21 NCAC 38 .0905. DELINEATION OF CLINICAL RESPONSIBILITIES

Regardless of the setting in which occupational therapy services are delivered, the occupational therapist and the occupational therapy assistant have the following responsibilities during evaluation, intervention, and outcomes evaluation:

(1)           Evaluations:

(a)           The occupational therapist shall;

(i)            Direct the evaluation process;

(ii)           Determine the need for services;

(iii)          Define the problems within the domain of occupational therapy that need to be addressed;

(iv)          Determine the client's goals and priorities in collaboration with the occupational therapy assistant and the client or caregiver;

(v)           Interpret the information provided by the occupational therapy assistant and integrate that information into the evaluation decision-making process;

(vi)          Establish intervention priorities;

(vii)         Determine specific future assessment needs;

(viii)        Determine specific assessment tasks that can be delegated to the occupational therapy assistant; and

(ix)          Initiate and complete the evaluation, interpret the data, and develop the intervention plan in collaboration with the occupational therapy assistant.

(b)           The occupational therapy assistant may contribute to the evaluation process by implementing specifically delegated assessments for which service competency has been established.

(2)           Intervention Planning:

(a)           The occupational therapist shall develop the occupational therapy intervention plan.  The plan shall be developed collaboratively with the occupational therapy assistant and the client or caregiver; and

(b)           The occupational therapy assistant may provide input into the intervention plan.

(3)           Intervention implementation:

(a)           The occupational therapist:

(i)            Shall implement the occupational therapy intervention;

(ii)           May delegate aspects of the occupational therapy intervention to the occupational therapy assistant depending on the occupational therapy assistant's service competency; and

(iii)          Shall supervise all aspects of intervention delegated to the occupational therapy assistant.

(b)           The occupational therapy assistant shall implement delegated aspects of intervention in which the occupational therapy assistant has established service competency; and

(c)           Occupational therapists or occupational therapy assistants shall not be subject to disciplinary action by the Board for refusing to delegate or refusing to provide the required training for delegation, if the occupational therapist or occupational therapy assistant determines that delegation may compromise client safety.

(4)           Intervention review:

(a)           The occupational therapist shall meet with each client who has been assigned to an occupational therapy assistant to further assess the client, to evaluate intervention, and, if necessary, to modify the individual's intervention plan.  The occupational therapy assistant may be present at this meeting;

(b)           The occupational therapist shall determine the need for continuing or discontinuing services; and

(c)           The occupational therapy assistant shall contribute to the process of determining continuing or discontinuing services by providing information about the client's response to intervention to assist with the occupational therapist's decision making.

(5)           Documentation:

(a)           The occupational therapy practitioner shall document each evaluation, intervention and discharge plan recognizing the unique requirements of specific practice settings, payors, and service delivery models.  Documentation shall include the following elements:

(i)            Client name or identifiable information;

(ii)           Signature with occupational therapist or occupational therapy assistant designation of the occupational therapy practitioner who performed the service;

(iii)          Date of the evaluation, intervention, or discharge plan;

(iv)          Objective and measurable description of contact or intervention and client response; and

(v)           Length of time of intervention session or evaluation.

(b)           The occupational therapist shall determine the overall completion of the evaluation, intervention, or discharge plan; and

(c)           The occupational therapy assistant shall;

(i)            Document intervention, intervention response and outcome; and

(ii)           Document client's level of function at discharge.

(6)           Discharge:

(a)           The occupational therapist shall determine the client's discharge from occupational therapy services; and

(b)           The occupational therapy assistant shall:

(i)            Report data for discharge summary; and

(ii)           Formulate discharge or follow-up plans under the supervision of the occupational therapist.

(7)           Outcome evaluation:

(a)           The occupational therapist is responsible for the selection, measurement, and interpretation of outcomes that are related to the client's ability to engage in occupations; and

(b)           The occupational therapy assistant must be knowledgeable about the client's targeted occupational therapy outcome and provide information relating to outcome achievement.

(8)           Supervision of occupational therapy students:

(a)           An occupational therapy practitioner shall comply with Accreditation Council for Occupational Therapy Education (ACOTE) requirements for experience when supervising Level II fieldwork occupational therapist and occupational therapy assistant students, which ACOTE requirements, including subsequent amendments and editions, are incorporated by reference.  Copies of the incorporated material are available for inspection at the Board office and are available for purchase for five dollars ($5.00);

(b)           The occupational therapist may supervise Level I and Level II fieldwork occupational therapist and occupational therapy assistant students; and

(c)           The occupational therapy assistant may:

(i)            Supervise Level I occupational therapist or occupational therapy assistant students;

(ii)           Supervise Level II occupational therapy assistant students; and

(iii)          Participate in the supervision of Level II occupational therapist students under the direction and guidance of the supervising occupational therapist.

(9)           Supervision of unlicensed personnel and volunteers.  Unlicensed personnel or volunteers may be supervised by occupational therapists or occupational therapy assistants.

 

History Note:        Authority G.S. 90-270.69;

Eff. July 1, 2007;

Amended Eff. December 1, 2009.