Originally Issued September 8, 2020

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Occupational therapists (OTs) have remained resourceful and resilient throughout this pandemic even as information has continued to change.  As schools are finalizing plans to reopen many uncertainties remain for OTs who are planning to resume services in this setting.  What we do know is that with reopening, school environments will be different from before, which will necessitate a shift in typical occupational therapy practice.

The College has reached out to the Ministry of Health to clarify some of the guidance surrounding schools reopening.  The Ministry has confirmed that OTs are required to follow Directive # 2. Where possible, occupational therapists (and all other health care providers) are still encouraged to limit the number of in-person visits for the safety of health care providers and their patients/clients (who are referenced as students throughout this document). 

Ontario government guidance for COVID-19 management in schools states “school boards should work with partners to develop protocols for school access by regulated health professionals, regulated social service professionals and paraprofessionals for the purpose of delivering school-based supports and services. Protocols should include support for remote delivery where in-school delivery is not possible.” (https://www.ontario.ca/page/operational-guidance-covid-19-management-schools). This means OTs should continue to work with their employers, parents and guardians, school boards, or individual schools to determine the most appropriate methods for service provision for the students to whom they will be providing service.

As a reminder, orders, directives and guidance from the Ministry of Health and CMOH overrule the information in this document. The information provided is not intended to take the place of legal advice.

The College has received questions from OTs requesting clarification about expectations. Questions and our answers are listed below:

1. Do I have to complete a self-screener each day as an occupational therapist working in schools?

Yes. All staff/occupational therapists and students must complete a self-screener every day before attending school. If a student or staff member is experiencing any symptoms of COVID-19, they must stay home from school and should seek testing and appropriate medical attention.

Staff with symptoms and parents/guardians of children with symptoms should be directed to use the online self-assessment tool and follow the instructions. Persons who test positive may not return to school until they are cleared according to public health guidance.

For more information please visit: ontario.ca/page/guide-reopening-ontarios-schools.

We recommend that occupational therapists create a contingency plan in advance, in case they test positive for COVID-19 and are required to remain in isolation at home. An occupational therapist may wish to clarify with their organization about work arrangements during isolation, how students/families will be notified during this time, etc. If an OT is providing private service, a plan should be in place to notify their remaining clients about service being temporarily suspended or if there is another OT that can provide coverage until you are cleared to return. The same applies if an occupational therapist’s child/family member is placed under quarantine by public health. 

We acknowledge that there is a lot of guidance to consider. As a regulator we are in the position of sharing Ministry guidance and aligning our resources accordingly. Ultimately it is up to an organization in how they will interpret and implement the direction in their policies and processes. We recommend occupational therapists collaborate with their employers and document the direction and decisions of the organization.

2. [Updated December 15, 2020] Is the self-screener completed before school by the student (or their guardian) sufficient for commencing in person (at school) occupational therapy services?

Yes and no.

Yes, if you are only observing a student in the classroom, then you can rely on the student’s (or guardian’s) completion of the self-screen.

No, if you are going to withdraw or provide individual assessment or intervention with a student then you must also follow the Ministry of Health’s Directive #2 for Health Care Providers and an active COVID-19 screen must be completed.    

Within Directive #2 is a reference to the COVID-19 Operational Requirements: Health Sector Restart which states patients should be screened over the phone or on site for symptoms of COVID-19 before engaging in appointments.

In consultation with the Ministry of Health, the College has confirmed that while over the phone or on site is suggested, sending or receiving screening results electronically (i.e. via email) may also be appropriate. Occupational therapists are reminded that all transmission of electronic client information should comply with privacy and confidentiality requirements.

[Update] For individual assessment/intervention, the active COVID-19 screening should occur as close to the visit as possible and ideally within the same day as service. Whether the parents/guardian is included in the screening process will depend on factors such as the student’s capacity to participate in the screening, parent/guardian consent, etc. Please note that the COVID-19 screener is the minimum expectation and should be done in combination with clinical judgment and collateral information.

Each school/school board may adopt different processes for conducting the COVID-19 screening.  In circumstances where the screener is carried out by other regulated or unregulated staff, for example, office personnel, the occupational therapist must confirm, document, and have confidence in the accuracy of the results before the visit can occur.

3. Do I have to complete a Point of Care Risk Assessment for in-person occupational therapy services?

Yes. If an occupational therapist is providing in-person service to a student they are reminded to comply with the Operational Requirements for Health Sector Restart which require a Point of Care Risk Assessment (PCRA) that assesses the task, the patient/student, and the environment. A PCRA should be completed by the occupational therapist before every patient/student interaction to determine whether there is a risk to the provider or other individuals of being exposed to an infection, including COVID-19. A PCRA is the first step in Routine Practices, which are to be used with all patients, for all care, services and interactions.

The results of this PCRA will help an occupational therapist to determine if and how the service should proceed, for example, defer, modify, virtual, in-person, as well as any equipment needs and appropriate levels of personal protective equipment (PPE).  For example, if an occupational therapist has decided to do an in-person mobility assessment that will involve student repositioning, there may be additional PPE needs to consider prior to the visit, for example, surgical/procedure mask, gloves and eye protection (goggles or a face shield), hand hygiene before and after contact with the patient and the patient environment, and after the removal of PPE.

4. What if a child becomes sick during the session?

Please be familiar with the Operational guidance: COVID-19 management in schools, which describes the processes to follow if an individual, including students, staff, contractors, visitors, parents, guardians, becomes ill while at school, including during any before and after school care affiliated with the school.

5. What constitutes a school outbreak?

A school outbreak is defined as two or more lab-confirmed COVID-19 cases in students and/or staff in a school with an epidemiological link, within a 14-day period, where at least one case could have reasonably acquired their infection in the school (including transportation and before or after school care).

The local public health unit will work with the school to determine epidemiological links, for example, cases in the same class, cases that are part of the same before/after school care cohort, cases that have assigned bus seats in close proximity to each other. The public health unit (PHU) will determine which cohorts are high risk contacts requiring isolation. Additionally please refer to COVID-19 Guidance: School Outbreak Management as it provides information for local PHUs investigating cases, outbreaks and suspected outbreaks associated with elementary or secondary school settings.

Where schools have websites, they will be asked to create a COVID-19 advisory section. School boards and schools will be asked to post information if there is a confirmed case of COVID-19 that involves a student or a staff member in a school setting. Please refer to the Operational guidance: COVID-19 management in schools for additional information on outbreak management.

6. How do I manage working at multiple schools?

For potential outbreak management, occupational therapists (OTs), if possible, should take efforts to minimize the number of schools they visit in one day. OTs should be transparent and inform each school of their work situation and follow the Ministry of Health’s guidance and Public Health Ontario protocols for infection prevention and control. This may include compliance with completing visitor logs, PPE, hand washing/sanitizing procedures and keeping up to date about information posted on the school’s COVID 19 advisory website.

7. What personal protective equipment (PPE) is required?

We are aware that each school board and potentially each school may have some variation on the requirements for PPE.  An active screening will determine the correct PPE required for each clinical encounter with the student. Examples of PPE include gloves, gowns, facial protection (including surgical/procedure masks and N95 respirators), and/or eye protection (including safety glasses, face shields, goggles, or masks with visor attachments). As per Directive #2 occupational therapists must follow COVID-19 Operational Requirements: Health Sector Restart from the Ministry of Health and the protocols and recommendations for PPE from public health.

The College’s Return to Work Guidance states: “At a minimum, occupational therapists must follow the required precautions respecting PPE as set out in the Operational Requirements and ideally wear a surgical/procedural masks for the full duration of their working day, including throughout all patient/client interactions”.

If your personal protective equipment supplies allow, the mask should be changed after each client interaction and always if it is damp, humid, damaged, or soiled. It is important to note that hand hygiene is a critical component in preventing the transmission of COVID-19. Occupational therapists must wash their hands before and after touching, adjusting, putting on, or removing their mask. This can be done by washing hands with soap and water or using an alcohol-based hand sanitizer (70-90% alcohol content is recommended).

Modules on Infection Prevention and Control Fundamentals are available through Public Health Ontario including a step by step demonstration on donning/doffing PPE.

8. What additional Infection Prevention and Control (IPAC) procedures should be in place when working in schools?

In addition to the IPAC reopening guidance issued by the College (COVID-19 Return to Work Guidance for Occupational Therapists V3), the Standards for Infection Prevention and Control are available for reference. The Ministry of Education has also issued their own IPAC guidance for school boards. OTs should familiarize themselves with the requirements within these documents.  OTs should also be aware of the process within each school/school board to report infection prevention and control concerns.

9. Disinfecting Equipment

Public Health Ontario has advised that spaces, toys, and equipment frequently and regularly used should be cleaned thoroughly. Public Health Ontario Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 3rd Edition is a resource that outlines best practices for cleaning equipment. OTs can also contact the manufacturer to determine the most appropriate infection prevention and control for cleaning equipment or devices to avoid damage. In addition, OTs can seek out and review organizational guidance pertaining to requirements for disinfecting equipment.

10. Are there special consent considerations?

The process for obtaining consent remains the same for OTs who will be providing services in person in schools, or remotely.  When obtaining consent, it is important for OTs to be transparent and clearly communicate the services they will be providing.

Occupational therapists are expected to obtain informed consent from their clients or substitute decision-maker (SDM) (in school settings this could be the student, parents/guardians) when remote or in person services are offered and are to ensure they provide an opportunity for clients to ask any questions. Consent discussions should include such things as the nature of the service, any modifications to service, withdrawal options, and alternatives. OTs working in schools should include any COVID19 related requirements and procedures in the consent process, for example:

  • Initial discussions with the parent(s)/guardian/SDM/student should describe any additional COVID-19 screening processes required that will occur prior to each occupational therapy session with the student
  • Discuss processes such as how and when to contact parents/guardian/SDM by phone, or email, if required
  • Who may be involved in the OT services in person or remotely and the participant’s role
  • Risks, benefits, and any limitation of participating in remote or in person service
  • For virtual services, information about privacy and security features of the platform being used

As a reminder, client/SDM(parent/guardian/student) consent can be given verbally. Obtaining written consent is not a College requirement but may be a requirement of the practice setting or organization.

Consent must be documented in the clinical record as outlined in the Standards for Consent.

11. What about virtual services for children that are staying home?

In addition to the required consent, when discussing remote services an occupational therapist can make suggestions to encourage the comfort and effectiveness of the overall experience. For example:  The OT could provide a brief orientation to the features of the platform, could discuss what to do in case of emergency or unexpected event, encourage privacy of sessions including use of headphones, private areas of the house, using the mute option to minimize disruptions and to maintain privacy. If using the school platform, OTs should be familiar with the privacy and security settings and take reasonable measures protect privacy and confidentiality.

OTs can refer to the Guidelines for Telepractice in Occupational Therapy for recommended practice when providing service virtually.  The Information and Privacy Commissioner of Ontario also has a helpful resource titled:  Working from home during COVID-19 pandemic.

12. Are there additional documentation needs for returning to providing services in a school setting?

The Standards for Record Keeping describe the clinical record as the legal document intended to officially record events, decisions, interventions, and plans made in the course of the occupational therapy service. In addition to regular documentation requirements an occupational therapist should be recording the following types of COVID-19 related information:

  • the outcome of the daily screening process of students/family and the individual who completed the screening if not completed by the OT
  • policies or local protocols of the organization/school board that may impact OT service or how service is to be carried out, for example, PPE, visitor log
  • results of the point of care risk assessment and any resulting occupational therapy service decisions, for example, defer, modify, virtual, or in-person
  • results of active COVID-19 screening conducted with the student just prior to an in-person individual session, including how the information was obtained
  • consent discussions with the child/family/SDM/guardian
  • any modifications to the occupational therapy assessment or interventions
  • any collaborations/discussions with other health care providers or support staff to minimize potential transmission, for example discussions with a teacher, EA, or nurse.

13. If I have additional questions who should I contact?

Now more than ever, the importance of open and informative communication is paramount. Here are some of the ways an occupational therapist can stay informed or seek additional information:

  • Keep up to date about COVID-19 demographics in the local community
  • Follow the direction of the organizations, the Ministry and local public health units about processes for providing occupational therapy services within schools.
  • Reach out to families regarding the occupational therapy service and offer parents/guardian/students/SDM a chance to ask questions like “how are you going to keep my child safe if you are not able to physically distance?”, “would my child get the same benefit from virtual service as in-person?”
  • Talk to colleagues to see if there are creative, safe, and efficient ways of providing services collaboratively
  • Ensure you are working closely with your employer regarding return to school processes and expectations
  • Seek guidance from the school where you will be working

Additional Questions?  Please reach out to our Practice Resource Service where our occupational therapy Practice Consultants are available to answer your questions by email: practice@coto.org or phone 1.800.890.6570 or 416.214.1177 ext. 240.

References and Additional Resources