The College has considered the factors related to the safe, effective performance of controlled acts.
The following section outlines the acts for which the College considers it appropriate for OTs to accept
delegation and the acts for which the College does not recommend OTs accept delegation.
Performance of some controlled acts fall outside the scope of practice for occupational therapy or
require knowledge, skills and experience not typically addressed in occupational therapy education.
For these reasons, the College recommends that OTs do not pursue or accept delegation for certain
controlled acts.
For each of the 14 controlled acts, the following section outlines:
- When it is not recommended for OTs to accept delegation for the act;
- Activities associated with the controlled act that OTs are permitted to perform within the scope
of practice of the profession; and,
- When delegation of the controlled act to OTs may be appropriate.
1. Communicating to the individual or his or her personal representative
a diagnosis identifying a disease or disorder as the cause of symptoms
of the individual in circumstances in which it is reasonably foreseeable
that the individual or his personal representative will rely on the
diagnosis.
(While occupational therapists are not permitted to communicate a diagnosis, they do play an important role in collecting and interpreting data that contributes to a diagnosis.
Communicating Assessment Findings
Occupational therapists do regularly communicate their assessment findings to clients and substitute decision maker (SDM). It is essential that the OT provide the client/SDM with an explanation of the nature of the problem, including labeling or naming the identified dysfunction, for example, ataxic gait, left neglect, fine motor delay. The College considers this to be communicating symptoms and does not require delegation.
If the dysfunction suggests the presence of a disease or disorder that a diagnosing practitioner has not identified, the OT, after obtaining appropriate consent from the client/SDM should communicate the findings to this practitioner. When appropriate, Occupational Therapists may be asked to comment on expected functional progress and outcomes within the scope of occupational therapy competency.
Explanation of the Diagnosis
In the process of assessment and intervention, occupational therapists must often explain how the client’s diagnosis may be impacting their occupational performance. In addition, clients/SDM may ask occupational therapists to provide them with information about functional abilities regarding the disease/disorder/injury. This is acceptable if the diagnosis has already been communicated to the client/SDM by the diagnosing practitioner.
Determining a Provisional Diagnosis
Occupational therapists in the course of their assessment and treatment may be alerted to signs and symptoms which are indicative of a disease/disorder/injury of which the client/SDM is unaware. In some instances, occupational therapists are uniquely qualified to assess signs or symptoms and provide clinical information that is essential for the diagnosing practitioner to arrive at a definitive diagnosis. In this case it is the occupational therapist’s professional responsibility to make the client/SDM aware of the significance of the signs or symptoms and to suggest the appropriate action.
Discussions with the client/SDM should occur in a manner that will not result in the client/SDM relying upon the information as a definitive diagnosis and thus, is not considered the controlled act of “communicating a diagnosis which identifies a disease or disorder.” During discussions occupational therapists can refer to a cluster of symptoms but may not relay a suspected diagnosis for example;
An occupational therapist may NOT say: “It seems like you have generalized anxiety disorder”
An occupational therapist may say: “most of the time you feel restless and can’t stop your worry, and that you are afraid something awful might happen…. I think it would be a good idea to make anappointment with your family doctor so they can assess these symptoms.”
Accepting Delegation
As occupational therapy roles evolve, there may be circumstances where occupational therapists
have developed the required competency to receive delegation to perform the controlled act of
communicating a diagnosis within a specific area of practice. If the authorizer determines that the
occupational therapist is competent to accept the delegation and procedures are in place to ensure
safe performance of the act, it may be appropriate for an occupational therapist to accept delegation
for this controlled act. For example, an occupational therapist with training and experience in arthritis
care may have the required competencies to safely accept delegation to communicate a diagnosis
of osteoarthritis of the thumb to the client.
2. Performing a procedure below the dermis, below the surface of a
mucous membrane, in or below the surface of the cornea, or in or
below the surfaces of the teeth, including the scaling of teeth.
OTs may assess and provide care for superficial wounds, pressure ulcers and burns without delegation if the stage of the wounds does not require the OT to work below the dermis.
For example, debridement of a wound may be performed by an OT when the wound is at the epidermis or dermis level. Once a wound is considered below the dermis, the OT is required to seek delegation to perform the procedure.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
Interventions that do not involve a fracture or dislocation, such as carpal tunnel syndrome, arthritis
and post-surgical tendon repair, do not require delegation when an orthotic is required.
While orthotics are not specified in this controlled act, applying them to an unstable fracture carries a
risk similar to applying a cast. Depending on the nature of the fracture and its healing stage, this
treatment may require delegation.
4. Moving the joints of the spine beyond the individual’s usual
physiological range of motion using a fast, low amplitude thrust.
The College recommends OTs not accept delegation of this act.
5. Administering a substance by injection or inhalation.
OTs are often delegated procedures within this controlled act when helping clients engage in daily
activities. If the activities are routine activities of living, they do not require delegation as they fall
under an exception.
However, when administering a substance by injection or inhalation is not a routine activity,
delegation is required. The procedure may no longer be routine if the client’s health status has
changed (become unstable), the client’s need for the procedure has changed or the client’s response
to the procedure has changed.
For example, a client with a history of Chronic Obstructive Pulmonary Disease (COPD) has been
admitted to hospital following a heart attack. The client experiences shortness of breath and
dizziness with minimal physical exertion, requires assistance to transfer, and has extremely low
activity tolerance. This is a significant change from the client’s pre-hospital admission status. Before
proceeding with the controlled act of oxygen titration during a therapy session, the OT must use their
clinical judgement to determine if the procedure requires delegation or falls under the routine
activities of living exception.
6. Inserting an instrument, hand or finger into a body opening.
Any or all parts of this controlled act can be delegated to an OT. For example, an OT could receive delegation to
provide suctioning beyond the larynx or through a tracheotomy. An OT may also receive delegation
for assessment and treatment of pelvic health conditions impacting daily function.
As previously noted, routine activities of daily living are excepted from the requirement for delegation.
Once established activities are well-established for the client, assisting a client with inserting a nasalgastric
tube, tampon, urinary catheter or birth control device may not require delegation.
7. Applying or ordering the application of a form of energy prescribed by
the regulations under the RHPA.
The forms of energy referred to in Ontario Regulation 107/96 include:
- electricity (for aversive conditioning, cardiac pacemaker therapy, cardioversion, defibrillation,
electrocoagulation, electroconvulsive shock therapy, electromyography, fulguration, nerve conduction studies, transcutaneous cardiac pacing);
- electromagnetism for magnetic resonance imaging; and
- sound waves for diagnostic ultrasound or lithotripsy.
This controlled act is specific only to the procedures listed above. This means that while diagnostic
ultrasound is a controlled act, the use of ultrasound as a treatment modality is not.
Likewise, while using lasers to dissolve kidney stones is a controlled act, using lasers to treat a
musculoskeletal condition, as would apply to occupational therapy practice, is not. Other procedures
that involve forms of energy but are not controlled acts include:
- applying heat;
- using transcutaneous electrical nerve stimulation (TENS), other than to the heart;
- attaching electrodes that do not pierce the dermis to receive biofeedback; and,
- electrical muscle stimulation.
The ordering of x-rays is also not a controlled act. Instead it falls under the
Healing Arts Radiation
Protection Act, 1990 (HARP) that does not permit OTs to order x-rays. While OTs are often interested
in ordering x-rays to support their practice, it must be recognized that it is the HARP and not the
controlled act that limits access to OTs.
8. Prescribing, dispensing, selling or compounding a drug as defined in
subsection 1(1) of the Drug and Pharmacies Regulation Act 1990, or
supervising the part of a pharmacy where such drugs are kept.
This controlled act is specific to the procedures of prescribing, dispensing, selling or compounding a
drug and does not include administration.
The College recommends OTs not accept delegation of this act.
Administration refers to everything that happens after the drug is dispensed. An OT does not require
delegation to administer a medication unless it involves the controlled act of
administering a substance
by injection or inhalation, or the controlled act of
inserting an instrument, hand or finger into a body
opening. Inserting a rectal or vaginal suppository involves the controlled act of
inserting an instrument,
hand or finger into a body opening.
Administration includes preparing a dose of a drug from the client’s labeled supply and providing it to
the client when it is due. Similarly, administering pro re nata (PRN) medication as required does not
require delegation if the medication has been dispensed to the client, is taken from his or her own
medication supply and does not involve a controlled act to administer. OTs may also repackage
properly dispensed medications into mechanical aids, such as a dosette, to facilitate selfadministration,
or administration by a family member or unregulated care provider. When administering
medication, OTs must take necessary precautions to ensure accuracy and compliance with the
prescribed medication.
9. Prescribing or dispensing, for vision or eye problems, subnormal
vision devices, contact lenses or eyeglasses other than simple
magnifiers.
The College recommends OTs not accept delegation of this act.
Page magnifiers and non-prescription reading glasses are considered simple magnifiers. Therefore,
recommending or providing magnifiers is not a controlled act and OTs do not need delegation to use
these assistive devices with clients.
10. Prescribing a hearing aid for a hearing impaired person.
The College recommends OTs not accept delegation of this act.
An FM system that transmits sound waves from one person (for example, a teacher) to another
person (for example, a student with a hearing or attention impairment) is not considered a hearing aid.
Consequently, recommending or providing such a system is not considered a controlled act and an
OT does not require delegation.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal
appliance or a device used inside the mouth to protect teeth from
abnormal functioning.
The College recommends OTs not accept delegation of this act.
Recommending a mouth guard to protect the teeth from external blows or falls does not involve a
controlled act so delegation is not required.
12. Managing labour or conducting the delivery of a baby.
The College recommends OTs not accept delegation of this act.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
The College recommends OTs not accept delegation of this act.
14. Treating by means of psychotherapy technique.
OTs who are competent to perform psychotherapy are authorized to perform the controlled act and use the title Psychotherapist in compliance with the requirements set out in the RHPA. Delegation is not required. All OTs performing psychotherapy are expected to adhere to the Standards for Psychotherapy.
Informed Consent
As with all interventions, informed consent must be obtained before the OT may perform all or part of a controlled act. The client must be advised if the act has been delegated and be given an opportunity to ask questions and receive answers about the procedure. For additional information regarding informed consent refer to the Standards for Consent. 15
Harm Clause
Section 30 of the RHPA includes a harm clause that prohibits
any person from treating or advising a person about his/her health in circumstances in which it is reasonably foreseeable that serious physical harm may result. This clause regulates dangerous activities that may not be specifically listed as controlled acts. It is primarily meant to capture conduct by unregistered practitioners.
There are exceptions to the harm clause including:
- Registered practitioners acting within the scope of their profession;
- Those acting under the direction or in collaboration with a registered practitioner acting withinthe scope of his or her profession; and
- Persons acting pursuant to a properly given delegation
Informing Employers and Other Stakeholders
As a regulated health professional, an OT is accountable for adhering to legislation and professional standards in all situations. If an OT is asked to perform a controlled act outside his or her competence, it poses a risk to the client. The OT is obliged under Ontario Regulation 95/07: Professional Misconduct to inform the authorizer and/or employer that he or she is unable to perform the activity.
The OT may use such a situation to inform stakeholders about controlled act legislation and the harm clause. Employers and other stakeholders need to recognize it is an offence to aid and abet a person to perform aspects of health care that the individual is prohibited from doing.
Documenting Delegation and Performance of Controlled Acts
As with any intervention, documenting the process is important. The Standards for Record Keeping (2016), state “The occupational therapist will ensure that information is documented on all delegated controlled acts that he or she performs for a client.” Documentation should contain:
- the controlled act that has been delegated;
- any specific instructions related to the delegation;
- acceptance of the delegation; and
- the name, date, and designation of the person delegating the controlled act. For example,referencing a medical directive or order may be appropriate.