One Therapist, Two Sites, a Student, and an Aide
Riverside Rehab has one physical therapist, Dana, two licensed physical therapist assistants, Luis and Priya, one physical therapy aide, Colt, who is unlicensed and three months into the job, and a first-year physical therapy student on her second clinical rotation. Dana covers a 26-bed inpatient unit and a satellite clinic 40 minutes away. On Thursday she is double-booked: a patient three days after total knee arthroplasty needs an initial examination and plan of care at 9:00, Luis is scheduled at the satellite with three follow-up visits, Priya is on the inpatient unit, and Colt has been told to get the satellite patients started by applying moist heat and setting up the NMES units before Luis arrives. The student has been asked to perform the initial examination and write the plan of care so that Dana can sign it later. A physician calls the satellite asking whether the patient's status has changed, and Colt answers, reporting that the patient is doing great and walked 100 feet.
1. Assign each activity to the appropriate person and explain the legal basis for each assignment.
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- Dana (PT): the initial examination, the diagnosis and prognosis, the plan of care, any re-evaluation, and discharge for the new arthroplasty patient. These require the professional judgment of the licensed therapist and are not delegable. She must also personally review and authenticate documentation that establishes or changes a plan of care.
- Luis and Priya (PTAs): they may deliver the delegated interventions and follow-up visits under an established plan of care and may document the treatment they provide and the patient's response. Neither may perform an initial examination, establish or change a plan of care, or discharge a patient.
- The student: she may perform components of the examination and treatment only under on-site supervision of the PT. She may not independently perform the initial examination or author the plan of care, and Dana may not later sign a plan the student reasoned through alone, because the signature represents who provided and directed the service.
- Colt (aide): transport, equipment setup, cleaning, and clerical tasks only. Applying moist heat or NMES as a treatment and reporting clinical status to a physician are unlicensed practice, regardless of how routine they feel.
2. What supervision structure must Dana put in place for the satellite site, and what should she do about the 9:00 conflict?
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Dana remains accountable for every patient treated at the satellite, and accountability has to be operationalized. That means: no patient is examined or started on a plan of care at the satellite unless Dana has personally examined the patient and written the plan; Luis has that written plan, knows the precautions for each patient, and can reach Dana by phone during treatment hours; Dana makes on-site visits at the interval the Board's supervision rules require and sees the patients herself at those visits; and notes are reviewed and co-signed per clinic policy.
None of that structure can be improvised by 9:00 on Thursday, so the honest answer is that the schedule is wrong. Dana should either move the evaluation, send Priya to the satellite and cover the inpatient unit herself, or reschedule the satellite follow-ups. Aides cannot fill the gap, and a student cannot be the therapist on record. The double-booking is a staffing problem that, left in place, becomes a licensure problem.
3. Analyze Colt's telephone conversation with the physician and the clinic's response.
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Colt crossed two lines at once. First, scope: reporting that the patient is doing great and walked 100 feet is a clinical status report that requires a therapist's assessment of the patient's current condition, not an aide's impression from the hallway. Second, privacy and accuracy: the aide likely disclosed protected health information without being authorized to do so, and the physician now has a reassuring report that no clinician has verified.
Dana should call the physician back the same day, correct the record, and document the correction and the time. She should also determine how much information Colt disclosed, whether a release covers the conversation, and whether the clinic's privacy officer needs to be notified. Colt needs documented retraining on scope of practice and on the script for handling clinical calls: take a message, obtain a callback number, and route it to the treating therapist. He should not be disciplined for doing what he was implicitly trained to do, but the assignment that put an unlicensed aide in that position is Dana's to fix.