, professional growth, positive societal impact, and responsiveness to broader public health concerns. They guide physical therapists and their assistants in delivering care that is not only clinically effective but also ethically grounded and socially conscious.

APTA Guide for Professional Conduct

The APTA Guide for Professional Conduct helps physical therapists understand the Code of Ethics for the Physical Therapist. This Code, revised in 2009 and effective July 1, 2010, outlines the ethical obligations of all physical therapists, offering a framework to evaluate conduct and guide professional development, including for students. The guidelines are dynamic and may change as the profession evolves and new healthcare practices emerge. For more information on the guide, please review it online.  

Key Points of the Guide

• Application: The Guide applies to all physical therapists and is updated as the profession evolves and new healthcare practices emerge.
• Interpretation: The Ethics and Judicial Committee (EJC) provides opinions and advice to help therapists apply ethical principles to specific situations.

The APTA Guide for Professional Conduct is a dynamic document, evolving with the profession. It provides a clear ethical framework for physical therapists to follow, ensuring they deliver high-quality, ethical care to their patients and clients.

APTA Code of Ethics for the Physical Therapist

The Code of Ethics for physical therapists serves as a comprehensive guide for professional conduct, yet it acknowledges its own limitations. It cannot address every possible scenario, and physical therapists are encouraged to seek additional guidance when faced with ambiguous situations. The APTA Guide for Professional Conduct and Core Values for the Physical Therapist and Physical Therapist Assistant offer supplementary direction in such cases.

This ethical framework encompasses the multifaceted roles of physical therapists, including patient management, consultation, education, research, and administration. It addresses ethical actions at individual, organizational, and societal levels, reflecting the profession's core values: accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility. Throughout the Code, specific principles are linked to these supporting core values.

The Code of Ethics applies universally to all roles of a physical therapist unless a specific role is mentioned. Central to this code is the commitment of physical therapists to support individuals with impairments, activity limitations, and disabilities. This commitment involves empowering, educating, and enabling these individuals to achieve greater independence, health, wellness, and an improved quality of life. Central to its philosophy is the unique obligation of physical therapists to empower, educate, and enable individuals with impairments, activity limitations, participation restrictions, and disabilities. This commitment aims to foster greater independence, improve health and wellness, and enhance these individuals' overall quality of life.

Purpose

The code of ethics, as determined by the House of Delegates of the American Physical Therapy Association (APTA), has a few purposes.

They include:

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. 

Principle #1

Physical therapists shall respect the inherent dignity and rights of all individuals.

This principle relates back to the core values of Compassion and Integrity.

It means that physical therapy practitioners must act respectfully toward each person, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 

Acknowledging and addressing personal biases is a critical principle reiterated in numerous codes of ethics across various professions. Recognizing biases is foundational to providing all individuals fair, just, and equitable care. In the contemporary landscape, extensive training and emphasis on implicit bias, diversity, equity, and inclusion aim to bring these biases to light and ensure they do not influence treatment, consultation, education, research, or administrative decisions.

Principle #2

Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of our patients.

This principle relates back to the core values of Altruism, Collaboration, Compassion, and Professional duty.

You shall adhere to the profession's core values and act in the best interests of patients and clients over the interests of the physical therapist. It emphasizes the need to provide physical therapy services with a compassionate and culturally sensitive approach, valuing individual differences and backgrounds. Furthermore, it is crucial to ensure that patients and their surrogates have access to necessary information for informed decision-making. Collaborative decision-making with patients and clients empowers them in matters concerning their healthcare. Additionally, safeguarding confidentiality and respecting patient privacy are integral components of ethical practice, with disclosures made to appropriate authorities in line with legal and ethical guidelines.

Principle #3

Physical therapists should be accountable for making sound professional judgments.

This principle relates back to the core values of Collaboration, Duty, Excellence, and Integrity.

Physical therapy practitioners should demonstrate independent and objective professional judgment in the patient's best interests and professional judgment informed by professional standards, evidence, experience, and patient values. Physical therapists should make judgments within their scope of practice and their level of expertise. Communicate, collaborate with, or refer to peers or other healthcare professionals when necessary and avoid conflict of interest. Provide appropriate direction and communication with physical therapist assistants and other support personnel. 

Principle #4

Physical therapists shall demonstrate integrity in their relationships with patients, families, colleagues, students, research participants, other healthcare providers, employers, payers, and the public. 

This principle relates back to the core value of Integrity, which brings us back to veracity.

It emphasizes the importance of providing accurate and truthful information, avoiding any misleading representations, and refraining from exploiting individuals under a supervisory relationship, be it students, patients, or employees. Moreover, it underscores the responsibility to discourage and report misconduct and illegal or unethical acts among healthcare professionals, highlighting the imperative to protect vulnerable individuals from abuse.

This principle's unequivocal stance against engaging in any form of sexual relationship with patients, supervisees, or students reinforces the critical importance of maintaining professional boundaries and ensuring a safe and ethical environment. Additionally, the strong stance against harassment, whether verbal, physical, emotional, or sexual, reinforces the commitment to a respectful and inclusive professional atmosphere. Altogether, this principle underscores a profound dedication to upholding the highest standards of ethical conduct and fostering a culture of accountability and integrity within the healthcare community.

Principle #5

Physical therapists shall fulfill their legal and professional obligations.

This principle relates back to the core values of Accountability, Duty, and Social Responsibility.

This principle includes complying with applicable local, state, and federal laws and regulations. Physical therapists must have primary responsibility for supervising assistance and support personnel. They should encourage colleagues struggling with physical, psychological, or substance-related impairments that could negatively impact professional responsibilities to seek assistance or counseling. Furthermore, if aware that a colleague is unable to perform duties with reasonable skill and safety, physical therapists should report this to the appropriate authority, whether that is a licensing board, organizational leadership, or other governing body. In the event that a physical therapist terminates a provider relationship while the patient still needs services, the physical therapist ought to notify the patient and provide information about alternative care options.

Principle #6

Physical therapists shall enhance their expertise through lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.

This principle relates back to the core value of Excellence.

This principle encompasses maintaining and improving professional competence through continued professional development based on critical self-assessment and reflection. Physical therapists should evaluate the strength of evidence and applicability of content presented in professional development activities before integrating that knowledge into practice. They ought to cultivate practice environments supportive of professional growth, lifelong learning, and excellence. Lifelong learning is crucial—physical therapists must move beyond checking boxes to satisfy continuing education requirements. Instead, they should actively broaden their skills and knowledge throughout their careers.

Principle #7

Physical therapists shall promote organizational behaviors and business practices that benefit patients, clients, and society.

This principle relates back to the core values of Integrity and Accountability.

This principle involves fostering practice settings that enable autonomous, accountable professional judgment. Physical therapists should seek fair and reasonable service remuneration, refrain from accepting gifts influencing professional decisions, and disclose any financial stakes in products or services recommended to patients. For instance, they should reveal ownership interests in durable medical equipment companies or other healthcare businesses. Physical therapists must ensure documentation and coding accurately conveys the nature and extent of services furnished. They should avoid employment arrangements that prevent the fulfillment of professional obligations to patients. Billing, coding, HIPAA, and social media merit particular attention, as lapses in these areas frequently lead to disciplinary action.

Principle #8

Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, and globally.

This principle connects to physical therapy's core values of Social Responsibility.

Practitioners can actualize this by providing pro bono services to the economically disadvantaged, uninsured, and underinsured, if feasible in their setting. They should advocate reducing health disparities, improving healthcare access, and addressing wellness and preventive services. Though physical therapists often treat existing disabilities and impairments, focusing on health promotion and disease prevention remains crucial.

Physical therapists ought to steward healthcare resources responsibly, avoiding over- and under-utilization. Another key facet is educating the public about physical therapy's benefits and the profession's unique role. Getting involved with advocacy organizations and meeting with legislators to promote the field allows practitioners to embody this principle fully. Sitting at the policymaking table helps ensure the profession's perspectives are heard.

Part of this speaks to me; as mentioned in my bio, I am part of the American Occupational Therapy Association Political Action Committee, one of my other roles with Select Rehabilitation. When I am on Capitol Hill, I'm in front of our senators and our representatives in Congress. That might be an opportunity for you to really enact this principle by getting in front of people and promoting who you are and what you do. Make sure that you have a seat at the table. We always have a saying: if you don't have a seat at the table for dinner, you are probably on the plate for a meal.

As I said earlier, while a code of ethics is a robust guiding framework, it's important to acknowledge its limitations. No code can comprehensively cover every situation or circumstance encountered in practice. In straightforward situations, aligning actions with the code is relatively clear-cut. However, the true challenge lies in navigating the gray areas, where careful consideration of the principles and core values becomes crucial in making ethically sound decisions.

Standards of Ethical Conduct for Physical Therapist Assistants

The Standards of Ethical Conduct outline the ethical obligations of physical therapist assistants (PTAs) as determined by the American Physical Therapy Association (APTA). These standards provide a foundation for the behavior expected of all PTAs, guided by core values like accountability, altruism, collaboration, compassion, duty, excellence, integrity, and social responsibility. PTAs are crucial in enabling patients to achieve greater independence, health, wellness, and quality of life.

Key Points

• Application: The Standards apply to all PTAs and are subject to change as the profession evolves.
• Guidance: The APTA Guide for Conduct of the Physical Therapist Assistant and Core Values for the Physical Therapist and Physical Therapist Assistant provide additional guidance.

Ethical Standards

Standard #1: Respect (Core Values: Compassion and Caring, Integrity)

• 1A: Act respectfully towards everyone, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.
• 1B: Recognize and overcome personal biases to avoid discrimination in providing services.

Standard #2: Trustworthiness and Compassion (Core Values: Altruism, Collaboration, Compassion and Caring, Duty)

• 2A: Prioritize patients' and clients' interests over personal interests.
• 2B: Provide interventions with compassionate and culturally sensitive behaviors.
• 2C: Inform patients and clients about the interventions provided.
• 2D: Protect confidential information and disclose it only when allowed or required by law, in collaboration with the physical therapist.

Standard #3: Sound Decisions (Core Values: Collaboration, Duty, Excellence, Integrity)

• 3A: Make objective decisions in the best interest of patients and clients in all settings.
• 3B: Follow best practices for interventions.
• 3C: Make decisions based on competence and patient/client values.
• 3D: Avoid conflicts of interest.
• 3E: Provide services under the direction and supervision of a physical therapist and communicate necessary modifications to the plan of care.

Standard #4: Integrity in Relationships (Core Value: Integrity)

• 4A: Provide truthful, accurate, and relevant information.
• 4B: Avoid exploiting those under their authority.
• 4C: Do not engage in sexual relationships with patients, clients, supervisees, or students.
• 4D: Avoid any form of harassment.
• 4E: Discourage misconduct and report illegal or unethical acts when appropriate.
• 4F: Report suspected abuse of children or vulnerable adults to the appropriate authority.

Standard #5: Legal and Ethical Obligations (Core Values: Accountability, Duty, Social Responsibility)

• 5A: Comply with local, state, and federal laws and regulations.
• 5B: Support the supervisory role of the physical therapist to ensure quality care and patient safety.
• 5C: Adhere to standards for protecting research participants.
• 5D: Encourage colleagues with impairments to seek assistance.
• 5E: Report colleagues who are unable to perform their duties safely.

Standard #6: Lifelong Learning (Core Value: Excellence)

• 6A: Maintain clinical competence.
• 6B: Engage in lifelong learning to stay current with advancements in physical therapy.
• 6C: Promote environments that support career development and learning.

Standard #7: Organizational Behavior (Core Values: Integrity, Accountability)

• 7A: Promote work environments that support ethical decision-making.
• 7B: Avoid accepting gifts that may influence decisions.
• 7C: Disclose any financial interests in recommended products or services.
• 7D: Ensure documentation accurately reflects services provided.
• 7E: Avoid employment arrangements that prevent fulfilling ethical obligations.

Standard #8: Community Health (Core Value: Social Responsibility)

• 8A: Support organizations that address the health needs of disadvantaged groups.
• 8B: Advocate for the participation of people with disabilities in the community and society.
• 8C: Collaborate with physical therapists to manage healthcare resources effectively and avoid overutilizing or underutilizing services.
• 8D: Educate the public about the benefits of physical therapy.

The Standards of Ethical Conduct for PTAs provide a clear ethical framework to ensure that PTAs deliver high-quality, ethical care. PTAs are encouraged to seek additional guidance when needed to navigate complex situations and to continually strive for excellence in their practice.

Licensure

While we've discussed national standards, licensure is state-specific, and each jurisdiction has its own code of conduct. States control licensure through individual laws, regulations, and physical therapy practice acts. Requirements vary, though many states have adopted licensure compacts. Regardless, therapists must understand their specific state's legal and ethical parameters.

Licensure laws aim to protect the public by outlining expected behaviors and minimum competence standards for initial licensure and renewal. Professional association codes of ethics often integrate within state practice acts. Importantly, these laws also detail disciplinary actions and penalties for prohibited behaviors and activities. Though the process differs by state, the intent is to handle infractions to uphold standards. Therapists must familiarize themselves with their state's licensure laws and disciplinary procedures.

The disciplinary process could range from a fine, a slap on the wrist with a warning, to a suspension or revocation of one's license. For example, I remember coming across a HIPAA-related story a few years ago. A clinician was working in the clinic and witnessed or saw across the room somebody who looked familiar to them. The individual wasn't their patient, and they were not actively treating this individual. However, this clinician went to the nurse's station and found this person's chart. The clinician discovered that this person was, in fact, a childhood friend's mother who had been estranged from her family for upwards of 20 years. 

The clinician tried to approach the person and then called the friend and said, "Hey, I found your mother; she is here in our hospital," several states away. There was a reason this woman was estranged. There was a reason she didn't want to be found. This particular clinician completely violated HIPAA. The clinician not only lost their license to practice in that particular state but because that state had a certain level of reciprocity with other states, they could not be licensed in other states. 

Therapists must thoroughly comprehend their state's licensure law and practice act provisions. These documents warrant close study and outline documentation frequency, supervisory visit timing for assistants, assistant supervision ratios, continuing education requirements, and more.

Do not rely on employers to convey licensure details - go straight to the licensing board with questions and get interpretations in writing. Recently, a therapist encountered ambiguity around allowable wound care modalities and debridement. The board clarified upon request. However, the practice act itself was unclear. Therapists should proactively join listservs and stay updated on changes to ensure they comply. Though employers may have information, therapists must ultimately know their license's parameters.

Behaviors Subject to Disciplinary Action

Behaviors subject to disciplinary action will vary by state. Some behaviors that could be subject to disciplinary action include but are not limited to the following:

1. Abuse of drugs or alcohol
2. Conviction of a felony
3. Conviction of a crime of moral turpitude, such as a sex offense, DUI, extortion, or embezzlement, are just a few examples.
4. Conviction of a crime related to the practice of the profession for which you hold a license
5. Practicing without a prescription or a referral if that is required by your state practice act or by the payer that you're utilizing.
6. Practicing outside of the scope of your practice or using interventions that you've not been certified to use or trained to use.
7. Obtaining a license using fraud or deception. For example, purposefully giving an incorrect address.
8. Gross negligence in practicing physical therapy
9. Breaching patient confidentiality
10. Failing to report a known violation of the licensure law by another licensee
11. Making or filing false claims or reports
12. Accepting kickbacks
13. Exercising undue influence over patients
14. Failing to maintain adequate records
15. Failing to provide adequate supervision
16. Providing unnecessary services
17. False, deceptive, misleading advertising
18. Practicing under another name
19. Failure to perform a legal obligation
20. Practicing medicine when you are not a physician 
21. Performing services not authorized
22. Performing experimental services without informed consent
23. Practicing beyond the scope permitted
24. Failure to comply with CE requirements  
25. Failure to notify the licensing board of an address change
26. Inability to practice competently

Licensure stipulations may seem excessive, but they exist due to real infractions. For instance, I was teaching continuing education live and didn't write out the names on the certificates. Someone actually took a blank certificate and then photocopied it and gave it to all of their friends. These therapists were using somebody else's CEs to get their licenses. That same individual utilized somebody else's address and name to get a different license type. While surprising, such situations demonstrate the need for rigorous standards.

Though seemingly improbable, the board documents these policies because such problems have happened. Therapists must take licensure provisions seriously, as they aim to uphold patient safety and care quality.

Fraud and Abuse

Abuse

Alongside licensure regulations, other laws impose legal duties on physical therapists, like mandated reporting of suspected child, spouse, or elder abuse. Most states designate health professionals as mandatory reporters to protect vulnerable groups. Physical therapists should familiarize themselves with reporting criteria, timeframes, and agencies in their jurisdiction. These requirements supersede patient confidentiality in cases of suspected abuse or harm. Though details vary by state, understanding mandated reporter status is crucial, given physical therapists' ethical and legal obligations to keep patients safe.

Fraud

Fraud generally involves deception to induce someone into action or inaction. In therapy, fraud often occurs in billing contexts. Common examples include:

• Billing for services never performed
• Billing for more units than furnished
• Billing non-covered services
• Backdating documentation
• Fabricating patient visit notes

These constitute true fraud versus colloquial use of the term. Medicare fraud specifically involves knowingly or willingly lying to get paid. Other insurers often follow Medicare policies, making their criteria significant.

The key distinction in fraud is purposeful deception to bill services inappropriately, not errors or misunderstandings. Physical therapists must ensure a thorough understanding of accurate coding and documentation to avoid fraudulent actions.

Medicare Fraud and Abuse

Abuse occurs when Medicare pays for services that should not be covered or anytime a provider bills Medicare for services that are not medically necessary.

Denials citing "not medically necessary" exemplify abuse. The Affordable Care Act expanded Medicare fraud and abuse oversight, establishing task forces and increasing audits. This receives extensive attention, with Presidents regularly addressing fraud reduction efforts in addresses.

If aware of fraudulent or abusive activities, physical therapists must report them. Failure to do so violates codes of ethics and practice acts while potentially incurring criminal charges for conspiracy in covering up Medicare fraud. Simply witnessing improper conduct triggers responsibility to take action. With increased scrutiny, therapists must ensure documentation proves medical necessity and accurately reflects services delivered.

Acts that Medicare specifically prohibits include the following:   

• Making false claims for payment.
• Making false statements again to receive payment.
• Billing for visits that were never made.
• Billing for non-face-to-face therapy services. Obviously, we have telehealth right now, and it is a billable service. However, this does not include telehealth. I'm referring to situations where the physical therapist bills for services never provided to a patient. 
• Billing for a one-to-one visit when perhaps group or concurrent was provided. We often see this, particularly in the Medicare world, with students when we look at a student involved in that therapy relationship.  If I'm the therapist and supervise a student, and we treat a patient simultaneously, that would be considered concurrent therapy for Medicare Part A. There is no such thing as concurrent for outpatient or Part B, but we would have to bill that as such. We can't call that one-on-one if truly that person was seen in a concurrent or group situation.
• Billing for therapy services not provided by a licensed provider. This comes up when we have a therapy aide/tech in our clinic who is working with a patient but is not technically licensed. 
• Billing for therapy codes reimburses at a higher rate than the provided code. This is upcoding. You may have heard others say you need to bill it under this code because that pays more than this, and this is how you justify it. That's not how it works. If you provide a therapeutic exercise, that's what you bill and document, and that is the code you use.  You don't bill it under something else just because you think you might get more money for that. 
• Paying or receiving kickbacks for goods or services.
• Soliciting from a physician and offering something to a physician so they can send you more referrals. This includes making offers for payment, receiving payment for patient referrals, or offering gifts in remuneration for receiving those referrals.  

Resident Rights and Elder Abuse

Resident Rights

The 1987 Nursing Home Reform Law established critical protections for long-term care residents, though these rights broadly apply across settings. Providers participating in Medicare/Medicaid must uphold resident dignity, self-determination, and well-being. The overarching right is to receive services enabling the highest possible physical, mental, and psychosocial health per an individualized care plan developed with patient and family involvement whenever practical. This landmark legislation obligates facilities to actively promote and safeguard rights through person-centered care planning and an environment fostering choice, inclusion, and purposeful living. While originating in long-term care, these principles today help shape contemporary practice expectations for empowering patients and optimizing quality of life across the healthcare continuum.

The Right to Be Fully Informed 

Individuals have the right to full disclosure regarding services, associated charges, governing rules and regulations, and a written copy of their rights. They must receive contact information for resources like the state ombudsman and applicable survey agencies. Facilities should provide access to survey reports and any plans of correction following deficiencies. Patients/residents deserve advance notice of room or roommate changes, along with appropriate assistance for sensory impairments. Importantly, they have the universal right to obtain all information in an understandable language or format, whether Spanish, Braille, or other accommodations tailored to their needs. Care settings must take steps to ensure transparent communication and cognizance of rights, including through translation or accessible means for diverse populations.

Right to Complain

Individuals have a right to present grievances without any sort of fear of reprisal and a prompt effort by the community to resolve those grievances. They have a right to complain to the Ombudsman and file a complaint with a state survey or any other certification agency.

Right to Participate in One's Own Care

They have a right to participate in one's own care. That includes receiving adequate and appropriate care, being informed of any change in medical condition, and participating in their care planning, treatment, and discharge. They have a right to refuse medication, treatment, therapy, and restraints (chemical or physical). They have a right to review their medical record, and they have a right to be free from charges for services that might otherwise be covered by an insurance provider. 

Right to Privacy and Confidentiality

This right included private and unrestricted communication with anyone of their choice during treatment and care. The communication could be regarding medical, personal, or financial affairs.

Rights During Transfers and Discharges

This right is very specific to long-term care. Individuals need to know that whatever that transfer is, it's necessary to meet their welfare. Maybe they've improved, and now they no longer need care. It might be needed to protect other individuals, including the safety of other residents or staff, or they haven't paid their bill, quite honestly. Individuals are to receive a thirty-day notice that includes the reason, effective date, and location.

Right to be Treated with Dignity, Respect, Freedom, and to Self-Determination

Individuals have a right to be treated with consideration, respect, and dignity and be free from abuse. 

Right to Visits (or refuse visits) 

Individuals have a right to visits, and that could be from anybody, including their physician, a representative from the state survey, the ombudsman, relatives, friends, other individuals, or organizations who might be providing social or legal services.

Right to Make Independent Choices

This goes back to autonomy, right? This right can include what they wear or how they spend their free time. It includes the right to choose their own physician and accommodations, to participate in community activities, and to manage their own financial affairs.

Again, this is very specific to long-term care. However, I think it is applicable to any setting that our patients might be in.

Your Role

So what's your role? Your role is to

• Know the rights of your patients wherever you're working.
• Respect their dignity and their privacy, 24 hours a day, seven days a week. That means knocking on the door before you enter and asking permission.
• Speak to individuals respectfully and in a positive manner
• Let them make choices about their care, giving them that informed consent we discussed.
• Respect their right to refuse therapy, to refuse care, medications, a specific diet, activity, or whatever that happens to be.
• Listen to them and their family members who might have concerns about their rights, treatment, and/or their plan of care. Refer individuals who may have questions or concerns to the appropriate person. 

Elder Abuse

Elder abuse is a growing geriatric concern. There are ethical issues related to this. We need to look beyond just protective services records. We need to look at financial, medical, social, and long-term care areas for any sort of breakdown, possible difficulties, and solutions.

Key definitions:

• Elder: 65 years or older
• Elder abuse: An act or omission by someone in a trusted relationship that harms or threatens an older adult's health/welfare
• Caregiver: Anyone with custody or control over an elder

Estimates suggest that 10-15% of elders experience abuse. While there is no single victim profile, 90% of perpetrators are known to the victim, mirroring child abuse dynamics. As therapists work closely with seniors and caretakers, we are well-positioned to detect and address signs of abuse through appropriate reporting and interdisciplinary collaboration. Education and advocacy regarding this often hidden issue are crucial.

Forms of Abuse

• Physical abuse
• Sexual abuse
• Emotional abuse
• Neglect
• Abandonment
• Financial exploitation
• Self-neglect

Elder Abuse Indicators

• Physical Abuse. Sprains, dislocations, fractures, or broken bones. Burns, internal injuries, abrasions, bruising. Injuries are unexplained or explanations are implausible. 
• Sexual Abuse. Fear of being touched/inappropriate modesty on evaluation. Inner thigh/breast bruising, tenderness. 
• Emotional Abuse. Depression, sleep, appetite disturbances, decreased social contact, loss of interest in self, apathy, and suicidal ideation. Evasiveness, anxiety, hostility. 
• Neglect and Self-Neglect. Inadequate, dirty, or inappropriate clothing, malnutrition, dehydration, odor and poor hygiene, and pressure sores. Misuse/disregard/absence of medicines, medical assistive devices, medical regimens. 
• Self-Neglect. Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference. 
• Financial Abuse. Fear, vague answers, and anxiety when asked about personal finances. Disparity between assets and appearance and general condition. Failure to purchase medicines, medical assistive devices, seek medical care or follow medical regimens. 

Some potential signs of elder abuse include depression, fear of being touched, and eccentric behavior. Importantly, many elder abuse indicators are very similar to bullying warning signs across age groups. As therapists, we must pay attention to these red flags wherever they occur and report them. Our skills in building trust, observation, and intervention enable us to identify concerning behaviors among vulnerable individuals at any age. 

Elder Justice Act

You have a duty to report any suspected acts involving resident mistreatment, neglect, abuse, crimes, misappropriation of resident property, or injuries of unknown source. The facility must report any reasonable suspicion of a crime against a resident or patient to: the Secretary of the U.S. Department of Health and Human Services (HHS), and the law enforcement authorities in the political subdivision where the facility is located. 

There are very specific timeframes for reporting any sort of elder abuse. If the events cause suspicion of a crime—suspicion is the key—we don't have to prove that truly elder abuse occurred. If we suspect it may have occurred, we have to report it.

• If the incident results in “serious bodily injury,” the facility must report it to HHS and law enforcement authorities immediately, but not later than two hours after forming the suspicion.  
• Do not result in “serious bodily injury.” The facility must report to HHS and law enforcement authorities no later than 24 hours after forming the suspicion.

Serious bodily injury is an injury  

• involving extreme physical pain or substantial risk of death;  
• involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty or
• requiring medical intervention such as surgery, hospitalization, or physical rehabilitation

Legal Issues

Malpractice

Most claims of malpractice surround negligence  

Negligence occurs when you, as the therapist, fail to follow the acceptable standard of care for the profession. The important piece with negligence is that you didn't need to intend to do something poorly. Negligence concerns itself with the conduct, not your state of mind. So it's not necessarily your intent; it's what your actual conduct was.

Negligence

Proving malpractice within the negligence framework presents challenges in a court of law. To substantiate such a claim, several critical elements must be met.

Firstly, there must be a clearly defined relationship between the involved parties, establishing a duty to act in a specific manner. Building on the foundational principle of ethical practice, this duty sets predetermined expectations, and failure to meet them signifies a breach of the established standards.

Secondly, the plaintiff, the individual alleging negligence, must show that your conduct fell below the accepted professional standards of care, thereby breaching your expected duty.

Thirdly, the plaintiff must establish a direct link between your breach of conduct and the resulting harm or damage. It is crucial to demonstrate that the breach directly contributed to the harm suffered by the patient.

Lastly, the plaintiff must present evidence of tangible harm or damages incurred. This requires illustrating the adverse consequences of the breach, emphasizing the actual and quantifiable impacts of the alleged negligence. While it is a demanding process, meeting these criteria is attainable with the right evidence and legal support.

Discrimination Laws

Discrimination laws raise many legal and ethical issues for us in relation to patient and student issues. We are aware that there are laws in place, and our code of conduct expressly prohibits discrimination based on a number of factors. Those include age, race, disability, religion, nationality, sexual orientation, gender, and marital status.

Whistleblowing

The term whistleblower is used to describe a person who exposes an activity that is illegal, unethical, or incorrect.

As a physical therapy practitioner, you are ethically obligated to act as a whistleblower when encountering such situations. Determining who to report the issue to can be complex, often involving multiple parties.

Acknowledging that many individuals hesitate to report due to fears of retaliation or prejudice from colleagues or supervisors is crucial. However, numerous protections are in place to encourage reporting without fear of repercussions. Nearly all states, if not all 50, have laws safeguarding whistleblowers. Additionally, companies have their own policies that emphasize protection against retaliation. At a federal level, the United States Congress passed the Whistleblower Protection Act in the late 1980s, providing protection for federal employees. The Sarbanes-Oxley Act in 2002 further fortifies protections for individuals who expose wrongdoing. The guiding principle remains: if you witness something wrong, speak up and take appropriate action.

Mandatory Reporting

Most state-licensed healthcare workers are considered mandatory reporters. It's a fundamental obligation, and this holds true across all 50 states within the United States. However, the specifics regarding the types of abuse that necessitate reporting can vary from one state to another. Each state has its own set of explicit guidelines delineating the obligations and procedures for reporting. Additionally, the definition and parameters of abuse, as well as the required reporting language and formats, will exhibit unique variations in accordance with the particular state's regulations. Healthcare practitioners must familiarize themselves with the distinct reporting requirements of the state in which they practice, ensuring compliance with the specific language and procedures dictated by that jurisdiction.

Common Ethical Issues

Ethical Challenges vs. Ethical Dilemma 

In my readings within the nursing literature, I encountered a distinction that resonated with me: ethical challenges versus ethical dilemmas. Ethical challenges encompass a broad spectrum of ethical issues, ranging from the ordinary to the significant. These challenges permeate our everyday professional experiences.

On the other hand, ethical dilemmas represent a unique subset wherein we grapple with choosing between distinct options, both of which may have ethical merit. The complexity lies in the realization that in an ethical dilemma, no choice is unequivocally ideal. When faced with such a dilemma, we find ourselves navigating the delicate balance of competing values. Regardless of the path we choose, we must come to terms with the fact that each option will bear its own set of consequences. 

Everyday Ethical Issues vs. Big Ethical Issues

When delving into the literature on ethics, it becomes evident that ethical issues can be broadly categorized into two major groups: everyday ethical issues and significant ethical dilemmas.

1. Everyday Ethical Issues:

   • These encompass a wide array of common ethical challenges encountered in daily practice. Examples include issues related to informed consent, respect for autonomy, patient refusal of services, addressing offensive behavior, and maintaining confidentiality. These issues are part of routine practice and require consistent attention and ethical decision-making.

2. Significant Ethical Dilemmas:

   • On the other hand, significant ethical dilemmas represent a more profound and intricate set of challenges. These encompass issues such as end-of-life care decisions, the delicate choices regarding withholding or withdrawing life-sustaining treatments, and the ethical considerations surrounding hospitalization. These dilemmas often involve critical and profound decisions, forcing healthcare professionals to weigh conflicting values and principles.

Reasons for Ethical Dilemmas

• Patients or their loved ones must make life-or-death decisions
• The patient refuses treatment
• Staffing assignments may contradict cultural or religious beliefs
• Peers demonstrate incompetence
• Inadequate staffing or resources

Patients are making potentially life-or-death decisions, and they are making choices in general. The patient refuses some level of treatment, whether physical therapy, medication, or food, for example. 

Moreover, healthcare professionals often encounter ethical challenges tied to cultural or religious beliefs, especially when these beliefs conflict with the assigned staffing arrangements. Such conflicts can raise dilemmas regarding balancing one's professional responsibilities with personal convictions.

Equally concerning are instances where healthcare professionals witness peers engaging in incompetent practices, potentially compromising patient safety and care quality. These situations force ethical deliberation on whether and how to address these concerns.

Inadequate staffing and resources, a pervasive issue that is a reality for most of us in today's healthcare landscape, present a critical ethical dilemma. Healthcare professionals often grapple with delivering optimal care under strained conditions, where there's an ethical tension between providing the best care possible and dealing with resource limitations.

Common Ethical Issues in Healthcare Setting

In the healthcare profession, we commonly encounter several ethical issues that deserve our careful attention. These encompass both the need for thorough and accurate documentation as well as navigating complex workplace demands:

• Documentation Lapses
  • Ensuring timely and accurate documentation of patient encounters is critical. We should document every single encounter as soon as it occurs or shortly thereafter, at least at a bare minimum, every day. Lapses in documentation, such as shortcuts, using Xs or dots, or cloning/copy-pasting records, can compromise patient care and credibility in legal situations. Documentation needs to accurately reflect what we did.
• Employer Demands and Productivity Quotas
  • Balancing productivity demands with ethical practice is essential. While efficiency and productivity are not inherently unethical, falsifying billing or misrepresenting services to meet quotas is unethical.
• Use and Supervision of Support Personnel
  • Utilizing support personnel within the boundaries of state practice acts is crucial. Clearly defining the roles and responsibilities of support staff to ensure they adhere to legal and ethical guidelines is vital.
• Impaired Practitioners
  • Recognizing and addressing impaired practitioners due to mental health issues or substance abuse is essential for patient safety and maintaining professional ethics. Prompt intervention and support are imperative in such cases.
• Student Supervision
  • Adequate supervision and mentorship for students during clinical placements are ethical responsibilities. Neglecting to provide proper guidance and supervision can compromise the learning experience and ethical conduct of students. I have heard students complain that their mentors didn't supervise them.  

Addressing these ethical challenges involves upholding professional standards, prioritizing patient care and safety, and ensuring compliance with legal regulations. It's incumbent upon healthcare professionals to maintain ethical conduct while navigating the demands and responsibilities inherent in their roles. I remember going on my fieldwork a long time ago, and I was just left to my own. I saw my supervisor the day I walked on the job and at the end of my fieldwork. That is reasonably unethical.

Common Ethical Issues in Student Supervision

• Patient welfare must come first
• Cannot delegate clinical decision-making
• Must inform client of qualifications/credentials
• Increase supervision based on knowledge, experience, competence
• Document the amount of supervision
• Protect client confidentiality
• It is unethical for therapists to sign for clinical hours they did not supervise

Patient welfare should always remain the top priority in healthcare settings. When supervising a student, the experienced practitioner, not the student, is responsible for clinical decision-making. The supervisor's role is to facilitate, guide, and collaborate with the student, but the supervisor is ultimately responsible for patient care and decisions.

Medicare and the setting can determine the level of supervision in the facilities I work in. It is also crucial to determine the appropriate level of supervision based on the student's competence. This supervision level may vary from direct onsite supervision to less direct supervision based on the student's abilities, experience, and current regulations. Clear documentation of the level of supervision provided is essential, ensuring transparency and compliance with guidelines.

Additionally, it's vital to inform the client about the presence of a student and share the supervisor's credentials and qualifications. This transparency fosters trust and allows for informed consent, maintaining the integrity of the patient-provider relationship. The supervising practitioner remains accountable for the entirety of the patient encounter, overseeing and ensuring the quality and safety of care provided.

Common Ethical Issues in Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Common Ethical Issues in Client Abandonment

Examples of misconduct

• Failing to give sufficient notice
• Failing to provide an interim plan
• Failing to complete the paperwork
• Withholding paperwork
• Removing materials or records
• Maligning the facility or organization
• Recruiting clients

There is nothing unethical about leaving a place of employment.  You may be leaving for a family reason or find a better job or a position advancement; however, you still need to focus on the ethics and the welfare of your client.

Key ethical considerations during a change of employment include:

Handling transitions in healthcare employment with ethics and patient welfare in mind is critical. Here are key ethical considerations during such transitions:

• Giving Adequate Notice
  •    Provide sufficient notice to your employer before leaving to prevent treatment disruptions for your clients. Be mindful of the impact on patient care and work with the employer on a transition plan.
• Completing Paperwork and Orders
  • Ensure all necessary paperwork, including treatment orders, is completed before leaving. Do not withhold essential documentation, as it may adversely affect patient care during the transition.
• Maintaining Professionalism and Integrity
  • Refrain from maligning your previous employer or facility when leaving. Maintain professionalism and ethical conduct during your departure, and consider assisting in recruiting efforts if requested.
• Avoiding Client Recruitment
  • Avoid soliciting clients to follow you to a new practice. This can be seen as unprofessional and may compromise patient trust and continuity of care.
• Addressing Patient Abandonment
  • Take responsibility for patient care to prevent abandonment during transitions, especially in critical settings like nursing homes. Collaborate with appropriate authorities and healthcare professionals to ensure patient safety and continuity of care.
• Reporting Ethical Violations
  • if faced with severe ethical violations, such as client abandonment, consider reporting to the relevant boards or authorities to ensure accountability and protect patient well-being.

These ethical guidelines underscore the importance of maintaining patient welfare, professionalism, and integrity throughout career transitions within the healthcare field. Balancing personal or professional changes with ethical obligations is essential to uphold the standards of care and trust patients place in healthcare professionals.

Examples

Reflecting on past experiences, I vividly recall an incident when transitioning into a new contract. The preceding provider chose to discharge every therapy order before departing, potentially to inconvenience the incoming provider. However, the true consequence of this action was a disservice to the patients, who were left without the necessary therapy services. It reinforced the importance of considering patient welfare above all else.

As you leave prior employment, it's essential not to remove essential services or contribute to a negative environment. Maintaining professionalism and a sense of responsibility toward the facility and the patients is paramount. Additionally, refraining from recruiting clients away from the previous facility showcases good professional practice and helps build positive relationships within the healthcare community.

One incident that stands out in my career involved a nursing home experiencing a change in ownership. In an unexpected turn of events, almost all the nursing staff, except two CNAs, decided not to report for duty. This left therapists and the remaining staff in a difficult position, risking patient safety and care. Nobody was there to pass meds, making it a very unsafe situation. It was a stark case of client abandonment, necessitating immediate action and involving authorities to address the situation.

In challenging circumstances like these, reporting such cases to the relevant boards is an ethical obligation to uphold the profession's integrity and ensure accountability. This incident underscored the critical need to prioritize patient well-being and act in the best interest of those we serve, even in the face of unexpected and unprecedented challenges. In this case, the individuals were reported, and many of them did, in fact, lose their license to practice. 

Common Ethical Issues in Reimbursement for Services

• Misrepresenting information to obtain reimbursement
  • Accurate documentation is required
  • Must remain current with payer policies
• Providing service when there is no reasonable expectation of significant benefit
  • Cannot provide services when the prognosis is too poor to justify therapy
  • Cannot exaggerate the extent of improvement in obtaining reimbursement

Accurate and honest documentation is fundamental in healthcare. When delivering therapeutic activities, it's crucial to document correctly what was performed and bill accordingly. Misrepresenting services to obtain higher reimbursement is unethical and undermines the healthcare system's integrity. If you performed therapeutic activities, that's what you document; that's what you bill. It's just as easy as that.

Ethical practice necessitates ensuring that the services provided hold a reasonable expectation of benefiting the individual receiving care. It's essential to continuously evaluate the efficacy of the interventions and modify the plan of care if necessary. If a person reaches a plateau or the chosen interventions no longer yield benefits, adjustments must be made to the plan of care ethically and professionally. 

Exaggerating improvement or progress to increase payment is unethical and compromises the trust and accuracy required in healthcare practice. Upholding transparency and providing care based on genuine needs and benefits to the patient should always be the guiding principle in healthcare documentation and billing.

• Scheduling services not reasonably necessary
  • Must be based on clinical need
• Providing more hours of care than can be justified
  • Must be based on clinical need
• Providing complimentary care or discounted care
  • Fee alterations are not provided based on referral sources or personal relationships.

Scheduling and providing services that are not clinically necessary or justified is an ethical concern in healthcare. It's essential to base the scheduling and provision of services on a genuine clinical need and avoid unnecessary or excessive care that doesn't benefit the patient. Similarly, offering more hours of care than what is required can lead to overutilization of resources and may not align with the patient's best interests. It's important to ensure that the care provided is appropriate and in line with the patient's needs and treatment plan. 

Providing complimentary or discounted care that is typically billable can be ethically complex. Considering the overall impact on the healthcare system, patient expectations, and professional standards is essential when determining the appropriateness of offering care without reimbursement. This differs slightly from pro bono services that might apply to your setting. It's more like, "Hey, if you follow me to this practice, I'll discount your bill by 25%."

I'll make it worth your while." That's what we don't do. Or "I want to continue services. Do you mind doing those for free even though they can't be reimbursed?" We shy away from those.

Common Ethical Issues in Therapy with Children

When working with children, it's essential to prioritize the child's best interests. However, common ethical considerations often revolve around follow-up care for the child. These issues may include families failing to adhere to appointments, following your instructions, or sharing confidential information with non-family members. Sometimes, there can be ambiguity in the relationships and responsibilities involved in managing the therapeutic alliance with parents and caregivers.

Distrust or frustration regarding reimbursement limitations, concerns about parenting techniques, or potential neglectful behavior can also arise. In some cases, parents may misuse resources, not follow the care plan, or even threaten to withdraw the child from services. Privacy and confidentiality issues persist, particularly when conducting telephone follow-ups, where the caller's identity may not be clear or non-legal guardians seek information they're not entitled to. Parents might request confidential information they shouldn't have access to, further complicating these situations.

Common Ethical Issues

• Documentation lapses
• Employer demands/lack of resources
• Impaired practitioners
• Coercion

These are some of the common issues. To reiterate, ethical concerns among staff members are prevalent, with approximately 90% of clinicians acknowledging that they encounter ethical challenges in their daily work. These issues typically revolve around everyday matters, not necessarily major ethical dilemmas. A significant concern, reported by 79% of clinicians, is the lack of resources. This shortage can encompass various aspects, from the unavailability of durable medical equipment (DME) to the absence of leg rests for wheelchairs, among other things.

Coercion is another significant ethical concern. It's not limited to therapy but can extend to various situations. For example, you might have observed people secretly mixing medications into applesauce for someone without their knowledge. This act could easily be avoided by simply informing the person about the medication. Additionally, lapses in documentation, as previously discussed, are common ethical issues in healthcare.

Ethical Dilemma Examples

Now, I will share a few examples of ethical dilemmas, some of which may involve therapy and others that have arisen recently.

Inadequate Staffing Example: Nurse Cathy is working the evening shift. The SNF has established protocols that include nurse-patient ratios. There was a callout, leaving three staff to provide care for the whole unit.

So, I'm focusing on nursing here, but I think we could extrapolate this to therapy. 

Resource limitations and staffing shortages are common challenges in healthcare. Dealing with these issues may require creative solutions and proactive communication. Consider strategies such as:

1. Calling in PRN Staff: If available, part-time or PRN (as needed) staff can help cover shortages.

2. Overtime: Sometimes, asking existing staff to work overtime may temporarily alleviate staffing issues.

3. Supervisor Involvement: It is essential to report your concerns to your supervisor. They may have insights, and their involvement can help address resource challenges.

4. Prioritizing Care: While not ideal, prioritizing patients based on their needs may be necessary during staffing shortages.

5. Flexible Scheduling: Adjusting treatment schedules, including evening sessions if possible, can help manage patient loads more effectively.

6. Team Collaboration: Work closely with your team to share responsibilities and help each other during resource shortages.

It's crucial to address these challenges promptly to ensure patient care remains a top priority and ethical standards are upheld.

Inadequate Resources Example-Nurse Judy is the wound care nurse for a home health agency. She stopped by the office to pick up additional wound care supplies for her weekend visits. However, the charge nurse told her the wound care supplies delivery did not arrive. As a result, there are not enough supplies on hand for the visits Nurse Judy has scheduled.

Nurse Judy faces a challenging situation with a shortage of wound care supplies for her scheduled weekend visits. To handle this issue ethically, she can consider several approaches:

1. Purchase Supplies: As suggested, Nurse Judy could explore local pharmacies or medical supply stores to purchase essential wound care supplies. While this may be an added cost, it ensures that patient care remains uninterrupted.

2. Physician Consultation: Nurse Judy can contact the physicians for patients with wound care needs. She can discuss the supply shortage issue with them and request adjustments in orders based on the current supplies available.

3. Supply Allocation: Based on the remaining supplies, prioritize the most critical cases. Ensure that patients with more severe conditions receive the limited available resources.

4. Notify Patients: If it's unavoidable that some visits will need to be postponed due to supply shortages, Nurse Judy should contact the affected patients as soon as possible. She should explain the situation honestly and reschedule their visits.

5. Resource Management: She will collaborate with her team and the agency's management to develop strategies for better resource management and supply monitoring in the future.

Open and honest communication is crucial in all these actions. Nurse Judy's primary ethical responsibility is to maintain patient safety and ensure that their care is not compromised.

Keep in Mind

Ethical issues in healthcare, including those related to resource shortages, patient care, and professional conduct, remain consistent regardless of the payer or healthcare setting. The fundamental ethical principles and values that guide healthcare professionals apply universally. Whether one works in a private practice, a public hospital, a home health agency, or any other healthcare context, the obligation to prioritize patient well-being, maintain confidentiality, and adhere to professional standards remains constant. Understanding and addressing these ethical challenges is a critical part of delivering quality healthcare services.

In ethics, it is essential to emphasize the role of evidence-based practices. Specifically, when considering treatment protocols for various diagnoses or clinical considerations, we must rely on empirical evidence. Questions that demand our attention include the frequency of treatment for a given patient, the duration of treatment (in weeks), the number of visits, time allocation, and the selection of appropriate modalities.

Within my practice, which primarily focuses on long-term care and involves Medicare, it's worth noting that Medicare administrative contractors often incorporate evidence into their guidance. This evidence-based approach determines which treatments are eligible for reimbursement and which are not. In cases where the evidence does not support a specific treatment, they clarify that reimbursement is not feasible.

Ideally, they define the recommended number of treatments, the appropriate timeframe for treatment delivery, and the associated guidelines. However, exceptions are acknowledged and justified through thorough documentation. It is imperative to highlight that quantifiable, measurable changes resulting from treatment interventions play a pivotal role in justifying the continuation of care. It's important to remember that our compensation typically hinges on the treatments we provide in each session. Exceptions arise only when a treatment session faces a challenge, such as a denial. In such cases, the accurate presentation of information is of utmost importance.

Cultural Biases

We need to be able to examine our own biases and change them in our daily practice.

• Stereotyping is common
  • Examine your own beliefs and values about aging
  • How do you react to bias or stereotyping?
• Values and beliefs impact care
  • •What care is provided, when, where, why, and how it is provided
  • E.g., the frail elderly stereotype may mean we do not provide the necessary therapy
• Practitioners must treat with respect, dignity, worth, and individual uniqueness, unrestricted by social/economic status, personal attributes, or the nature of health problems. 

If you haven't explored this before, various cultural bias inventories available online can help you assess and understand your own potential biases. This is a crucial step because acknowledging and addressing our biases is essential. It's a recognized fact that biases exist within us; the challenge is not allowing them to influence how we deliver treatment. We are not immune to making assumptions and stereotypes even as healthcare professionals. We must take a closer look at our own beliefs and reactions.

For instance, consider how you respond when you hear statements like, "They're old; they've earned it; they can manage on their own," or, "I'm highly focused on this issue, so I'm less concerned about that one." Our biases, values, and beliefs undoubtedly impact how we provide care. This includes decisions about when and where care is delivered and the methods used.

So, let's give an example of a bias related to, again, the elderly. If we stereotype the elderly as frail and in need of protection, we might inadvertently overlook the full spectrum of therapy or treatment necessary to address their unique issues. Thus, it is imperative to approach care provision with unwavering respect, dignity, recognition of their self-worth, and a celebration of their individuality, all while consciously considering and mitigating our biases. 

Ethical Dilemma Example

Nurse Gloria is instructed by the attending physician to have Mr. Isaac sign a consent form before a scheduled colonoscopy. As she reviews the form with the patient, she notices that he seems confused and unsure where or how to sign the paperwork.

Various factors can contribute to this situation, and it's worth considering that it's not exclusive to the nursing profession. We may encounter similar scenarios when explaining the potential benefits of a treatment, such as aquatic therapy. The patient's confusion may stem from a genuine lack of understanding. In such cases, the fault may not lie with the patient but rather with how information has been conveyed. Perhaps medical jargon or overly complex language was used. Cultural factors could also come into play; English might not be the patient's first language, further complicating comprehension. In such instances, an interpreter or a cultural broker may be necessary.

The paramount concern here is to avoid any form of coercion. The patient must be fully informed about their options and the procedures involved. When in doubt, the principle of caution should guide our actions. Re-engaging the physician, presenting the information differently, or bringing in a translator, among other possible solutions, may be required to ensure the patient's understanding and informed decision-making.

These are everyday ethical issues. It is important for someone to understand us. Sometimes, we don't see those big ethical issues, but our ethical obligation, as outlined in our professional code of ethics, is to educate and ensure informed decision-making.

Education

• Ethical duty to educate the public and ourselves
  • Are you as educated as you should be about long-term care?
  • Do you listen for and correct misperceptions?
• Staying current in one’s profession is an ethical duty to the constituency the profession serves
  • Formal education, clinical competence, personal growth

It is essential to continuously educate the public while also maintaining our own knowledge base. A fundamental question we should ask ourselves is whether we are as well-informed as we need to be in our specific clinical setting. This involves being aware of the rules and regulations governing our practice, staying updated on legislative developments in Congress relevant to our field, and understanding the dynamics with our payers.

How often have we heard someone say, "I simply don't grasp the complexities of insurance," or witnessed a divide between those in acute care and long-term care, each harboring misconceptions about the other's domain? As professionals, we have a duty to address such misperceptions. Whether it's debunking the idea that a particular care setting is only for end-of-life care or correcting misunderstandings between colleagues, it falls upon us to ensure clinical competence and foster personal growth.

Competence is not merely a goal in physical therapy; it is an expectation. We trust that our colleagues are competent, and it is our responsibility to uphold and contribute to this competence as well.

Ethical Dilemma Examples

• Incompetence among peers
• Asked to perform a treatment for which you are not trained or competent
• Questioning MD orders (e.g., order written for medication to which patient is allergic)

Nobody wants to entertain the thought of someone being incompetent to provide care. However, the reality is that issues of incompetence do exist and can present significant ethical dilemmas in therapy. What should we do when confronted with a situation where we are asked to perform a treatment for which we lack training or competence? Ideally, we should respond by acknowledging our limitations and readily admit that we are not qualified for the task while suggesting a more suitable colleague who can address it effectively. For example, if it involves a specialized treatment like lymphedema therapy, we should avoid attempting it ourselves, assuming we can manage it or misrepresenting our capabilities.

Another vital aspect of our professional duty is to question physician orders when we have concerns. If we encounter a treatment plan or modality that raises doubts or poses a risk to the patient's well-being, it's our ethical responsibility to express these reservations. For instance, if a physician orders a specific modality, but we suspect that the patient's skin integrity in that area is compromised and unlikely to tolerate it, we should seek clarification from the physician or suggest an alternative approach.

In all cases, the guiding principle must be the unwavering commitment to putting the patient's best interests first. Our paramount duty is to ensure our patients' highest level of care and safety, even if it means challenging or seeking clarification on medical decisions.

Involving Patients in Medical Decisions

Frequently, healthcare providers encounter situations where there is a conflict between the patient's preferences and the desires of their family, significant other, adult child, or parents. These conflicts can manifest in various ways, such as a patient refusing medication when their family insists they should take it or family members wanting to withhold information from the patient, thereby excluding them from their care plan. Other examples include patients refusing nutrition, treatment, and blood sugar control.  

Ethical Dilemma Example

Mr. Morris is in end-stage renal failure. Despite efforts to help manage the disease, including dialysis three times weekly, his condition has worsened. Mr. Morris's physician has noted the decline in his status and has informed the family that Mr. Morris may have only a few weeks to live. Mrs. Morris and their children are skeptical about telling Mr. Morris how bad his condition is, and the physician has made no effort to talk to the patient about it. After his family left for the evening, Mr. Morris called for the nurse and asked her to tell him what the doctor said, stating he felt like he was not getting the whole story.

This is a real ethical dilemma. It is not uncommon for family members or significant others to withhold information, often with the intention of protecting their loved ones. Nevertheless, from an ethical perspective, this raises concerns related to paternalism, where someone else is presumed to know better than the patient. Ethical principles such as veracity, informed consent, and autonomy are paramount here.

In situations like this, healthcare practitioners must uphold their duty to provide information. Patients have the inherent right to be informed about their condition and prognosis. While it may not always fall on the physical therapy practitioner to deliver such information, it is crucial to know where to direct the patient to ensure they receive the information they are entitled to. Resolving such situations requires a collaborative approach, ensuring that the patient's rights and autonomy are respected while addressing the concerns of their family. This case highlights how various ethical principles intersect and must be carefully navigated to provide the best care.

End of Life Wishes

This issue frequently arises, particularly in acute care, hospitals, long-term care, and even home care. A survey of ethical challenges in end-of-life care often reveals two prevalent issues: a lack of resources and a breach of the patient's autonomy. In these circumstances, family members, healthcare staff, or others may exert pressure on the healthcare team to undertake actions that run counter to the wishes of the dying individual.

What becomes paramount in such cases is the necessity to be aware of the dying person's wishes. Is there an advanced directive or some form of documented guidance in place? Waiting until the last moment to address these critical matters is far from ideal. Ideally, well in advance, someone should have worked with the patient to articulate their true desires and what they wish to avoid in their end-of-life care.

The complex aspect emerges when family members express differing opinions from the patient. Some may assert, "We can't just let mom die," while others may believe, "Mom wouldn't have wanted to live like this." There is no conflict of interest when family members concur with the patient's wishes. However, it's common for conflicting statements to arise, complicating the situation. Healthcare providers, including therapists, can sometimes feel caught in the middle as they hear both the patient's and the family's perspectives.

In such situations, it can be beneficial to involve an ethics committee. The central principle to uphold is that of autonomy and self-determination. The patient's voice and choices should be respected and preserved whenever possible.

This underscores the fact that our primary duty and commitment always lie with the patient we are treating. Patient advocacy remains paramount, but there may be scenarios where family interests come into play, as our second duty is to the family. 

Ethical Dilemma Example

Mrs. Douglas has metastatic lung cancer. Her physician has advised about treatment options that may prolong her life by six months to a year. However, to the dismay of her family, Mrs. Douglas has chosen comfort measures only. Mrs. Douglas has prepared an Advanced Directive, including signing a DNR. 

In cases like these, where the patient's wishes diverge from those of the family, it is crucial to prioritize the patient's autonomy and documented preferences. The patient's wishes, as outlined in their Advanced Directive, should be respected and followed. This is a fundamental principle of medical ethics and legal practice.

Conversely, if a patient lacks an Advanced Directive and the healthcare facility is unsure of their preferences, it is imperative to initiate the appropriate discussions. While it may not fall upon us directly, someone within the care team should engage with the patient and their family, if possible, to understand their preferences and document them. These critical conversations should explore the patient's values, goals, and treatment preferences, ensuring their decisions are at the forefront.

Lifestyle Choices

• Ethical questions can be raised about individual client responsibility and preferences about lifestyle choices.
  • Do we discuss choices about exercise, religious beliefs, or cognitive activities?  
  • Screen for depression, functional change, or cognition changes, or do we wait to do these screens until symptoms become problematic?
• Commonly voiced beliefs, biases, and stereotypes make health promotion harder to implement
• Health promotion is seen as easier to set aside than other healthcare
• Elderly have chronic conditions linked to lifestyle choices that do not include positive health promotion activities

The role of lifestyle and health promotion in our practice is critical but often overlooked. We must ask ourselves how frequently we engage in discussions about exercise and cognitive activities with our patients. Do we regularly screen for issues like depression, functional changes, and cognitive decline, or do we wait until these problems become severe? It's a common scenario where we only address these concerns when they reach a critical point.

To illustrate, a recent case came to my attention where an occupational therapist questioned the responsibility of addressing lifestyle choices with a patient, specifically regarding type 2 diabetes. The therapist observed the patient's diet and lifestyle choices and wondered about their obligation to initiate a conversation about healthier lifestyle choices, including nutrition. While we are not dietitians or nutritionists, this raises the question of our ethical obligation to promote healthier choices.

Unfortunately, we often encounter biases and stereotypes in our practice, such as the belief that people's choices are unchangeable or that older individuals can do as they please because they've reached a certain age. These preconceived notions can hinder our efforts in health promotion, prevention, and addressing lifestyle-related chronic conditions. We must revisit our professional code of ethics and remember that health promotion is a crucial part of our role, not to be set aside in favor of solely focusing on impairments. This applies across all age groups and emphasizes the importance of encouraging positive health promotion activities.

Issues Surrounding Dementia

In the realm of end-of-life care and the advanced stages of dementia, we often encounter complex scenarios where patients may refuse nutrition, fluids, or treatment. These behaviors can sometimes serve as a form of communication or be linked to the need for human contact. Additionally, in cases where two individuals with dementia are attracted to each other, it can be challenging when one of them is married. Family members may voice concerns, and the facility may prioritize the family's wishes over the desires and happiness of the individuals involved.

This situation underscores the complexity of balancing patient autonomy with the concerns of family members. It can be a difficult task to navigate, but it is essential to genuinely inquire about what each individual involved wants and what brings them contentment.

Engagement in meaningful activity is another critical aspect, and we often encounter situations where individuals are not actively participating in activities and are, as you described, "busy doing nothing." Encouraging proper hydration, a healthy diet, and physical activity is well within our professional scope. While we may not provide detailed dietary recommendations, we can certainly promote general principles of a healthy lifestyle.

Sexuality can be equally complex and sensitive, and the approach may vary depending on the specific care setting and policies in place. Having clear policies and procedures to address such issues is essential. When these situations arise, it's crucial to know who to consult and how to handle them appropriately, ensuring the rights and dignity of all involved are respected.

Accountability

Our primary accountability in healthcare is to the patient. The patient's well-being and best interests should always be at the forefront of our decisions and actions. Our families are second. However, there are situations where it might be necessary to consider the family's needs and welfare as well.

For example, I observed the following:

A well-intentioned daughter took her father into her home after discharge. The daughter had a family that included a husband and children. During the home care sessions, I witnessed the father making frequent and excessive demands on the family. While the daughter aimed to provide care, the unreasonable requests placed a major strain on the household.

An example illustrating when family interests may take precedence is when a patient's unreasonable demands, which they can handle themselves, begin to put undue stress and burden on their family members. In such cases, the distress and disruptions caused by the patient's behavior can lead to the potential breakdown of the entire family unit. When this occurs, healthcare professionals may advise the family to seek alternative care arrangements, prioritizing the family's well-being.

Nonetheless, these instances are exceptions and should be approached carefully considering the clinical situation, social dynamics, and the best interests of all parties involved. In most cases, our primary obligation remains with the patient. The concept of a "rejection of responsibility" is complex and should be assessed on a case-by-case basis, considering the patient's specific circumstances, their family dynamics, and the broader context.

This issue frequently arises when working with adults who have faced neglect or abuse early in life or when dealing with complex family histories, such as a caregiver with a history of alcoholism. In each case, it's essential to gather all relevant information to make a sound value judgment regarding whether a true rejection of responsibility is occurring and how to best address it while upholding the patient's rights and well-being. 

Ethical Dilemma Example

Mr. Simms was diagnosed with lung cancer three years ago. After chemotherapy, he experienced a brief remission but recently learned the cancer had recurred. Mr. Simms's doctor advised him and his family that treatment would likely be unsuccessful and, although it may offer a few more months of life, Mr. Simms's quality of life will rapidly deteriorate. The doctor recommends hospice with comfort measures only, including oxygen and opioid pain relievers. Despite symptoms of pain, such as grimacing and crying, Mr. Simms refuses pain medication, stating he does not want to experience the effects of feeling sleepy and missing precious time with his family. His wife is distraught and asks the nurse if there is a way to administer pain medication without her husband knowing.

The ethical dilemma presented in the case of Mr. Simms revolves around the tension between beneficence and autonomy. Beneficence dictates the healthcare provider's duty to act in the patient's best interests, ensuring their well-being and comfort. This scenario translates to providing pain relief to alleviate Mr. Simms's suffering.

On the other hand, autonomy grants patients the right to make decisions about their own care, including the choice to refuse certain treatments or interventions. Mr. Simms, despite experiencing pain, exercises his autonomy by refusing pain medication, fearing that the side effects may deprive him of precious time with his family.

The wife's distress and her inquiry about administering pain medication without Mr. Simms's knowledge introduce a complex layer to the situation. It implies a level of paternalism, where she believes that she knows what is best for her husband's well-being.

This scenario is a poignant example of the ethical challenges healthcare professionals face when trying to balance the principles of beneficence and autonomy. It highlights the need for careful analysis, communication, and ethical decision-making to ensure that Mr. Simms's wishes are respected while addressing his pain and suffering in a way that aligns with his values and preferences.

Entering a Skilled Nursing Facility (SNF)

• Disparity between views (taking a medication or getting a specific type of treatment)
• Paternalism contradicts autonomy
• Must discuss decisions with the client in detail and make the decision best for the client and the family

Entering a skilled nursing facility highlights the common disparity between the views of healthcare professionals and patients or clients regarding certain treatment options or medications. This discrepancy often underscores the ethical conflict between paternalism and autonomy.

Paternalism suggests that healthcare providers may act in what they believe to be the patient's best interests, even if it means overriding the patient's autonomous decision. However, this approach contradicts the principle of autonomy, which grants patients the right to make informed decisions about their care.

Engaging in detailed discussions with the client or patient and providing comprehensive information to ensure informed consent are imperative. Open and honest communication, or veracity, is critical to ensure that the patient truly comprehends the options and is actively involved in decision-making. Ultimately, the decision should best serve the well-being and preferences of the client and their family.

The scenario becomes even more complex when a person's legal competence is in question, particularly in the context of seniors. 

Legal Incompetence

There has to be legal incompetence. When the person is cognitively unable to decide, we look to the family. The actual decision rests with the legal guardian, who must weigh the implications of the family’s standpoint in relation to the patient’s interests. Consideration is given to the patient's needs, physical condition, personality, and whether continued home care is possible.

If the individual has not been deemed incompetent, they must be part of that decision. Ethics play a significant role when considering placement. It's crucial to assess whether the individual can genuinely be adequately cared for at home.

Healthcare Ethics & Common Related Offenses

Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Example HIPAA Violations

Unencrypted Thumb Drives and Laptops

Recently, a Department of Health and Human Services Administrative Law Judge ruled in favor of the Office of Civil Rights (OCR) and required a Texas cancer center (MD Anderson) to pay $4.3 million in penalties for HIPAA violations for failure to mitigate known security risk vulnerabilities and the use of unencrypted thumb drives and laptops. 

OCR is serious about protecting health information privacy, and it will pursue litigation.

Dermatology Practice Penalized for HIPAA Violations

Private practices are the kind of covered entity most scrutinized by the Office of Civil Rights (OCR).

In one HIPAA violation case, a dermatology practice lost an unencrypted flash drive that contained protected health information.

The group was fined $150,000 and was required to install a corrective action plan.

Submitting Bills to Collections with Protected Information

This one was related to billing and sending past-due bills to a collections agency. Dr. Helfmann’s employees regularly forwarded past-due patient bills to a collections firm. The bills contained protected information like CPT codes, which can reveal patient diagnoses, and they didn't remove that information prior to sending them to the collection agency. Collections agencies have no need to know other information other than the amount that was owed. As a result, the State of New Jersey sought to suspend and revoke Helfmann’s license.

Hospital Worker Charged with HIPAA Violation

In 2014, Texas hospital employee Joshua Hippler received an 18-month jail term for wrongful disclosure of private patient medical information. He was arrested in Georgia and found to be in possession of medical records. Though the filing didn’t say how many records he had, he was charged with wrongful disclosure of private health information for personal gain.  

Case Against Walgreens Pharmacist Leads to $1.4 Million HIPAA Award

Also, in 2014, a Walgreen Co. pharmacist shared confidential medical information about a customer who once dated her husband. $1.4 million lawsuit, and the customer’s lawyer, Neal F. Eggeson Jr., said the case sets an example since it proves businesses can now be held liable for the actions of their employees.   

HIPAA Violation-OBGYN office

A similar situation I read recently was a woman went to her OBGYN, and when she got there, the person who worked the desk knew her mother, and she just said, hi, hello, how are you? The woman went in to see her OBGYN and discovered she was pregnant. She did not want to be pregnant, which was the key here. The patient left, and the person behind the desk, who was friends with Mom, looked at that person's record. She had no right to look at that record, and she phoned the patient's mom, who was her friend and said, oh, congratulations, your daughter is pregnant; this is wonderful. The patient didn't want her mom to know that she was pregnant. Again, there was a lawsuit there.

Criminal HIPAA Conviction for a Respiratory Therapist

Jamie Knapp, a respiratory therapist and employee of ProMedica Bay Park Hospital in Ohio, accessed 596 medical records in a 10-month period. 

Knapp was authorized to view records as part of her job, but only for the patients she was treating.  Allegedly, she viewed files for almost 600 unrelated patients.

Knapp was convicted of criminal HIPAA violations by a federal jury in Ohio, facing up to one year in prison.

$2.5 Million Settlement in Stolen Laptop HIPAA Case

A cardiac monitoring vendor got into HIPAA "hot water" when a laptop containing hundreds of patient medical records was stolen from a parked car. The OCR reached a $2.5 million settlement with the vendor, demonstrating that the federal government is extremely aggressive in prosecuting HIPAA cases involving third parties and portable digital media.

Facebook HIPAA Violation

In 2017, a HIPAA violation resulted in the firing of a medical employee after she posted about a patient on Facebook.  

The 24-year-old med tech commented on a post about a patient killed in a car crash, using the words, “Should have worn her seatbelt…”  While that seemed pretty innocent, believe it or not, it disclosed patient health or protected health information about that patient.

The person was fired, and there was an obviously HIPAA violation. Past that, I don't remember what happened, but at a bare minimum, they were fired.

Analyze Ethical Dilemmas-CELIBATE Model

CELIBATE stands for clinical ethics, and legal issues bait all therapists equally. 

The process for analyzing ethical dilemmas, as presented, is a comprehensive and multi-step approach that considers both legal and ethical considerations. This systematic multi-step process can guide healthcare professionals through complex ethical situations. Here are the key steps in this analytical method:

1. Identify the Problem: The first step is to clearly define and identify the problem or ethical dilemma at hand. This step sets the stage for the subsequent analysis.

2. Gather All the Facts: It's essential to gather all the relevant facts and details pertaining to the situation. This includes not just the surface-level information but a deep dive into the specifics of the case.

3. Identify Interested Parties: Determine all the individuals or groups who are interested in the situation. This can include the patient and healthcare professionals, colleagues, supervisors, rehab directors, administrators, family members, caregivers, payers, and more.

4. Understand the Nature of Their Interest: It's crucial for each interested party to understand why the issue is important to them. This may be related to professional, personal, business, economic, intellectual, societal, or other factors. This helps in assessing the motivations behind their perspectives.

5. Assess for Ethical Issues: Analyze whether there is a genuine ethical issue at play. Evaluate whether the situation violates your professional code of ethics, state practice act, or any other moral, social, religious, or cultural values. It's vital to compare the actions or decisions to the relevant ethical standards.

6. Consider Legal Aspects: Determine if there are any legal issues involved. This entails reviewing practice acts, licensure laws, and regulations to identify which sections, if any, are being violated.

Legal Issues 

Legal issues can be any of the following:

• Age Discrimination?
• Antitrust?
• Assault and/or battery?*
• Breach of contract?
• Child abuse?
• Copyright violation?
• Confidentiality of student records?
• Covenants not to compete?
• Disability Discrimination?
• Elder abuse?
• Embezzlement?
• Family Medical Leave Act?
• Fraud? (Insurance)*
• Gag clauses?
• Guardianship/conservatorship?
• Kickbacks?
• Malpractice?
• Medical fraud?
• Modalities without training?
• Negligence?
• Omnibus Budget Reconciliation Act (OBRA) violation-long-term care facilities would ascribe to?
• Patient confidentiality?
• Plagiarism?
• Sex discrimination?
• Sex with a patient?
• Sexual harassment?
• Spousal abuse?
• Theft?
• Trade secrets?
• Treatment without a prescription or referral?
• Violation of privacy laws?

Addressing ethical issues within your workplace is a complex matter that can lead to various outcomes and ramifications. It's essential to consider both your professional and personal perspectives when deciding how to handle these situations. Here are some key points to keep in mind:

Many ethical issues can be addressed internally within your workplace. Depending on the nature and severity of the issue, actions taken within the organization may include verbal warnings, written warnings, suspensions, or even termination. Your workplace policies and procedures will guide the internal resolution process.

The decision to involve licensing boards should be made on a case-by-case basis. There may be instances where a breach of ethics is severe enough to warrant reporting to the relevant licensing board. This is typically appropriate when the issue involves a violation of professional standards outlined in your state's practice act.

Deciding whether to report to the board is a personal choice. It depends on the specific circumstances, your level of involvement or responsibility, and your own ethical and professional standards. There is no one-size-fits-all answer, and it's essential to consider the potential consequences and the potential impact on your career.

Familiarize yourself with your state's practice act and any specific requirements related to reporting ethical violations. Your practice act provides guidance on when and how to report violations and the potential consequences.

Some ethical issues may have legal implications, leading to criminal or civil lawsuits. Depending on the nature of the issue, you may need to contact the relevant legal authorities or law enforcement agencies.

Ultimately, how you address ethical issues in your workplace should align with your professional and personal values and the specific circumstances of the situation. It's important to act in a way that upholds the integrity of your profession while also considering the best interests of all parties involved.

The remaining steps in this process:

7. Assess the Need for More Information: Determine if you require additional information to fully understand the ethical dilemma. Consider whether there are policies, procedures, laws, or regulations that you may not be aware of and need to research. Explore the existing evidence and literature related to the issue. Consult with experts, mentors, supervisors, or individuals who can provide guidance and expertise in the specific area of concern.

8. Brainstorm Possible Action Steps: Generate a list of potential actions or solutions to address the ethical dilemma. Brainstorming encourages creativity and exploring various options.

9. Analyze Action Steps: Evaluate the proposed action steps and eliminate those that are obviously inappropriate or unfeasible. For the remaining options, consider how they will impact the patient, involved parties, society, and yourself. Assess whether the choices align with your practice act, regulations, and code of ethics, as well as your personal moral, religious, and social beliefs and values.

10. Choose a Course of Action: Select the most appropriate course of action based on the analysis, considering all relevant factors. Evaluate your decision using criteria such as the Rotary Four-Way Test: Is it truthful, fair, goodwill-building, and beneficial to everyone concerned? You should strive for a win-win outcome, but that may not always be possible.  You may not feel great if you had to report somebody to the board or they lost their job, but you have to feel good about the fact that you made the best choice possible, considering the available information and ethical considerations.

This structured approach helps healthcare professionals navigate complex ethical dilemmas, ensuring that their decisions are well-informed, ethically sound, and aligned with their professional and personal values.

Let's Practice: Example  (Terri)

Terri is a student at the Sunnyside Nursing Home.  She has struggled throughout her student internship. Calling her performance marginal would be a compliment. As her supervisor and her CI, you have repeatedly given her very specific feedback, including instructing her in various ways that she can change her behavior. Unfortunately, Terri fails to heed your advice. At midterm, her performance merited a failing grade. She forgets to lock the brakes on wheelchairs. She shows a complete disregard for other patient safety precautions. Well, here you are now at her final evaluation, and after spending half an hour at a minimum struggling with this failing final evaluation, your boss, the rehab director, looking over your shoulder, says, "Well, whoa, you can't fail, Terri. She's done her best even though she has a learning disability." And she says, "Even though she really failed this clinical internship, it's just too much trouble to give her a failing grade." Your supervisor reminds you that your facility doesn't want to be sued for an Americans with Disabilities Act violation. And should Terri fail her clinical internship, that's what you would see. You had no previous knowledge of Terri's learning disability, only her failing performance.

Let's go through the steps.

What is the problem?   

• The boss wants the supervisor to pass a failing student intern whose performance doesn't warrant a passing grade. I hope that that would make most of us feel some level of conflict and discomfort.

What are the facts of the situation?  

• Terri is a student intern at Sunnyside Nursing Home
• Midterm performance was failing  
• Terri’s supervisor provided her with adequate supervision and ample specific feedback on how she could perform better and improve her performance in various areas.
• Terri failed to modify her behavior in response to your feedback
• Terri forgets to abide by patient safety precautions
• Terri’s is still failing at the end of the fieldwork
• The supervisor intends to fail her
• The rehab director tells the supervisor not to fail Terri
• The supervisor learns for the first time about the learning disability
• The learning disability was not considered  
• The facility does not want a lawsuit

We know that she is not abiding by safety precautions, specifically locking the brakes on wheelchairs during transfers and some other things. We also know that at the end of this clinical affiliation, she still warrants a failing grade. The supervisor feels that Terri earned a failing grade and intends to fail her. The rehab director tells the supervisor, you are not to fail Terri. At the end of the internship, the rehab director informs the supervisor for the very first time that she has a learning disability. In assigning a failing grade, the supervisor did not consider any sort of learning disability. The rehab director tells the supervisor that he/she cannot fail her because of the fear of an unwanted ADA lawsuit. 

Who are the interested parties?

• Terri
• Supervisor  
• Rehabilitation Director and Facility
• Terri’s future patients and employers  
• Academic program from which Terri came
• Other therapists/students at the facility
• Terri’s professional association/licensing board

What is the nature of their interests?

Many different stakeholders have an interest in Terri's situation as an intern struggling to pass her clinical internship. Analyzing the nature of these interests is complex but necessary to make an ethical decision.

Terri: Personally, she wants a job and needs to pass. She also has professional (she wants her license and desires to practice therapy) and economic interests in passing the clinical, obtaining licensure, and securing employment, as she spent a lot of time and money going to school.  

Supervisor - Professional interest in competent therapists and reputation; Personal desire to avoid failing students; Business interest as a supervisor need to balance management expectations and patient safety 

Facility - Economic/business interests 

Terri’s parents - Economic interest in her career success 

Terri’s future patients - Safety and quality care

Federal government - Societal interest- individuals with disabilities are not denied opportunities.

Academic program - Reputation and student outcomes

Other therapists - Professional standards  

Licensing board - Public protection

Considering these diverse perspectives helps illuminate the full scope of consequences in either reporting Terri or assisting her. An ethical resolution will account for all stakeholder needs.

Is there an ethical violation?

Yes. At the very least, passing a student who achieved a failing grade violates a code of ethics addressing justice, veracity, and maybe non-maleficence too, because this student could possibly harm someone in the future.

Is there a legal issue?

Again, we would need to look at the practice act there. We don't have much information there.

Are there other possible legal issues?

Although our information is limited, it's possible that an ADA violation occurred, such as filing a false report, contract breach, or confidentiality issue. Additionally, issues of negligent supervision could come into play.

ADA, filing a false report, practice act, contract breach, confidentiality, negligent supervision, and other legal issues. Do you need more information? Possibly, possibly. Other good information. Was this this person's first internship, or would maybe it be the last? If it was the first, maybe there's another opportunity. Maybe you fail her because she will have another opportunity. Maybe you need to familiarize yourself with ADA, the practice act, and maybe somebody else on the management team for advice. So, let's brainstorm. Remember, there are no right or wrong answers here. What can you do?

Do you need more information? 

It's conceivable that this may not have been Terri's first internship, and there might be more at stake than initially apparent. If it indeed was her first internship, other opportunities may be available. It would be prudent to familiarize yourself with the ADA and the practice act or seek advice from a colleague within the management team. Let's brainstorm. Remember, there's no definitive right or wrong answer in this situation. What options can you consider?

• Brainstorm possible courses of action.
  • Fail Terri
  • Pass Terri 
  • Call the coordinator at the university 
  • Research the ADA issue  
  • Complain to the rehabilitation director’s boss 
  • Call the police?  Terri’s parents? 
  • Contact the Justice Department 
  • Consult with an ADA lawyer 
  • Discuss the situation  
  • Quit your job rather than fail Terri

You might choose to fail Terri, or you could pass her. Another approach would be to contact the university's academic coordinator and request guidance. Researching the ADA to determine if a failing grade is permissible is another avenue. Discussing the matter with the rehab director's immediate supervisor is a possibility. Alternatively, you could reach out to the police or Terri's parents. If you're unsure, you could contact the Justice Department, responsible for enforcing the ADA, to inquire if failing Terri violates the law. Consulting with an ADA lawyer is also an option. You could discuss the situation with your spouse, significant other, or a religious or spiritual advisor. Quitting your job rather than failing Terri, however, is an extreme step.

Let's evaluate these options by first eliminating those that are clearly inappropriate. Calling the police is unnecessary as there is no criminal activity involved. Contacting Terri's parents, your spouse, or your clergy would breach confidentiality. Quitting your job is not a rational choice. Now, let's apply a moral and ethical litmus test to the remaining choices. Do they align with your personal code of ethics and professional standards? Finally, you can select the best course of action based on the contextual factors at hand.

In this case, it might be advisable to call the academic program to seek guidance and involve another supervisor at the facility to gather additional insights before making a final decision. Keep in mind that the goal is to achieve a win-win outcome, ensuring that your choice aligns with the situation's ethical considerations. There may not be a definitive answer, but this is how we could approach the analysis.

Analyze Ethical Dilemmas-RIPS Model

The Realm-Individual Process-Situation Model (RIPS)is another way of analyzing ethical dilemmas.

Step 1: Recognize and Define the Ethical Issue 

• Realm
• Individual process
• Implications for action
• Type of ethical situation
• Barriers

Step one involves recognizing and defining the ethical issues at hand. This process is quite similar to our previous discussion. In this step, you need to determine the realm, the process, the implications for action, the nature of the ethical situation, and any barriers you might encounter. Let's delve into these aspects in greater detail:

Realm. Begin by identifying the ethical realm to which the issue belongs. There are three primary realms to consider:

• Individual Realm: This pertains to matters related to the patient's or client's well-being. It focuses on rights, duties, interpersonal relationships, and individual behaviors.

• Institutional or Organizational Realm: Here, the emphasis is on the organization's well-being. You should consider the structures and systems that contribute to its achievement of goals.

• Societal Realm: This realm is concerned with the common good of society as a whole. It involves ethical considerations that transcend individual or organizational interests and aim to benefit the broader community.

Individual Process. The second aspect of recognizing ethical issues involves assessing individual processes. These processes help you understand how the problem manifests in terms of moral decision-making. Consider whether the issue aligns with any of the following aspects:

• Moral Sensitivity: Recognizing, interpreting, and framing ethical situations. It involves being aware of the ethical dimensions of a situation and understanding the potential implications for all involved parties.
• Moral Judgment: In this step, you are tasked with deciding what is morally right or wrong. You evaluate the ethical principles and values at play and decide on the most appropriate course of action.
• Moral Motivation: Moral motivation concerns your ability to prioritize ethical values, principles, and considerations over personal financial gain or self-interest. It involves a willingness to act in accordance with one's ethical beliefs even when there may be external pressures to do otherwise.
• Moral Courage: This aspect is about implementing the chosen ethical action, even when doing so may lead to adversity or challenges. It requires the determination to follow through with the right course of action despite potential consequences or resistance.

Situation. How do you classify the ethical situation? To effectively analyze the ethical situation, you should classify it into one of the following categories:

• Problem or Issue: Determine whether the situation qualifies as a problem or issue, meaning whether important moral values are being challenged.
• Temptation: If the situation involves a choice between a right action and a wrong action, where the wrong action may offer personal benefits, it falls under the category of temptation. This often tests your moral integrity.
• Silence: When key parties recognize the existence of ethical issues but remain passive, not discussing or taking any action to address them, the situation can be classified as one of silence. This is a scenario where there is an unspoken agreement not to confront ethical challenges.
• Distress: If a structural barrier hinders you from doing what you believe to be the right thing, it falls under the category of distress. There are two subcategories:
  • Type A Distress: In this case, the barrier is apparent, but it prevents you from doing what you know is right.
  • Type B Distress: Here, there is a barrier, but you are uncertain about the specific nature of the problem. Something feels ethically wrong, but you may be unable to pinpoint it.

Dilemma. There are two or more correct courses of action that cannot both be followed. You're doing something right and also doing something wrong, and most often, this involves ethical conduct. Ethical dilemmas typically involve the need to balance and make decisions between conflicting principles. Some common examples include:

• Honoring Autonomy vs. Preventing Harm: On one hand, you may be required to respect an individual's autonomy and their right to make decisions about their own life, even if it might lead to harm. On the other hand, there's an obligation to prevent harm, which may require intervention that infringes upon their autonomy.
• Conflicting Traits of Character: Ethical dilemmas can also involve conflicting character traits, such as honesty vs. compassion. For instance, you might need to decide between being completely honest and potentially hurting someone's feelings or showing compassion by withholding some information to protect them.

Step 2 Reflect

• Background
• Major stakeholders
• Consequences of action or inaction
• Laws broken?
• Professional guidance
• Right-versus wrong tests

The process is very similar to the ethical decision-making (CELIBATE) model we discussed earlier. When faced with an ethical dilemma, it's crucial to consider the following factors carefully:

• Relevant Facts and Contextual Information: Gather all the pertinent facts and contextual information about the situation. This provides the foundation for making an informed ethical decision.

• Major Stakeholders: Identify and understand the key parties involved in the situation, as their interests and perspectives can significantly influence the ethical implications.

• Consequences: Analyze both intended and unintended consequences of potential courses of action. This includes considering the impact on individuals, organizations, and the broader community.

• Relevant Laws, Duties, and Ethical Principles: Examine any applicable laws, regulations, professional duties, and ethical principles that are relevant to the situation. These provide a framework for ethical decision-making.

• Professional Guidance: Seek guidance from your profession's ethical guidelines or code of conduct. This guidance can help you align your decision with industry standards and values. Examine whether the situation aligns with the code of ethics, the guide to professional conduct, or any core values of your profession.

• Right vs. Wrong Tests: Evaluate the situation by asking if a course of action is morally right or wrong, considering your own values and principles. You may include: 

  • Legal Test: Determine if any actions the involved parties take are illegal, as this can impact the ethical assessment.

  • Stench Test: Assess whether the situation feels wrong or unethical, even if it may not be clearly defined as such by laws or regulations.

  • Publicity or Front Page Test: Consider how the situation would be perceived by the public or if it were to become widely known. This can shed light on potential reputational and ethical concerns.

  • Universality or Mom Test: Reflect on whether the decision is right, regardless of who is involved. Consider what your moral compass or what your "mom" would advise. 

Step 3 Decide the Right Thing to Do

You can do this in three different ways.

• Principle-Based Ethics (Deontological): This approach focuses on following universal rules or principles, regardless of consequences. You act based on what you believe everyone should do in a similar situation. For example, you should always tell the truth to patients, even if it might cause distress.
• Outcome-Based Ethics (Teleological): This method prioritizes actions that result in the best overall outcome for the majority. Decisions are made by weighing potential benefits against harms for all affected parties. For instance, allocating limited resources to treatments that will help the greatest number of patients.
• Care-Based Ethics (The Golden Rule): This perspective emphasizes empathy and treating others as you would want to be treated. It involves considering how you would feel in the patient's position and acting accordingly. For example, explaining procedures thoroughly because you would want the same if you were the patient.

Step 4 Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

We're considering implementation here. Did it meet our expectations? What were the challenges? How does it compare to other situations? Did it enhance our professionalism? Do we need to establish policies or procedures to prevent such occurrences in the future?

Example Using RIPS Model (Kate)

Kate graduated last year from State University and is working at County Hospital. Her PT school best friend, Sandy, works in a small rehab hospital across the state. They often compare experiences and ideas for interventions. The young colleagues, typical of their generation, primarily communicate via text messaging and Facebook. They rarely talk on the phone.  

On a Monday morning, Kate starts her workday by reviewing scheduled patient charts. Looking through the new admissions, she notices a familiar last name. She checks the face sheet and confirms that the patient is Ms. Edwards, one of her former professors at the state university. Kate is surprised to see that Ms. Edwards was admitted to rule out a brain tumor.

Kate walks down the hall to visit her former professor but doesn't find her in the room. Assuming she's undergoing tests, Kate plans to check back later. However, she doesn't get the chance to meet Ms. Edwards that day. Later in the evening, while on Facebook, Kate writes a message on her friend Sandy's wall about their former professor's hospital admission. The message quickly spreads through the Facebook news feed, and Kate discusses Ms. Edwards' condition with several former classmates and others.

That evening, Ms. Edwards' daughter discovers the news of her mother's hospitalization on the social networking site, which surprises her. She immediately calls her mother, who is upset by the news, and contacts Joanne, the County Hospital's Director of Physical Therapy. Joanne summons Kate to her office the following day, expressing irritation and asking for an explanation.

Kate is confused by the issue and attributes it to a generation gap between herself, Ms. Edwards, and Joanne, all of whom are baby boomers. She defends her actions, stating that sharing and communicating information in this manner is common among people her age. However, Joanne emphasizes that the problem isn't about technology or etiquette but about confidentiality. Kate is puzzled by Joanne's frustration.

This situation resembles the one I mentioned earlier, where someone who wasn't directly involved with the patient's treatment shared information about the location of an estranged mother with family and others.

Let's go through the RIPS model now. 

Step 1: Recognize and Define the Ethical Issue  

• Realm: While Kate is sure it is individual, Joanne considers it institutional.  
• Individual process: Kate doesn't have the moral sensitivity to recognize that her messages and decision to read the chart of a patient to whom she had no professional connection or obligation were breaches of confidentiality.
• Implications for action: Joanne must address Kate's obvious lack of understanding of confidentiality issues.
• Type of ethical situation: A problem: Kate's actions are inappropriate in that they are not even clear to her.
• Barriers: Yes, there are barriers. Joanne has the authority to take action, but it's unclear if she fully understands the generational challenge she is confronted with.

Step 2: Reflect

• Background: We don't really know anything more than this. We know that Kate is not treating Ms. Edwards; she's just curious about her.
• Major stakeholders: Kate, Joanne, Ms. Edwards, and Kate's friend, Sandy, who is dragged into this because Kate was chatting with her.
• Consequences of action or inaction: Yes. Joanne is obligated to take action. As a new professional, Kate must understand that her professional responsibilities affect her personal life and values.
• Laws are broken: There is a HIPAA violation at a bare minimum.
• Professional guidance: Kate would do very well to reflect on the principles of the code of ethics regarding the rights and dignity of all individuals and the exercise of sound professional judgment. She needs to consider integrity and social responsibility.
• Right versus wrong tests. Is it illegal? The situation feels wrong for sure, if not to Kate. Would there be discomfort if this information became public? Probably. Would your parents take action in a similar situation? The answer is probably yes. Finally, is there a violation of the professional code of ethics? Again, the answer is yes.

Step 3: Decide the Right Thing to Do

So what do you do? For Kate, the barrier to behavior change is getting her to understand that her actions, while perhaps socially acceptable and expected among her peers, are inconsistent with the expectations of her profession and her patients.

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

So what do you do? This situation may result in a change in institutional behavior as Joanne examines her orientation program and recognizes that she has young staff with social norms that differ from hers. 

This whole situation looks at confidentiality and how we, as therapists, manage protected health information that we have at our disposal. Again, confidentiality is one of our biggest obligations. Changes in technology and communication are challenging how we view confidentiality. We need to look at it in light of the technology. Some levels of policy and procedures should be in place, reviewed regularly, and are part of orientation as well.

Second Example Using RIPS model (Mike and James)

James works in home care and enjoys independence and variety in his work. One of his current patients, Mike, an active 72-year-old retiree and widower who recently had a left total knee replacement, spent a week at a rehab center before he came home.

Mike has a great attitude and is eager to get back in the swing of things. Payment for his physical therapy is unaffected by outpatient guidelines as long as he remains at home. This makes James very happy because Mike is a hard worker and an ideal patient. He can't afford to pay for physical therapy beyond what Medicare and supplemental insurance will allow. James aims to ensure Mike's safety in the home environment and his ability to manage independently. His discharge goal is to be self-sufficient while possibly experiencing some residual pain and capable of transporting himself to physical therapy on an outpatient basis. The plan of care is estimated at three times a week for three weeks.

When the PT arrives for his third appointment in the first week, he notices that his patient's car is in the driveway rather than in the garage. Mike answers the door and goes into the kitchen, where he's putting away groceries. James knows there's no family in the area, and he asks Mike who did the driving and the shopping. Mike says, "Well, I did." James is surprised because Mike should be technically homebound to receive physical therapy at home. There are physical and clinical issues, but Mike's like, "Yeah, I get it, but there's gotta be a little wiggle room. What harm is there in me trying to do a little bit for myself?"

When James arrives for the next follow-up appointment, Mike's car is gone. About five minutes later, Mike returns to his house in his car. Mike says he went to the hardware store for plumbing supplies to fix the leaky sink. Jamie notices Mike getting up the stairs, and he's getting back into the home safely, but obviously with some level of effort. 

James feels conflicted. Mike needs more physical therapy, but based on the fact that he's shown obvious progression, he's technically no longer homebound; what does he do? Does he continue home care, or does he discharge and send him to outpatient?

Step 1: Recognize and define the ethical issue

• Realm: Individual and societal
• Individual process: Moral sensitivity on James's part
• Implications for action: Mike will stop receiving PT that can benefit him
• Type of ethical situation: A dilemma
• Barriers: Concern for Mike's safety 

The realm is individual between James and Mike, but I think there's also a societal element here because of reimbursement. In the individual process, there's that moral sensitivity, particularly for James.

Implications for action. So if James exercises moral courage, Mike will stop receiving home care that could benefit him, and we don't know if he could or could not go to outpatient at this point.

This is a dilemma. Mike is exercising his autonomy, but James is concerned for his safety. James is exhibiting non-maleficence in wanting to keep Mike on home care. James is also concerned about veracity. He believes in being truthful. He doesn't want to lie about his homebound status.

Are there barriers? Yes, one barrier is for Mike's safety if home health is discontinued.

Step 2: Reflect

• Major stakeholders: James and Mike
• Consequences of action or inaction: If James takes action, Mike will lose the additional PT he needs.  Inaction means that he receives PT while not technically homebound.
• Laws broken? Medicare laws are very specific regarding homecare
• Professional guidance: Principle 7 of the Code of Ethics
• Right vs. Wrong: Illegal? Yes. The situation feels wrong. Discomfort if information becomes public? Yes. Are your parents likely to take action in similar circumstances? Yes. Violations of APTA's professional codes and documents? Yes. 

However, inaction means that he has a patient who is not homebound. Are there laws broken? Yeah, Medicare obviously has very specific laws regarding home care. What is the professional guidance? Regarding the state and the code of ethics, a physical therapist shall seek only such remuneration as is deserved and reasonable. There's a core integrity here as well. Right versus wrong tests. I think all of these, we could say it feels wrong. Your mom would take action in a similar situation. It doesn't pass the stench test.

Step 3: Decide the Right Thing to Do

• So what does James do? While James must consider discharge, he must also do all he can to ensure Mike's safety by ensuring his continued access to the outpatient services he needs.  

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• It's unclear whether any institutional policy or culture change is warranted, but that possibility should be fully explored. I think what we're looking at here is, to some degree, pressure to provide patients with optimal care within the guidelines. There's pressure always to do the right thing in light of reimbursement. You can't let reimbursement drive practice. We have to make sure that proper sequence is followed and that we do the right thing for our patients and for our practice as well.

Example-Jenna

Jenna has been working at Pond View for about six years. She is known for her wound care expertise. She's been the CI for the past four years and recently completed the CI credentialing course. She supervises at least three students yearly as they rotate through their clinical experience. She enjoys the interactions, particularly those related to wound care. This is the next to last clinical rotation for Brendon, a third-year DPT student at the local university who made a career change from the corporate world and is thus a little older than the students who generally rotate through. He is working with another PT, Mary, for the first part of his rotation, and then he will move on to Jenna's supervision about midway through.

One day, three weeks into the affiliation, Brendon stays late to finish up some paperwork. He ends up leaving the building at the same time as Jenna, who also worked late. They get into a long conversation while standing in the parking lot. Brendon's very interested in wound care and asks Jenna many questions about what he'll see when working with her in the next few weeks. They also exchanged a little small talk, during which Jenna mentioned that her birthday was next week. With the conversation ending after 20 minutes, Brendon asks Jenna if she would let him buy her a birthday drink at a nearby bar (within walking distance). She responds that she appreciates the offer, but it strikes her as inappropriate given that she'll be his supervisor in just a few weeks.

He responds that, having worked in the corporate environment, he's sensitive to these types of issues. "It's just one birthday drink, and anyway, you can think of it as a penny for your thoughts because I want to pick your brain about some cases that I've seen." She sees this as reasonable. Would having a single drink with Brendon while engaged in a professional dialogue be so wrong?

I would like you to take this one back with you and go through the steps I have laid out.  

Step 1: Recognize and define the ethical issue

• Realm: Into which realm or realms does this situation fall: individual, organizational/institutional, or societal? 
• Individual process: What does the situation require of Jenna? Of Brendon? Which individual process is most appropriate: moral sensitivity, moral judgment, moral motivation, or moral courage?
• Implications for action: Are there implications for action on the parts of anyone besides Jenna and Brendon?
• What type of ethical situation is this: a problem, dilemma, distress, or temptation?
• Are there barriers to Jenna taking action?

Step 2: Reflect

• What do you know about the legal obligations Jenna may face?  
• Who are the major stakeholders?
• What are the potential consequences of action or inaction on Jenna's part?
• What ethical principle(s) may be involved?
• How does this scenario stack up against the “tests?”

Step 3: Decide the Right Thing to Do

• If it fails all of the “tests,” this step is superfluous
• If it passes the tests, then determine the right thing to do
  • Rule-based: Follow only the principle you want everyone else to follow
  • Ends-based: Do whatever produces the greatest good for the greatest number of people
  • Care-based: Do unto others as you would have them do unto you

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• Having determined in your own mind the right thing to do and the best way to implement the decision, reflect on the course of action chosen and think about whether a change in the clinic's organizational policy or culture might prevent this scenario from recurring

Analyze Ethical Dilemmas-Rest’s 4-Component Model

This next model is a nursing model, but I believe it is appropriate. We will go through it quickly. It looks at four different areas.

• Moral Sensitivity  
• Moral Judgment  
• Moral Motivation  
• Moral Action

Moral Sensitivity

• Recognition that an ethical dilemma exists  
• Ability to empathize with others  
• Be aware of how one’s actions affect other people  
• Recognize the values, beliefs, understandings, and obligations of others  
• Appropriate emotional response  
• Impact of actions on others  
• Discern relevant aspects of the situation  
• Consider other aspects, such as care

Moral Judgment

• Judging which action is most ethically justifiable for a moral dilemma  
• Identify the morally relevant aspects of the situation  
• Weighs the significance of aspects  
• Identify potential actions and consequences  
• Clarifying factual, conceptual, and ethical issues

Moral Motivation

• Whether the practitioner is motivated to enact the moral decision made  
• Internal or external barriers can undermine motivation  
• Requires clarity, courage, support, skillful advocacy, and a willingness to subordinate other important commitments  
• Wisdom and virtue are essential elements

Moral Action 

• Executing and implementing a plan with perseverance and resoluteness  
• Consider the best way to implement the decision  
• Requires diplomacy, skilled communication, collaboration, and strategic planning  
• Create a trustworthy process with clear expectations, fair processes, and precise communication.  
• Attention to objections/resistance

Consequences Of Ethical Dilemmas

Ethical dilemmas can affect individuals, potentially leading to burnout and stress. For several reasons, it's essential to address these dilemmas promptly and effectively. Unaddressed ethical dilemmas can fester and grow, making them more challenging to resolve later. Addressing them early can prevent escalation. Swift resolution of ethical dilemmas can help reduce the stress and emotional burden that staff may experience. This, in turn, supports their well-being and mental health.

Some ethical dilemmas may have legal consequences, potentially resulting in actions such as loss of licensure, termination of employment, reprimand, or implementing an action plan to respond to the issue.

Ethics Committee

Hopefully, you have an ethics committee that you can go to regarding some of these issues. If you don't, it might be something that you consider in your place of employment, suggesting or, at a bare minimum, having a team there.

As mentioned, I practice in nursing homes and recently found a study. In this study, out of 40 ethics committees, a striking 29 of them did not include a single patient. This underscores the importance of having all relevant stakeholders, including the patients, actively participate in an ethics committee. Ethical discussions should encompass major ethical dilemmas and everyday ethical considerations that arise in our practice.

Avoiding Ethical Dilemmas

How do you avoid ethical dilemmas? You do it by Protecting Thy Patients and Thyself. It's a mnemonic.

• P: Put a copy of your licensure law on your desk and read it!
• R: Report ethical and legal violations
• O: Open your eyes
• T: Tell them you want it in writing or in an email. If it doesn't seem right, it probably isn't right. If somebody asks you something that doesn't make sense or you're questioning it (it doesn't pass your stench test), ask for it in writing. If it's illegal or unethical, they won't typically put it in writing.
• E: Encourage ethical behavior
• C: Complete, thorough documentation
• T: Think!! Don't fall into the trap of panicking first and thinking later.

• T: Take the patient’s interest above all
• H: Handle situations as they arise
• Y: Yearn to learn

• P: Plug into your professional associations
• A: Ask a lot of questions
• T: Train and supervise all subordinates properly
• I: Internet sources (but be cautious too-Clarify and make sure you have the correct information)  
• E: Establish a relationship with a mentor or peer
• N: Never fall behind
• T: Take a good look at the professional literature
• S: Surf the internet for regulatory changes   

• &

• T: Take the time to read your code of ethics
• H: Hand over patients to those with expertise
• Y: Yield to the dictates of payers  
• S: Save a copy of the correspondence
• E: Explore all alternatives
• L: Look at professional association/licensure homepages
• F: Fill out all forms accurately and truthfully

Resources to Help

• Core documents from APTA -- APTA Code of Ethics, APTA Guide for Professional Conduct, Standards of Ethical Conduct for the Physical Therapist Assistant
• Consensus Statement on Clinical Judgement in Health Care Settings
• Other resources from APTA
  • Coding and Billing
  • Compliance
  • Managed care contracting tool kit  
  • PT in Motion

Situational Examples

I'm going to go through these examples a little bit on the quick side. I would like you to bring these back to your clinics and maybe talk about them as a group as they relate to ethics.

When compiling documents for an additional request, you discover that the restorative nursing assistant documented that services were rendered when the resident was clearly out of the facility at the hospital. 

I've seen this in physical therapy and occupational therapy, where we continue to document, and the patient was discharged. It's clear the person was never seen or actually treated because we probably would not have that documentation. That is an ethical violation; you can brainstorm what you would do.

You, the therapist, have delegated the treatment of a client to the physical therapy assistant under your supervision.  The client complains of pain during the treatment session.  The PTA applies ultrasound to the patient during the session without consulting you and without a physician's script/order to do so.

We see this sometimes when the PTA has applied a modality that was not part of the plan of care, and they have changed the plan of care without consulting the physical therapist - of course, that is a huge "NO."

When reading the daily notes of the assistant you supervise, you discover that he is adding and changing goals for the client without consulting you. 

This is very similar to the prior example. It is also a no-no, as it is not in the PTA's scope of practice, and the therapist must be consulted on any change to the plan of care (treatments and goals).

You work in an outpatient clinic, primarily dealing with Medicare Part B as a payer. Your clinic has an aide. You ask the aide to complete the therapeutic exercise program with the client, and you bill for these services.

This example goes back to fraud and abuse. We cannot bill for services provided by individuals who are not legally allowed to provide that service in that setting.

As a PT, you have been told to continue treating your patient—just three more sessions—so the facility can continue to obtain skilled reimbursement and because the family is not quite ready at home for discharge.

Could you work on something? I suspect yes, but that might be wrong if it's just for that facility to get reimbursed. So I think you'd have to look at that one cautiously—if there truly is something clinically skilled that you could be doing, then by all means, but if there isn't, then we would probably want to continue with discharge.

A patient attended a follow-up appointment, which did not go as expected. There was bad news.  The patient wants to know the extent of the report, but the family wants to withhold the information to protect their emotions. 

We talked about this earlier. Again, maybe it's not up to us to give that information, but it is definitely up to somebody to share that information with the patient.

A 56-year-old man is referred to physical therapy for sciatica, degenerative disc disease, and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the last month, he has lost his capacity to bend, lift, and carry during daily living and work activities. Medicaid will only provide for a PT evaluation.  No follow-up services are covered.  The PT recommends follow-up twice a week for four weeks.

I mean, this is a tough one. How do you proceed? Should the patient be asked to pay out of pocket? Should the patient be offered free or discounted services? No, because we don't do that. We need to look at alternatives to traditional duration and frequency, as well as models of care. Maybe there are some other options there. Maybe we need to advocate for the patient to the insurance provider to seek additional services. 

As a therapist, you suspect that a patient is concealing information that may impact his health, but you want to respect his privacy.

This situation is a tough one. If your patient doesn't share, they don't share. We develop that trusting relationship, and we hope they share it with us. We have to obviously always keep their confidentiality.

As the supervisor of your department, you see that Marie, one of the PTs, has been regularly receiving expensive gifts from the elderly woman's family. The woman was scheduled to be discharged from the program weeks ago, but Marie continues to delay the discharge, citing many reasons.

This is a problem. I think most of us work in a situation where we are not allowed to accept gifts, and it looks like we're getting some gift or kickback from this patient. That is a no-no. 

You are friends with Paula on Facebook, and you happen to notice that she is also friends with several of your patients and their family members. 

Is that terribly wrong? Not necessarily, but I think at a bare minimum, we would want a policy that addresses whether we can be friends with these individuals or not. Maybe we could be friends after treatment ceases, and maybe not during treatment. Again, that would be up to a policy and procedure there.

Lauren, a PT, is the only witness to a patient fall in the clinic gym. The patient has balance problems, and the PTA, Hal, who is working with her, was not guarding her. Lauren observed Hal placing a gait belt on the patient after the fall and before calling for assistance. Lauren is unsure what to do about this situation. 

That's another ethical situation. This person was not maintaining appropriate patient safety, which must be addressed.

Jim, a PT, works at a private practice with several regional clinics. It has a centralized management structure. One of the top managers calls Jim and asks him to call a previously scheduled new patient to reschedule an initial evaluation since a VIP/shareholder has been referred to the clinic and wants to be seen as soon as possible. Jim is uncomfortable with this request.

This goes against justice and fairness, really. What do you do here? It's an ethical consideration. I don't know that we have an exact answer, but I think it's something we need to talk through. Maybe there's room for both people to be treated. If there's not, we must put our patients first.

Sara works in a private practice with a profit-sharing plan. Her year-end bonus is directly related to maximizing return visits as they are the most cost-effective. Her boss has been heard to say to other staff members that they should treat patients to the maximum of their benefits; after all, you can always change the goals so there is more therapy to do – it just requires being a little creative. She has also been heard to encourage therapists to discontinue treatment early for those patients with poor reimbursement. Sara is uncomfortable with this situation but is counting on her year-end bonus.

Obviously, this needs to be addressed. This is a serious "no" that would be frowned upon by any state practice act, where we deliver treatment based not on that patient's needs but on something else.

Rob, a morbidly obese disabled veteran, arrived at an outpatient clinic requesting PT services. His doctor referred him to this clinic because of their great reputation. Mary, a PT, was working in the gym and saw Rob walking into the clinic. She called the front desk requesting they not assign her the patient. The patient was scheduled two days later for another PT. Ellen, a PTA who works with Mary, overheard the conversation requesting that the patient not be assigned to her. Ellen knows that Mary is a fitness fanatic and has heard her make derogatory comments about people who are overweight. Ellen feels very uncomfortable about this situation and wonders if she should do anything.

If there was a real reason for that person not to be on her caseload, that's one thing, but if it's because of bias or discrimination, that's a whole other issue that would need to be addressed. 

Q&A

Q: "Working in home health, sometimes I'm assigned more patients than I can see. How can I ethically navigate which patients to see? I can't see them all, there's not enough staff. Some patients will have a missed visit."

A: So, you know, that's an interesting one. I think that's one you have to return to; there's no easy answer here. You must return to your supervisor and discuss staffing; what else can we do? Can we, you know, could some visits be shortened, some visits be longer? Could you look at frequency and duration, et cetera? Unfortunately, in some cases, I think do need to prioritize, and I know that's not the right answer, but, you know, this person we can put off today and maybe see tomorrow because they're doing very well. Maybe that person it's time for them to go to outpatient. Again, it's an ethical challenge, but at a bare minimum, you must return to your supervisor and discuss that.

Q: "If an aid or a rehab tech is guiding your patient to complete the rest of their exercises during a session, how do you bill for this?"

A: Well, you know, again, I'm gonna caution what I say. You must know the payer source and whether you can bill those services. I come from an area of Medicare Part B, where we can't bill for those services again. So, in that case, if the tech is overseeing that and you are not there, that is likely not a billable service. You have to go back to the payer, of course. The question then becomes, should this be turned over to an independent home exercise program? If the patient can do it without you physically present, is there a skill you are bringing to the table? And I think the answer to that would be no. 

Q: "If you're leaving a practice and you have patients who want to know where you'd be practicing next, would this be seen as recruitment to share that information with them?"

A: That is a wonderful question. Thank you for asking that. If the patient says, "Hey, where are you going next?" And you say, "Oh, I'm going to Happy Day Clinic down the street." That is one thing. Then, if that patient chooses to follow you to that new practice, that's a different story. I think what we discussed taking patients with you by saying, "Hey, I provide really, really good care. This place really doesn't. I'm moving down here, and you need to follow me." So, enticing or asking them is one thing. They are asking us, I think, a totally different story. 

References

American Physical Therapy Association. (1981). APTA guide for professional conduct (Issued by the Ethics and Judicial Committee). (Last amended: March 2019). Retrieved from https://www.apta.org/contentassets/7b03fbe1fa5440668a480d2921c5a0b6/apta-guide-for-conduct-pt.pdf

American Physical Therapy Association. (2020). Code of Ethics for the Physical Therapist. Retrieved from https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-2825.pdf

American Physical Therapy Association. (2021). Core values for the physical therapist and physical therapist assistant. Retrieved from https://www.apta.org/contentassets/1787b4f8873443df9ceae0656f359457/corevaluesptandptahodp09-21-21-09.pdf

American Physical Therapy Association. (2020). Standards of ethical conduct for the physical therapist assistant. Retrieved from https://www.apta.org/siteassets/pdfs/policies/standardsofethicalconductptahods06-20-31-26-.pdf

Balak, N., Broekman, M., & Mathiesen, T. (2020). Ethics in contemporary health care management and medical education. Journal of Evaluation in Clinical Practice. https://doi.org/10.1111/jep.13352

Centers for Medicare and Medicaid Services. (n.d.). What is Medicare fraud and abuse? Retrieved from http://www.medicare.gov/navigation/help-and-support/fraud-and-abuse/fraud-overview.aspx

Hedman, M., Häggström, E., Mamhidir, A.-G., & Pöder, U. (2019). Caring in nursing homes to promote autonomy and participation. Nursing Ethics, 26(1), 280–292. https://doi.org/10.1177/0969733017703698

Jakobsen, R., Sellevold, G. S., Egede-Nissen, V., & Sørlie, V. (2019). Ethics and quality care in nursing homes: Relatives’ experiences. Nursing Ethics, 26(3), 767–777. https://doi.org/10.1177/0969733017727151

McArthur, A., & Gill, C. (2021). Building bridges: Integrating disability ethics into occupational therapy practice. American Journal of Occupational Therapy, 75(4), 7504347010.

Muhammad Rafique, R., Siddique, M. B., & Owais, F. (2022). A study on the perception and implementation of ethics in clinical practice. Pakistan Journal of Ethics, 2(2), 48–53.

Nicholson, J., & Kurucz, E. (2019). Relational leadership for sustainability: Building an ethical framework from the moral theory of ‘ethics of care.’ Journal of Business Ethics, 156, 25–43. https://doi.org/10.1007/s10551-017-3593-4

Sellevold, G. S., Egede-Nissen, V., Jakobsen, R., & Sørlie, V. (2019). Quality dementia care: Prerequisites and relational ethics among multicultural healthcare providers. Nursing Ethics, 26(2), 504–514. https://doi.org/10.1177/0969733017712080

Sohail, M., Ashraf, H., Zafar, L., Zafar, A., & Zaheer, M. (2021). Knowledge, interest, and perception of academic physiotherapists with regard to professional ethics. Medical Forum, 32(11), 154-159.

VanderKaay, S., et al. (2020). Doing what’s right: A grounded theory of ethical decision-making in occupational therapy. Scandinavian Journal of Occupational Therapy, 27(2), 98-111.

1. Any errors in transcription or editing are the responsibility of Continued.com and not the course presenter.