SNF Delegation to a PTA and a Rehabilitation Aide
A physical therapist is the only PT in a 90-bed skilled nursing facility. She is on site Monday and Tuesday and available by phone the rest of the week. She evaluates a new resident on Monday, sets a plan of care for gait training and therapeutic exercise, and delegates follow-up to a PTA. On Wednesday the PTA adds a new resistance band exercise, increases gait-training distance, and changes the resident's knee immobilizer setting because the resident 'seems ready.' On Thursday a rehabilitation aide applies ultrasound to the resident's knee for 12 minutes and documents it as 'PTA treatment.' On Friday the PTA completes the resident's discharge summary and signs the PT's name. The PT returns Monday to find these entries. The facility's administrator says the PTA is experienced and asks the PT to sign off on the week's notes to keep billing current.
1. Identify each delegation or documentation problem and explain whether the PTA or aide acted within Missouri scope and supervision rules.
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The PTA may carry out selected interventions under the PT's plan and report changes, but the PTA may not independently add a new exercise, increase the plan's gait-training parameters, change a knee immobilizer setting, or discharge the resident. Those are PT-level decisions because they require interpreting the patient's condition and modifying the plan of care. The PT's phone availability does not convert the PTA into an independent practitioner.
The aide's ultrasound treatment is also improper. Ultrasound is a skilled physical therapy modality; an unlicensed rehabilitation aide may not apply it, and documenting it as 'PTA treatment' is falsification. The PTA signing the PT's name is a separate documentation violation. The PT cannot retroactively approve these acts by signing the notes. The PT remains responsible for supervision, but responsibility does not make the underlying acts permissible.
2. What must the PT do before signing anything, and what corrective action and notifications are required?
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The PT must not sign the week's notes as written. She should personally reassess the resident, including the knee immobilizer setting and response to the added exercise, and document her own findings and plan. She should write dated addenda that correct the record without deleting the original entries: identify who performed which service, what was unauthorized, and what the PT did after discovering it. The aide's ultrasound entry should be corrected to reflect that the aide applied it, not a PTA.
The PT should notify the administrator and compliance officer, stop the aide from performing skilled modalities, and retrain the PTA on the plan of care and documentation boundaries. The facility should review other aide and PTA entries for similar problems. Because the record contains falsification and unlicensed modality use, the PT should consult the Board's reporting requirements and report if required. Billing should be corrected and overpayments evaluated.
3. What supervision model should be put in place to prevent recurrence?
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The PT should define in writing which interventions the PTA may provide, what changes the PTA must report, and when the PT must see the resident. The PTA should have a clear communication pathway for changes in status, and the PT should schedule a reassessment after any reported change rather than relying on phone availability alone. The aide's role should be limited to non-skilled tasks permitted by facility policy and state law, with no independent modalities or clinical documentation.
The PT should also audit documentation regularly, verify that PTA notes identify the supervising PT and the services actually provided, and confirm that discharge summaries are completed by the PT or by the PTA only in a manner the Board permits. If the facility cannot support that level of supervision, it should not assign the resident to a PTA on days when no PT can reasonably supervise.