PTP 2 Final

units 10-13 only

Why is risk management important per the APTA

it is important that you manage the risks in your personal life in order to reduce worry for yourself and your loved ones and also to protect you assets

What are 3 ways you can manage risk?

1. avoid risk (assess, identify, analyze, reduce, control, transfer)

2. insurance (for claim or potential claim)

3. tools (forms and trainings)

Avoid Risk- Scope of Practice (assess, analyze and identify)

1. review annually your state practice act and direct access laws

2. review job descriptions annually with manager

3. decline a service outside scope of practice

4. contact state board if need an opinion

5. use chain of command to resolve safety of patient care issues

Avoid risk- supervision of personnel (control)

1. direct support staff (AIdes and PTAs) to perform only those tasks that are appropriate to state and federal laws and within their training

2. provide supervision for aides, PTAs and students within compliance of all laws and practice acts

3. documented and updated competencies on file for aides

4. report a complaint to board violations of supervision that cannot resolve internally

(risk management) Avoid risk- documentation (control and transfer)

Avoid Risk – Documentation (Control and Transfer)

• Authenticate all documentation and all handouts to the patient.

• Document every single encounter and non-encounter (cancellation/no-show).

• Correct errors per current guidelines. 

• Avoid late entries, documenting as you go (concurrently).

• Refrain from documenting slander, inappropriate opinions, conclusions or derogatory statements about patients, colleagues, or the healthcare team members.

• Contact manager, risk manager, or legal department for assistance with documentation concerns.

• Ensure your documentation: 

  • Is consistent to the treatment plan

  • Includes skilled services that are medically necessary

  • Justifies the services billed

  • Reflects established billing (CPT codes, G codes etc.), and coding procedures (FIM, ICD-10, MDS). 

  • Meets state, local, federal guidelines as well as ethical/professional guidelines

Documentation importance

• Quality and thorough documentation is as important as the quality of the care that is delivered to patients, since medical records are legal documents and serve as valuable evidence as to what transpired between patients and the healthcare providers.

avoid risk- everyday practice

• Establish rapport, minimize negativity, and have a helping/healing attitude

• If documentation or supervision regulations differ, or when in doubt, it is recommended to go with the most restrictive rules

• Document timely, accurately, completely, appropriately, and legibly all items, including HEP instructions, handouts etc.

• Never alter records after the fact, follow correct error reporting.

• Label correction and addendum notes as, “late entry” and only add these things if need to be added for patient’s sake

• Attending all required training: Mandate reported/Elder abuse, annual compliance training, CPR training etc.

• Ensure all equipment is cleaned, functioning, and maintained; the environment is safe.

• Review safety precautions and comply with gait belt policies etc. 

Conflict resolution and Minimization of Staff

• The challenge of resolving conflict, gaining improved interdisciplinary communication, relationships, and job satisfaction; minimizing stress to improve workgroup cohesiveness; increase staff retention; empower autonomous staff; and improve patient outcomes, a healthcare organization’s success depends on how well it attends to conflict and its resolution

Insurance- When to utilize?

Immediately contact your professional liability insurance carrier if:

• You become aware of a filed or potential professional liability claim asserted against you.

• You receive a subpoena to testify in a deposition or trial.

• You have any reason to believe that there may be a potential threat to your license to practice physical therapy. 

Insurance reporting

• If you purchased your own professional liability insurance, report claims or potential claims to your insurance carrier, even if your employer advises you that the organization will provide you with an attorney and/or that the employer’s insurance will cover you for a professional liability settlement or verdict amount.

• Refrain from discussing the matter with anyone other than your defense attorney or the claim professionals managing the case.

• Promptly return calls from your defense attorney and the claim professionals assigned by your insurance carrier. Contact your attorney or claim professional before responding to calls, e-mail messages or requests for documents from any other party.

Insurance questions: Be prepared

• Provide your insurance carrier with as much information as you can when reporting such matters, including contact information for your organization’s risk manager and the attorney assigned to the litigation by your employer.

• Never testify in a deposition without first consulting your professional liability carrier or, if you do not carry individual liability professional insurance, the organization’s risk manager and/or legal counsel.

• Copy and retain all legal documents for your records, including the summons and complaint, subpoenas and attorney letters pertaining to the claim.

Examples of tools you may use for risk management

• Clinical Education Incident Form (CEIF) 

• HPSO: Risk Control Self-Assessment Checklist for Physical Therapists (.pdf)

• Complaint forms on State Boards

The extent of patient safety issues in the US was first identified in the institue of Medicine’s 1999 report______.

• “To Err is Human."

• In this report, it is estimated that in the United States between, 44,000 and 98,000 patient deaths occurred each year as a result as of medical errors. 

“To Err is Human”: at the time medical error related deaths ranked as high as 8th leading cause of death in the US. recent studies have shown that the medical error related deaths are now

• the third leading cause of death in the United States. Unfortunately, the medical error related death is increasing instead of decreasing. 

In most facilities, there are three categories of incidents. what are they?

1. patient incidents

2. employee incidents

3. visitor incidents

what is a patient safety incident?

it is defined as any unplanned or unintended event or circumstance which could have resulted in or did result in harm to a patient.

What is a harmful incident (patient incident) ?

• it is a patient's safety incident that resulted in harm to a patient.

• This includes when a patient did not receive his or her planned or expected treatment.

• This was formerly known as an adverse event or a sentinel event. 

Patient incident: what is a near miss?

• is a patient safety incident that did not actually cause a patient harm but had the potential to do so. 

Investigation of incidents should focus on

processes and not pointing blame at staff

It is important that the incident form is completed

as soon as possible and by the end of the staff member shift

Are incident forms part of the medical record?

• Incident forms are not part of the medical record but are a work product that is not disclosable in the case of a lawsuit. 

When completing the incident report you should be

• be factual. However, avoid placing blame or suggesting causes. That is the role of the person investigating the incident. When completing the incentive reform, you want to limit your responses to the facts that are known to you. 

A typical incentive reporting form will ask for the following

• Patient demographic information

• A description of the incident, including the time, location

• People present. 

• Injuries were sustained 

• If medical care was required

• If a physician was contacted and any orders for a patient incident

The goal of an incident investigation process is to

improve safety by identifying causes to avoid the recurrence

T/F transparency is important in an incident report?

YES

• You should be honest and forthcoming about what you know about the incident. Data will be collected and analyzed from a combination of interviews and documentation review. 

Patient incidents that result in severe injuries, such as fractures, head injuries or death are required to be reported to

the joint commission for those facilities that are accredited by the joint commission and possibly the state department of health or other regulatory agencies

The incident investigation looks specifically for

the cause of the incident/ root cause

What is the root cause

the highest- level cause or fundamental cause

The root cause is related to

• an issue with the facility’s processes, not an individual. Even if there’s human error involved, there is a lack of processes that would prevent the error. This could be a lack of appropriate training, insufficient staffing or equipment, or no verification or other safety checks built into the processes. 

A root cause analysis is a

• a systematic process for identifying the root cause of the incident. The process is looking for ways to prevent future incidences. The primary goal is to discover what, how, and why the incident occurred and to develop an action plan to prevent a recurrence. 

What is step one in a root cause analysis

• Step one collecting data to try to reconstruct all the steps in the event, and then you analyze the sequence of events that have led up to the incident or breakdown in processes.

What is a tool used to identify the causes of an incident?

Fishbone diagram

when a root cause is identified for an incident

an action plan needs to be developed to address these causes

• The same approaches that are used for the quality improvement program can be used to develop an action plan. Possible approaches include PDSA, PDCA, and focus. 

A fish bone diagram includes

• develop problem statement

• major categories of causes

• brainstorm possible causes

• continue asking why about each cause and place under each category

PTAs must graduate from

a CAPTE-accredited program and licensure or certification is required

PTA’s must pass the

national exam for licensing/certification in all states and several US territories

PTAs work under

Supervision of licensed physical therapist

PTA program details

• associate of science degree

• completed in 2-2.5 years

• total of 69-76 credit hours

• passing the licensure board exam after graduation is required to practice as a PTA

PTA program students will learn common PT techniques such as

• Therapeutic Exercises and Activities 

• Balance, Gait and Transfer Training 

• Modalities, Soft Tissue Massage and Aquatic Therapy 

• Including the all-important topic of patient education These techniques are consistent with interventions students learn while enrolled in the DPT curriculum.

T/F PTAs may also measure changes in the patients performance as a result of the physical therapy provided

true

PTAs implement

• PTAs implement selected components of patient interventions, obtain data related to the interventions provided, and adjust in selected interventions to progress the patient as directed by the physical therapist to ensure patient safety and comfort.

APTA general supervision level: General Supervision

• applies to a licensed/certified PTA. The physical therapist is not required to be on site for direction and supervision but must be available at least by telecommunications. 

APTA general supervision level: direct supervision

• applies to the student PT or PTA.

• The physical therapist is physically present and immediately available for direction and supervision.

• The physical therapist will have direct contact with the patient during each visit as defined in the Guide to Physical Therapist Practice.

• Telecommunications does not meet the requirement of direct supervision.

• ON SITE

APTA supervision level: direct personal supervision / line of sight supervision

• applies to the physical therapy aide. The physical therapist or, where allowable by law, the physical therapist assistant is physically present and immediately available to direct and supervise tasks that are related to patient management.

• The direction and supervision are continuous throughout the time these tasks are performed.

• Telecommunications does not meet the requirement of direct personal supervision.

PT supervision considerations when working with the PTA should also include considerations of

• State Practice Acts, Third Party Payers Rules, and Regulations such as Medicare, Medicaid, or private Insurance Companies. When practicing, PTs and PTAs should be aware of the rules to avoid fraud and abuse.

T/F some states may vary supervision levels for the PTA by setting

true

In a skilled nursing facility, the physical therapist provides what level of supervision

General supervision- requiring the initial direction and periodic inspection of the actual activity unless different requirement in state practice act

When a PTA works in a physicians office, what type of supervision must be provided

Direct supervision of a physical therapist that is enrolled under Medicare

-physician cannot bill services provided by a PTA

-services must be billed under the provider number of the supervising physical therapist

PTA requires what level of supervision in home health setting?

• general supervision

Most states require what kind of supervision level for the PTA

• Most states require general supervision of the PTA regardless of setting, for example California and Texas. A few states require onsite supervision of the PTA based on the setting, for example, Florida. Per the Florida state practice act, when the PTA works in a Hospital Inpatient setting AND when the patient is in an acute phase of injury or illness, the PT must be readily and physically available to provide consultation. General supervision is required in all other situations.

Model PTA

• right hand of PT and works under their supervision

• directly involved in the patient treatment

• duties include: mobility training, applying physical agents like cold heat electrical stimulation or paraffin to decrease pain, decrease swelling and or increase healing or function

• should design and carry out exercise programs to build strength, endurance, coordination and improve function

What is the best way to avoid risk?

1. Delegate documentation to the biller to ensure it is correct.

2. Complete all documentation at the end of the day.

3. Document in the first person.

4. Authenticate all documentation and all handouts to the patient.

4. authenticate all documentation and all handouts to the patient

Which of the following is NOT a strategy for conflict resolution?

1. Minimizing stress to improve workgroup cohesiveness.

2. Empower autonomy. 

3. Delivering mixed messages.

4. Clear communication.

3. delivering mixed messages

What is it called when an incident did not actually cause a patient harm but had the potential to do so?

1. Safety incident 

2. Harmful incident 

3. Sentinel event

4. Near miss

4. Near miss

Sample Question 31

Which of the following is NOT true of root cause analysis?

1. The root cause is the highest-level cause or the fundamental cause. 

2. The root cause is related to an issue with the facility’s processes, not an individual. 

3. A root cause analysis is a systematic process for identifying the root cause of the incident. 

4. Root cause analysis is performed by the Department of Health.

4. Root cause analysis is performed by the Department of Health.

Sample Question 32

Under which type of supervision is telecommunications acceptable? 

1. General Supervision

2. Direct Supervision

3. Direct Personal Supervision

4. Telcommunication Supervision

1. General supervision

The PTA supervision algorithm is a great tool to

allow consistent decision-making

• it encourages the PT to provide a higher level of supervision when the patient is less stable

Patient 1 scenario:

Patient 1 underwent an ORIF surgery of the ankle 3 weeks ago. The PT has evaluated the patient and goals of tx include edema reduction, increase ROM, and progression to full weight bearing w. one crutch to prepare for full WB and to achieve a greater level of independence of ADLS.

Should they be delegated to a PTA

YES

Indicated interventions are w. in scope of practice, patient is sufficiently stable, intervention outcomes are suffifiently predictable and the PTA has the knowledge and skills to perform ininterventions

• no liability or reimbursement issues that will negatively affect care

• PT should monitor pt progress by reviewing documentation and discuss w. PTA and ongoing observation and reassessment of the patient

Patient scenario 2:

SNF-Patient has LBP and radiation of pain into R posterior thigh. POC includes spinal mobilization, therex for trunk stabilization and improved flexibility of the hip and LE to decrease pain symptoms and correct trunk and pelvic function. the plan also calls for instruction on body mechanics and posture as this patients work requires frequent bending and occasional lifting

should this case be given to a PTA

For the first 2 weeks→ PT should see patient 2x per week and the PTA should see the patient 3 times per week

*Spinal manip not in scope of practice for PTA and radicular symptoms that patient isnt as stable

PT should→spinal mobilization and initial instruction of exercises

PTA should→ progress therex, correct errors and performance, body mechanics and postural training as directed in the POC

Patient 3 scenario (outpatient)

Patient has been diagnosed with C5 radiculopathy with biceps weakness, paresthesia and constant pain interfering w. sleep. An MRI has been scheduled and surgery will be considered if the signs and symptoms do not improve considerably with physical therapy over the next week. POC considers mobilization

should a PTA see this patient?

NO

Patient isnt stable and they require mobilization and intervention outcome is not stable

Case 4: acute care patient is 26 weeks pregnant with twins, she has significant LBP and buttock pain since early in the pregnancy. they have difficulty with walking, standing and finding a comfortable sleeping position. He pain is 8/10 after medication. POC includes a supportive device, body mechanics, posture training, joint mobilization, ADLs and bed positioning

Should a PTA see them?

PT should provide all interventions

• b/c joint mobs, not stable, high risk, interventions not predictable, PTA might be incorporated later on when they are transitioning settings to focus more on body mechanics

Cognitive skills

• Conscious intellectual effort, such as thinking, reasoning, or
  remembering

• Require capabilities in reading and mathematics

Non Cognitive skills

• aka soft skills

• Related to motivation, integrity, and interpersonal interaction

• involve intellect, but more indirectly and less consciously than cognitive skills

• Associated with an individual’s personality, temperament, and
  attitudes

What type of skills (COGNITIVE OR NON- COG) fall outside of traditional definitions of intelligence

Non- cognitive skills

Non cognitive skills allow individuals to contribute to society in meaningful ways through:

• Critical thinking skills-analysis of facts to derive at a
judgement
• Metacognition-setting goals, planning and problem-
solving, awareness of one’s strengths and growth areas,
and knowing when and why to use certain strategies
• Social skills-ability to communicate and work effectively
with others
• Persistence—steadfastness on mastering a skill, grit
• Creativity-mental flexibility, ability to derive at new
solutions

Cognitive domain skills are a

test of knowledge

Psychomotor domain skills are

clinical application of hands and body for ceases, practical, mock and real patients

Affective domain skills are

• Verbal,

• Non-verbal

• Self reflection

• Conflict resolution

• Assertiveness

• Time management

• Emotional Intelligence

• Leadership

• Caring

• Wellness

• Healing Attitude

• Trust

• Rapport

• Professionalism, etc.

Affective domain skills are also know as

non-cognitive skills

what are non-cognitive skills

Considered as ‘soft skills’ of attitudes, behaviors, and strategies.
• Evidence that they underpin success in school and at work.
• Different than ‘hard skills’ (cognitive abilities) like academic test performance.
• More employers are increasingly considering NCS to be as important as, or even more important than, CS or IQ to interview for, and develop
• Policymakers are very interested in seeing how such ‘character’ or ‘soft’ skills can be developed in children and young people.

Domains of non-cognitive skills

1. emotional intelligence is a large blend of emotional and social skills

2. caring (client centered)

3. moral judgements (codes of conduct based on code of ethics and values held largely by US society/laws)

CIP cognitive and psychomotor areas

PURE
7 Clinical Reasoning
8 Screening
9 Examination
10 Evaluation
11 Diagnosis and Prognosis
12. Plan of Care
13. Procedural Intervention
14. Educational Intervention
15. Documentation
16. Outcomes Assessment
17 Financial Resources
BLEND
1 Safety
18 Direction and Supervision of Personnel have

CPI non- cognitive areas

PURE
2 Professional Behavior
3 Accountability
4 Communication
5 Cultural Competence
6 Professional Development
BLEND
1 Safety
18 Direction and Supervision of Personnel have

ways to enhance non-cognitive skills

2 Professional Behavior: Professional behaviors self-assessment with a person who can be honest with you, faculty member or classmate.

3 Accountability: If clear expectations, capabilities, measurements, and consequences, then can hold people accountable and yourself as well, be sure to clarify anytime you are uncertain (Bregman, 2016, January 11).

4 Communication: Practice, practice, practice… Continuing education like Toastmasters

5 Cultural Competence: Self assess your cultural competence, trainings

6 Professional Development: Develop yourself in free time, weekends during internships and evening should be somewhat devoted to preparing for next day and week.

Ethics are

• are moral codes that develop when people are aware of what is right and wrong, and they become a standard that everyone must conform to

Laws are

rules developed and enforced by the government to protect its citizens and balance the society

Rational reflection

ethics

standards for what is right or wrong

values

what is jurisprudence

a theoretical study of law. it seeks to explain the understanding of legal reasoning, legal systems and the role of law in society

Professional scope of physical therapy practice is defined as

practice that is grounded in the profession’s unique
body of knowledge, supported by educational preparation, based on a body of evidence, and linked to existing or emerging practice frameworks.

Jurisdictional (legal) scope of physical therapy practice

The jurisdictional (i.e., legal) scope of practice is established by a
state's practice act governing the specific physical therapist’s
license, and the rules adopted pursuant to that act.

Personal scope of physical therapy practice

The personal scope of practice consists of activities undertaken
by an individual physical therapist that are situated within a
physical therapist’s unique body of knowledge where the
individual is educated, trained, and competent to perform that
activity

what guides our profession

Individual—Personal values and beliefs based on our
culture and religion
• Organization—Code of ethics, core values, standards of
practice, APTA policies, APTA position statements,
generic abilities, and professional behaviors
• Society—Practice laws, regulations, statutes, and
administrative code

Constitution is the

• highest form of law

• exists at a national and state level

statutes are

• what most of us think of as laws

• they exist at national and state levels written by legislators

administrative code are

rules and regulations which govern practice, exists at national state levels

Common law is based on

Precedence (priority in importance, order or rank)

Federation state board of physical therapy mission and vision

Our Mission: To protect the public by providing service and leadership that
promote safe and competent physical therapy practice
• Our Vision: To achieve a high level of public protection through a strong
foundation of laws and regulatory standards in physical therapy, effective tools
and systems to assess entry-level and continuing competence, and public and
professional awareness of resources for public protection

Physical therapy licensure compact

April 25, 2017 FSBPT has
launched a project to develop an
interstate licensure compact for
physical therapy to increase
consumer access to physical
therapy services by reducing
regulatory barriers to interstate
mobility and cross –state
practice

Keys to PT practice

-licensure

supervision

delegation

false claim act

anti-kickback statute

stark law

FSPBT develops, maintains and administers the NPTE for 2 reasons:

To help ensure that only those
individuals who have the requisite
knowledge of physical therapy are
licensed in the physical therapy field
• To help regulatory authorities evaluate
candidates and provide standards that
are comparable from jurisdiction to
jurisdiction

there are variations of supervision for physical therapy students

according to individual payer and insurers, state practice act provisions and the setting where the PT services are provided

General supervision (simple definition)

• least restrictive type of supervision

• requires that PT is available for direction via telecommunication, not onsite

Direct supervision

requires PT to be physically present in the facility and
immediately available for face-to-face direction

direct personal supervision is considered what level of supervision?

• highest level of supervision

• PT must be physically present and immediately available to direct

• PT must provide continuous direction for the entire duration of treatment

Medicare supervision info

PTs may not bill for services provided by PT
students, students may help PTs provide services,
but PT must be involved
• Medicare Part B—PT must provide at least one
onsite visit every 30 days where the PTA is the
primary provider
• Starting in 2022, services provided by PTAs will be
reimbursed at 85% of the rendered by PTs

PT delegation responsibility

It is the responsibility of the PT to know:
✓What interventions can be delegated and under what conditions
✓How those services must be supervised, documented, and billed
✓To include documentation that the plan of care was reviewed with the
PTA and that the PTA is receiving the correct level of supervision
(Belles, 2018, July 18.)

False claim act

Federal law which states that it is a crime for any person or
organization to “knowingly” make a false to the federal health care program

• Examples:
• Billing for services not provided
• Billing for the same service more
than once
• Making false statements to
obtain payment for services

False claim act violations could result in

1. Financial penalties: recovery of 3x’s the amount of the false claim(s) + an additional penalty of $5,500.00 - $11,000.00 per claim

2. Potential imprisonment
   (Total Health Care, n.d.)

T/F Employee of a physical therapy services provider signed his name on patient files as the provider of PT services, including blank treatment data forms, progress notes, and daily physical therapy records. He was not licensed, trained, or otherwise qualified to provide physical therapy. Sentenced to 9 years of incarceration and ordered to pay more than $26 million for health care fraud.

True