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Standards for the Supervision of Occupational Therapist Assistants, 2018

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Introduction

Occupational therapists (OTs) routinely include occupational therapist assistants in their delivery of occupational therapy services to optimize service delivery. The purpose of the Standards for the Supervision of Occupational Therapist Assistants is to ensure that OTs in Ontario are aware of the minimum expectations for the supervision of occupational therapist assistants when assigning occupational therapy components.

Titles for Occupational Therapist Assistants (OTA)

The term occupational therapist assistant (OTA) is a descriptor for service providers, who are assigned occupational therapy service components under the supervision of an OT. The term occupational therapist assistant relates to the role as one of assisting and attaches accountability to an OT.

The specific tasks assigned to the OTA must be part of the overall occupational therapy service. The OTA must work under the direction and supervision of an OT and the OT must assume responsibility and accountability for the ongoing quality of occupational therapy service delivery. Student OTs and volunteers are not considered to be OTAs.

OTAs may have various titles such as support person, rehabilitation coach, rehabilitation support worker, rehabilitation assistant, rehabilitation therapist, occupational therapist assistant (OTA) or occupational therapist assistant/physiotherapist assistant (OTA/PTA).

There is considerable variation in OTA training and education. Some OTAs have completed post-secondary programs specific to the knowledge, skills and abilities required to assist an OT in the delivery of occupational therapy services, while others may have completed on-the-job training that is specific to occupational therapy. Regardless of the OTA’s training, it is the accountability of the supervising OT to ensure the OTA is competent to safely, effectively and ethically deliver the assigned occupational therapy service components.

Situations Where the OT is Not Accountable for the Actions of the OTA

In some settings OTAs may be required to perform additional tasks that do not fall under the responsibility of the OT. The OT is not professionally accountable for the actions of the OTA in the following situations:

When the OTA is acting as an assistant to another regulated health professional, for example, administering a mobility plan that was assigned by a physiotherapist;
When the OTA is working on activities with the client that were not assigned by the OT, for example, an assistant may run a group as part of the overall facility program, which is not part of the occupational therapy program;
When the OTA deliberately performs occupational therapy service components that have not been assigned by the OT or are outside the parameters of care set by the OT¹;
When the OTA is performing administrative activities required by an employer who is not the OT.

In many cases, the OT is not responsible for OTA performance management; however, if the OT becomes aware of OTA performance issues impacting the provision of safe occupational therapy service, the OT must take steps to address the issue which may include:

Discussing the concern with the OTA;
Reporting the concern to the OTA’s respective manager;
Discontinuing assignment of some or all OT plan components to the OTA until the issue is resolved.

Consultation Recommendations and OT Accountability for Implementation

In some occupational therapy practice environments, OTs assume the role of a consultant. For these Standards, consultation is described as the process of identifying problems, providing recommendations, education and/or training or facilitating problem-solving regarding a specific issue with a client, another care provider, or groups of individuals or organizations, on a time-limited basis². In this consultation role, the OT does not assign occupational therapy service components and is not directly responsible for the implementation or outcome of their recommendations.

When assuming a consultation role, the OT is accountable for the recommendations they make, however, they are not accountable for the implementation of the recommendations or the individual carrying out the recommended activities. Individuals who carry out recommendations based on an occupational therapy consultation are not acting in an OTA role. For example, an OT may consult to an educational assistant (EA) on appropriate positioning techniques that the EA can use when working with a student in the classroom. Another example is consulting with a personal support worker (PSW) or family member on environmental adaptations to support bed mobility. In these examples, the EA, PSW or family member would not be considered an OTA. The OT would not have the responsibility for supervising and monitoring the care provided by others following the consultation service.

OTs must be clear on the distinction between situations that involve the use of OTAs and situations when they are fulfilling a consultation role and must make this distinction clear to all stakeholders, including clients, employers, OTAs and other health care providers. The OT remains accountable for the quality of the consultation provided and, when relevant, should consider who may be responsible for implementing the recommendations.

¹ If the OT knew or ought to have known that the OTA was performing occupational therapy services that were not assigned by the OT or are outside the parameters of care set by the OT, then the OT has an obligation to stop that from occurring, failing which the OT might very well be seen to be accountable for the OTA’s actions.
² CAOT, 2009

Application of the Standards for the Supervision of Occupational Therapist Assistants

The following standards describe the minimum expectations for OTs.
The performance indicators listed below each standard describe more specific behaviours that demonstrate the Standard has been met.
It is not expected that all performance indicators will be evident all the time. It is expected performance indicators could be demonstrated if requested.
There may be some situations where the OT determines that a performance indicator has less relevance due to client factors or environmental factors.
It is expected that OTs will always use their clinical judgement to determine how to best meet client needs in accordance with the standards of the profession.
It is expected that therapists will be able to provide justification for any variations from the standard.

In the event of any conflict or inconsistency in these Standards for the Supervision of Occupational Therapist Assistants with any other College standards, the standards with the most recently issued or revised date prevail.

College standards contain practice parameters and standards which should be considered by all Ontario OTs in the care of their clients and in the practice of the profession. College standards are developed in consultation with OTs and describe current professional expectations. College standards may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

Pursuant to the Regulated Health Professions Act, 1991, the College is authorized to make regulations in relation to professional practice. The College’s Professional Misconduct Regulation establishes that “contravening, by act or omission, a standard of practice of the profession or failing to maintain a standard of the profession” constitutes grounds for professional misconduct.

Accountability

Standard 1

The OT will be fully accountable for all occupational therapy service components assigned by them to the OTA.

Performance Indicators

The OT will:

1.1

Be competent to perform all occupational therapy service components assigned to the OTA;

1.2

Ensure the quality and safety of client care will not be compromised when assigning occupational therapy components to an OTA giving consideration to the level of risk, client’s status, related environmental factors, and the OTA’s level of competency³;

Note: Refer to Assignment of OTA Decision Tree - Appendix A

1.3

Not assign the following activities to an OTA:

Initiation of occupational therapy service;
Aspects of assessment requiring clinical judgement by the OT;
Interpretation of assessment findings;
Planning of intervention and goal identification/modification of an intervention beyond the limits established by the supervising OT;
Intervention where ongoing analysis and synthesis is necessary to closely monitor and guide client progress;
Communication (written or verbal) of occupational therapy recommendations, opinions or findings requiring clinical judgement;
Decision to discharge and related discharge planning;
Controlled acts that were delegated to the supervising OT by another professional;
Controlled acts that fall within the scope of occupational therapy;
Occupational therapy components that the OT is not competent to direct.

1.4

Clearly outline the occupational therapy service components to be assigned and monitor the treatment approaches used by the OTA to ensure the OTA is following through with the assigned tasks;

1.5

Ensure the OTA has the required knowledge, skill, and judgement to perform the assigned occupational therapy components in a safe, effective and ethical manner, for example: on-the-job training, observation, supervision and support to perform the assigned occupational therapy service components safely; or ensure the hiring institution is aware of the requisite knowledge, skill, and judgement required to carry out the assigned occupational therapy components;

1.6

Monitor client progress and modify occupational therapy service components assigned to the OTA as necessary;

1.7

Be accountable for the communication of occupational therapy opinions or recommendations to the client or substitute decision maker (SDM), team members, or others;

1.8

Comply with any legislation and/or organizational policies regarding the use of OTAs.

³ Essential Competencies of Practice for Occupational Therapists in Canada, 3rd Edition, (2011).

Supervision and Communication

OTs are expected to establish a supervision and communication plan with the OTA to ensure the expected outcomes of service are achieved. The degree of supervision provided by the OT is dependent on several factors: the practice setting, the specific client factors, the nature of the components assigned to the OTA, the environment, the OT’s level of knowledge, skill, and judgement, and the OTA’s level of competence. The OT must know the OTA’s level of competence, through observation, training, or employment required qualifications and skills.

There are many methods for supervising and communicating with the OTA, including but not limited to: observation of interventions, informal and formal meetings, and clinical record review.

Standard 2

The OT will supervise the OTA in the delivery of the occupational therapy service components assigned to the OTA.

Performance Indicators

The OT will:

2.1

Establish a supervision and communication plan for how and when the OT will review the client’s care plan and the assigned components with the OTA with consideration of:

the client’s condition and therapy goals;
the risks associated with the components assigned;
the OTA’s knowledge, skill and abilities;
the practice setting requirements.

2.2

Ensure the OTA understands the supervision and communication plan including:

Roles and responsibilities of the OT and OTA;
Expectations for how, when and under what circumstances the OTA will report to the OT regarding the assigned components;
Activities that will be assigned to the OTA;
The method(s) of supervision (record review; observation, formal and informal meetings, etc.);
Any activities that the OTA can carry out in the event the OT is unavailable to provide direct supervision;
Any limits imposed on the OTA’s ability to progress the assigned components of the OT plan.

2.3

Ensure an alternate OT or other health care professional is available and able to assist the OTA in the event of an emergency or unexpected occurrence when the supervising OT is temporarily not available or during short term absences, where the client is stable and there is no anticipated change to the plan.

2.4

Transfer supervision of the OTA to another OT when the OT is expected to be absent for a prolonged period or has resigned from the position;

OR

Discontinue assignment to the OTA where there is no OT to provide supervision or oversee the occupational therapy plan of care.

Consent

Standard 3

The OT will obtain informed consent when assigning occupational therapy components to an OTA in compliance with the Standards for Consent.

Performance Indicators

The OT will:

3.1

Obtain informed consent from the client or substitute decision maker (SDM) by providing detailed and specific information to enable the client’s understanding of the role and activities that the OTA will perform related to occupational therapy services;

Note: Refer to the Standards for Consent.

3.2

Ensure the OTA understands the requirement to confirm agreement from the client to participate in occupational therapy based on consent previously obtained for the plan of care;

3.3

Transparently communicate any fees associated with OTA services when obtaining client consent for the involvement of the OTA.

Record Keeping

OTs are expected to comply with the College’s Standards for Record Keeping as well as any organizational record keeping policies that may apply within their practice setting. If an OTA is expected to document their delivery of occupational therapy service components, the OT should communicate expectations for the content of the documentation to the OTA. For example, the OTA would likely document the date, the duration of the intervention, the activities performed and apply their signature and job title as per organizational requirements.

Standard 3

The OT will ensure that occupational therapy service components assigned to the OTA are documented in accordance with the expectations of the occupational therapy service, organizational policies and the Standards for Record Keeping.

Performance Indicators

The OT will:

4.1

Document the assignment of the occupational therapy service components to the OTA including:

The name and title of the OTA

or

The process for assigning occupational therapy components to OTAs (for example, an OTA roster, protocol for weekend coverage) including information regarding accountability for service;
Service components assigned and any specific instructions or reference to a care protocol that the OTA will be following;
Frequency of OTA intervention.

Note: Refer to the Standards for Consent.

4.2

Document that consent was obtained from the client or SDM for participation of the OTA in the delivery of occupational therapy service;

4.3

Review the OTA’s documentation (if applicable to the practice setting), and document that this record review has occurred;

4.4

Ensure the name and title of the OTA(s) appear on invoices when billing for OTA services.

Risk Management and Safety

Risk management is the process of minimizing risk to an individual or organization by developing systems to identify and analyze potential hazards to prevent accidents, injuries, and other adverse events. OTs should take reasonable measures to recognize and minimize the risks to client safety and be responsive in managing adverse issues that may occur with assigning occupational therapy service components to an OTA.

Standard 5

When assigning occupational therapy service components, the OT will evaluate risk and implement strategies to minimize any potential harm to the client, the OTA and others.

Performance Indicators

The OT will:

5.1

Communicate to the OTA any risks associated with the assigned occupational therapy components and the strategies to manage the risks during occupational therapy service delivery;

Note: Refer to the Standards for Consent.

5.2

Discuss the risks and benefits associated with assigning service components to the OTA with stakeholders as necessary to evaluate the safety and quality of client care. Stakeholders may include supervisors, employers, client/family, other team members, other agencies;

5.3

Promote a safe work environment; and ensure that there is a process to report and act on unsafe practices;

5.4

Address and/or report any concerns regarding OTA service delivery;

5.5

Discontinue assignment of occupational therapy service components if there is a risk to client or provider safety.

Appendix A

Reference

Canadian Association of Occupational Therapists (2009). Practice profile for support personnel in occupational therapy.

College of Occupational Therapists of Ontario (2011). Essential Competencies of Practice for Occupational Therapists in Canada, (3rd ed.).

College of Occupational Therapists of Ontario (2016). Standards for Record Keeping. Toronto, ON.

College of Occupational Therapists of Ontario (2017). Standards for Consent. Toronto, ON.

College of Occupational Therapists of Ontario (2015). Standards for Professional Boundaries. Toronto, ON