| (a) Medical Conditions.
(1) Occupational therapists may evaluate the client
to determine the need for occupational therapy services without a
referral. However, a referral must be requested at any time during
the evaluation process when necessary to ensure the safety and welfare
of the client.
(2) Intervention for a medical condition by an occupational
therapy practitioner requires a referral from a licensed referral
source.
(b) Non-Medical Conditions. The evaluation or intervention
for a non-medical condition does not require a referral. However,
a referral must be requested at any time during the evaluation or
intervention process when necessary to ensure the safety and welfare
of the client.
(c) Methods of Referral. The referral must be from
a licensed referral source in accordance with the Occupational Therapy
Practice Act §454.213 (relating to Accepted Practice; Practitioner's
Referral) and may be transmitted in the following ways:
(1) by a written document, including paper or electronic
information/communications technologies;
(2) verbally, either in person or by electronic information/communications
technologies. If a referral is transmitted verbally, it must be documented
by the authorized personnel who receives the referral. In this subsection,
"authorized personnel" means staff members authorized by the employer
or occupational therapist to receive referrals transmitted verbally;
or
(3) by an occupational therapy plan of care, developed
according to the requirements of this section, that is signed by the
licensed referral source.
(d) Screening, Consultation, and Monitored Services.
A screening, consultation, or monitored services may be performed
by an occupational therapy practitioner without a referral.
(e) Evaluation.
(1) The occupational therapist is responsible for determining
whether an evaluation is needed and if a referral is required for
an occupational therapy evaluation.
(2) Only an occupational therapist may perform an initial
evaluation or any re-evaluations.
(3) An occupational therapy plan of care must be based
on an occupational therapy evaluation.
(4) The occupational therapist is responsible for determining
whether any aspect of the evaluation may be conducted via telehealth
or must be conducted in person.
(5) The occupational therapist must have contact with
the client during the evaluation. The contact must be synchronous
audio and synchronous visual contact that is in person, via telehealth,
or via a combination of in-person contact and telehealth. Other telecommunications
or information technology may be used to aid in the evaluation but
may not be the primary means of contact or communication.
(6) The occupational therapist may delegate to an occupational
therapy assistant the collection of data for the evaluation. The occupational
therapist is responsible for the accuracy of the data collected by
the occupational therapy assistant.
(f) Plan of Care.
(1) Only an occupational therapist may initiate, develop,
modify, or complete an occupational therapy plan of care. It is a
violation of the Occupational Therapy Practice Act for anyone other
than the occupational therapist to dictate, or attempt to dictate,
when occupational therapy services should or should not be provided,
the nature and frequency of services that are provided, when the client
should be discharged, or any other aspect of the provision of occupational
therapy as set out in the Occupational Therapy Practice Act and Rules.
(2) Modifications to the plan of care must be documented.
(3) An occupational therapy plan of care may be integrated
into an interdisciplinary plan of care, but the occupational therapy
goals or objectives must be easily identifiable in the plan of care.
(4) Only occupational therapy practitioners may implement
the written plan of care once it is completed by the occupational
therapist.
(5) Only the occupational therapy practitioner may
train non-licensed personnel or family members to carry out specific
tasks that support the occupational therapy plan of care.
(6) The occupational therapist is responsible for determining
whether intervention is needed and if a referral is required for occupational
therapy intervention.
(7) Except where otherwise restricted by rule, the
occupational therapy practitioner is responsible for determining whether
any aspect of the intervention session may be conducted via telehealth
or must be conducted in person.
(8) The occupational therapy practitioner must have
contact with the client during the intervention session.
(A) The contact must be either:
(i) synchronous audio and synchronous visual contact
that is in person, via telehealth, or via a combination of in-person
contact and telehealth; or
(ii) synchronous audio contact, provided that the occupational
therapy practitioner makes use of store-and-forward technology in
preparation for or during the intervention session. The synchronous
audio contact may be in person and/or via telehealth. In this subsection,
"store-and-forward technology" means technology that stores and transmits
or grants access to a client's clinical information for review by
an occupational therapy practitioner at a different physical location
than the client.
(B) Other telecommunications or information technology
may be used to aid in the intervention session but may not be the
primary means of contact or communication.
(9) Except where otherwise restricted by rule, the
supervising occupational therapist may only delegate to an occupational
therapy assistant tasks that they both agree are within the competency
level of that occupational therapy assistant.
(g) Documentation.
(1) The client's records include the medical referral,
if required; the initial evaluation; the plan of care, including the
goals and any updates or change of the goals; the documentation of
each intervention session by the OT or OTA providing the service;
progress notes and any re-evaluations, if required; any patient related
documents; and the discharge or discontinuation of occupational therapy
services documentation.
(2) The licensee providing occupational therapy services
must document for each intervention session. The documentation must
accurately reflect the intervention, decline of intervention, and
modalities provided.
(3) In each intervention note, the occupational therapy
assistant must include the name of an occupational therapist who is
readily available to answer questions about the client's intervention
at the time of the provision of services. The occupational therapist
in the intervention note may be different from the occupational therapist
who wrote the plan of care. The occupational therapy assistant may
not provide services unless this requirement is met.
(h) Discharge or Discontinuation of Occupational Therapy
Services.
(1) Only an occupational therapist has the authority
to discharge clients from occupational therapy services. The discharge
or discontinuation of occupational therapy services is based on whether
the client has achieved predetermined goals, has achieved maximum
benefit from occupational therapy services, or when other circumstances
warrant discontinuation of occupational therapy services.
(2) The occupational therapist must review any information
from the occupational therapy assistant(s), determine if goals were
met or not, complete and sign the discharge or discontinuation of
occupational therapy services documentation, and/or make recommendations
for any further needs of the client in another continuum of care.
|
| Source Note: The provisions of this §372.1 adopted to be effective October 11, 1994, 19 TexReg 7717; amended to be effective August 31, 1995, 20 TexReg 6337; amended to be effective May 8, 1996, 21 TexReg 3716; amended to be effective November 4, 1997, 22 TexReg 10752; amended to be effective October 25, 1998, 23 TexReg 10912; amended to be effective August 21, 2000, 25 TexReg 8063; amended to be effective July 22, 2001, 26 TexReg 5442; amended to be effective July 22, 2002, 27 TexReg 6546; amended to be effective February 27, 2005, 30 TexReg 910; amended to be effective December 4, 2005, 30 TexReg 7892; amended to be effective February 25, 2008, 33 TexReg 1604;amended to be effective September 7, 2009, 34 TexReg 6124; amended to be effective January 9, 2012, 37 TexReg 69; amended to be effective October 6, 2013, 38 TexReg 6931; amended to be effective July 1, 2016, 41 TexReg 4050; amended to be effective March 1, 2017, 42 TexReg 696; amended to be effective March 1, 2018, 43 TexReg 902; amended to be effective June 1, 2019, 44 TexReg 2465; amended to be effective June 1, 2022, 47 TexReg 3064 |
