One PT, Two PTAs, an Aide, and a Student: Who May Do What
Cornerstone Rehab staffs one physical therapist (you), two PTAs, and a rehab aide for a four-hour afternoon block with 18 patients booked. The aide, hired three weeks ago, has been applying hot packs and ultrasound and typing daily notes into the EMR under your name; a PTA trained her by demonstration. Yesterday, while you were at a hospital discharge meeting across town, PTA #1 performed the initial examination on a new total knee replacement patient and wrote the plan of care. PTA #2 wants to change the plan of care for a shoulder patient who has plateaued. The DPT student on her second rotation has been treating two patients each afternoon while the aide assists. The clinic owner tells you not to worry because 'everyone here works under a licensed PT.' Nobody has documented supervision, and no one has checked the aide's competency since she was hired.
1. Sort each assignment in the clinic into permitted or not permitted under Georgia law and Board rules, and state who is responsible for each.
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Separate the tasks by who is legally allowed to perform them.
PT only (non-delegable): the initial examination and evaluation, clinical diagnosis, prognosis, establishing and modifying the plan of care, discharge decisions, and interpretation of tests. PTA #1's initial examination and plan of care are outside the PTA scope no matter that a PT is employed at the same clinic; you must perform or redo the examination and adopt the plan of care yourself so the record reflects a PT decision. PTA #2 may carry out and progress within your plan and report the plateau, but the decision to change the plan is yours.
PTA: delegated interventions and re-assessment data within the plan of care, under the supervising PT's direction.
Aide: only non-skilled, non-treatment tasks - transport, equipment setup without patient contact, clerical work, cleaning. Applying a hot pack or ultrasound is delivery of a physical therapy intervention and requires a PT or PTA. A note signed by you describing treatment the aide performed is false documentation.
'S/he works under a licensed PT' is not a legal theory. Supervision means the PT is responsible, available, and able to intervene - not merely on the payroll. Being across town during an initial evaluation defeats it.
2. What must you do about the notes already in the record and about the aide's role going forward?
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Correct the record; do not sanitize it. Add an addendum to each affected note (never delete or overwrite) stating what was actually performed, by whom, and that the aide's services were not skilled physical therapy. Date and sign each addendum. Assume the EMR preserves an audit trail, because it usually does.
Stop the aide's treatment role today and restrict her to non-skilled tasks. Document the retraining, a competency check, and a written delegation policy that names which tasks are aide-appropriate and which are not.
Notify compliance and billing so any claim for aide-delivered treatment, or for a PTA-delivered initial evaluation, is reviewed, corrected, and refunded if already paid. Billing for services not delivered by a qualified provider can become a false-claims problem far larger than a licensing problem.
Tell the owner in writing why the current staffing model cannot continue and what the schedule must look like instead.
Anticipate a complaint. If a patient, payer, or employee reports this to the Board, your addenda and prompt correction are the difference between a documentation error and a cover-up. Disclosure is mitigating; concealment is not.
3. How may the DPT student be used, and what does your role as clinical instructor require?
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Use the student as a learner, not as staff. A student may participate in patient care only as part of the educational program, under your supervision, within a plan of care you set. The student is not counted in staffing, does not substitute for a PTA or an aide, and should never be the reason the clinic can book more patients than its licensed staff can safely cover.
Consent: tell patients a student is involved and let them decline without penalty.
Clinical instructor duties: confirm the student's level and the school's supervision requirements (close supervision early, less later), review and co-sign notes as the clinical education agreement and Board rules require, provide documented supervision and feedback, and never sign off on a skill you did not observe.
The real fix is the schedule. If the caseload only works because an unlicensed aide or a student is delivering treatment, the caseload is the problem - reduce it or add licensed staff. Delegation decisions should be driven by patient complexity and legal scope, not by the number of slots on the books.