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Frequently Asked Questions about Ethics

Q: When was the Occupational Therapy Code of Ethics updated?

A: The Code was last updated and adopted by the American Occupational Therapy Association’s (AOTA’s) Representative Assembly (RA) in April 2010. The 2010 Code integrated the three previous documents that comprised the Ethics Standards (the Occupational Therapy Code of Ethics (2005), the Guidelines to the Occupational Therapy Code of Ethics, and the Core Values and Attitudes of Occupational Therapy Practice) into one comprehensive document, now titled the Occupational Therapy Code of Ethics and Ethics Standards (2010). The document is often referred to as the Code and Ethics Standards.

Q: Where can I find a copy of the Code and Ethics Standards document?

A: The Code and Ethics Standards document is available on AOTA’s website (www.aota.org) in the Practice section under Ethics. It can also be found in the About Occupational Therapy section of the website, where it is available to nonmembers and consumers. You can also find it in the Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards, 2010 Edition which is available for purchase.

Q: Are any resources available to explain the Code and Ethics Standards in greater detail?

A: Yes. The Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards, 2010 Edition may be purchased through AOTA. In addition, members can access ethics advisory opinions on topics of current interest to assist them in applying the Code and Ethics Standards to professional issues.

Q: Do the Code and Ethics Standards apply to behaviors of occupational therapy personnel conducted in non–occupational therapy related roles?

A: The Code and Ethics Standards was specifically “tailored to address the most prevalent ethical concerns of the profession in education, research, and practice.” The document relates to actions taken by occupational therapy personnel in any professional role, and although the Code and Ethics Standards is intended to guide professional conduct, occupational therapy personnel should also be cognizant of how personal interactions and choices may impact the public perception of the profession and occupational therapy clients in all spheres. Occupational therapy personnel should be aware that the public may not differentiate private from professional roles, particularly when professional credentials or other forms of identification with occupational therapy are used. Therefore the conduct and judgment of occupational therapy personnel may reflect on the profession, even outside the workplace.

Q: I am interested in being a candidate for an AOTA volunteer position on a standing committee but I received a disciplinary action by the AOTA Ethics Commission last year. Can I still run for office?

A: Candidates for AOTA elected and appointed positions must sign an attestation on the nomination form that states that they have not had a public disciplinary action (censure, probation, suspension of membership or revocation) in the past 3 years. In addition, candidates for an AOTA office must be members of AOTA so if you had a public sanction of revocation (permanent denial of membership), you would not be able to run for office.

AOTA, National Board for Certification in Occupational Therapy (NBCOT®), and State Regulatory Boards (SRBs)

Q: What are the differences between AOTA, NBCOT®, and SRBs?

A: AOTA is a voluntary professional membership association. The National Board for Certification in Occupational Therapy, Inc. (NBCOT) is a private, non-governmental credentialing agency that provides initial certification and recertification for the occupational therapy profession (e.g., occupational therapists and occupational therapy assistants).

State regulatory boards (SRBs) or licensure boards are legal entities that have jurisdiction over individuals licensed to practice in that state. State regulatory contact information is available on the AOTA website.

The differences between these bodies are outlined in “Disciplinary Action: Whose Responsibility?” and “Overview of the Ethical Jurisdictions of AOTA, NBCOT, and SRBs” in the Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards, 2010 Edition which is available for purchase through AOTA.

Ethics Complaints and Reporting Process

Q: Can I file a complaint against any occupational therapist or occupational therapy assistant?

A: Yes. However, as a first step, document what occurred and, if possible, discuss the potential unethical conduct with that individual as an educative opportunity.

If the decision is made to report, depending on the nature of the incident and the setting, there are several options. Unethical conduct by an individual occupational therapist or occupational therapy assistant can be reported to:

However, questions of jurisdiction will affect which organization’s authority will accept the complaint.

AOTA is a membership organization and is only permitted to handle ethics complaints against occupational therapists and occupational therapy assistants who are, or were, AOTA members at the time of the alleged misconduct. The Enforcement Procedures for the Occupational Therapy Code of Ethics and Ethics Standards outline the jurisdiction of AOTA’s Ethics Commission.

The state in which the occupational therapist or occupational therapy assistant is licensed and in which the objectionable activity occurred also has procedures for filing a complaint. (See State Regulatory contact information.) Or are you saying that determining jurisdiction is also variable/complicated if (a) individuals are licensed by a state and (b) certified by NBCOT?

For an occupational therapist or occupational therapy assistant who is currently certified by NBCOT there are procedures in place for filing a complaint as well.

A complaint may be filed simultaneously with more than one of these organizations if appropriate.

Q: What is the process for filing a complaint with AOTA?

A: The specific process for AOTA is detailed within Section 2 of the Enforcement Procedures. The Ethics Commission accepts written complaints about issues that have occurred during the past 7 years.

Q: What do I do if I have an ethics complaint against someone from another discipline?

A: Unethical conduct by a professional of another discipline can be reported to his or her state licensure board, professional association, and/or credentialing body. Medicare fraud (which is a legal issue) can be reported to the Office of the Inspector General (OIG), which handles Medicare and Medicaid fraud and abuse prevention, detection, and reporting. Contact the OIG National Hotline at 800-HHS-TIPS (800-447-8477).

Depending on the situation, you can also report improper practices in your facility to the state survey agency that licenses the facility:

In addition, the facility or organization may have an ombudsman or compliance hotline for reporting.

Links to Other Professions’ Web Sites:

American Physical Therapy Association

American Speech-Language-Hearing Association

American Psychological Association American Medical Association

Q: I’m a fieldwork student and I want to report unethical behavior by university faculty or my clinical instructor. What do I do?

A: The Ethics Commission accepts reports of ethics violations from a variety of sources, including students. Although a student may find it difficult to report a faculty member or clinical instructor due to the innate power imbalance in the relationship, he or she can look to the Code and Ethics Standards for guidance if facing such a situation. Indeed, Principle 1M of the Code and Ethics Standards directs occupational therapy practitioners to report to appropriate authorities any acts, including those related to education, that appear unethical or illegal. Before reporting, however, a student should proceed prudently and use critical reflection to determine whether an ethics violation did occur and what actions are available and most appropriate. Students should refer to policies related to filing a grievance within their respective department and/or college/university if the offence involves a faculty or staff member. If the potential offense relates to conduct by the clinical instructor in the facility, contact the academic fieldwork coordinator. If these strategies are ineffective and the issue remains unresolved, the student should follow the procedures (Enforcement Procedures) for filing a complaint (Complaint Form) with the Ethics Commission.

For additional information, contact ethics@aota.org

Client Health Insurance

Q: What should I do if my clinical judgment indicates a different plan of care than what is supported by the client's insurance plan?

A: Refer to the advisory opinion “Ethical Issues Around Payment for Services” or the Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards, 2010 Edition for information related to this issue.

Criminal Record

Q: I am applying for admission to an occupational therapy or occupational therapy assistant program. Several years ago I was involved in a legal incident that resulted in a criminal record against me. Can I now become an occupational therapy practitioner?

A: A criminal record may impact your future ability to enter an educational program, complete required clinical fieldwork, take the NBCOT certification exam, become licensed or regulated to practice, and obtain a job in occupational therapy. Any or all of these activities or entities may require a criminal background check.

You may want to seek information about the NBCOT Early Determination Process related to a previous criminal conviction

You can also contact NBCOT at 301-990-7979, or www.nbcot.org

It is also important to contact the licensure board/regulatory agency in the jurisdiction(s) in which you anticipate practicing. Each state, and the District of Columbia and Puerto Rico, has a regulatory contact.

Record Keeping

Q: How long should I keep records in home care or at an outpatient treatment facility?

A: There may be both legal and ethical responsibilities related to medical records.

If you are governed by the Centers for Medicare & Medicaid Services (CMS) or any other accrediting agency (e.g., JCAHO) you should check the standards of these organizations. You usually can find copies of records management procedures in the medical records or health records office of a facility.

Q: I’m in a private practice. How long do I need to retain my records?

A: The general legal standard for retaining records is 5 years but may vary by state. However, pediatric records must be retained until 7 years after the age of majority (usually age 18, but can vary by state.) States and individual facilities may have more stringent standards for medical record retention, so be sure to check any relevant regulations or policies. The HIPAA privacy regulations require that all medical records, signed consent forms, authorization forms, and other HIPAA-related documentation be retained for a period of 6 years. The Centers for Medicare & Medicaid Services (CMS) requires patient records for Medicare beneficiaries to be retained for a period of 5 years (see 42CFR482.24 (b)). Medicaid requirements vary by state.

Laws regarding record retention are passed by the state legislature as well as the federal government. You can search your state’s website to find applicable laws or your state’s Department of Health website. You can also contact a lawyer knowledgeable about federal and state medical record laws.

In addition, the American Health Information Management Association (AHIMA) has published recommended record retention standards, and created summaries of accreditation agency and federal health record retention requirements.

Occupational Therapy Assistant Issues

Q: I’m an OTA and I want to be sure that I’m practicing ethically within my scope of practice. Can an OTA perform evaluations? Can an OTA perform assessments?

A: Occupational therapy assistants work under the supervision of an occupational therapist. Be sure to check your state regulations for specific language related to the occupational therapy assistant (OTA) scope of practice and supervision requirements. In addition, the AOTA official document, “Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services” provides guidance about appropriate delegation of aspects of evaluation and intervention. As per this document, the occupational therapist directs the initial evaluation process. However, the occupational therapy assistant may, if directed by the occupational therapist, and deemed competent, perform designated assessments to contribute to the evaluation, but may not interpret data. The interpretation of assessment results and the overall evaluation is the responsibility of the occupational therapist. Also, check state law related to language about occupational therapy assistants contributing to an evaluation.

For more information about contributing to the evaluation process, see the advisory opinion “OT/OTA Partnerships: Achieving High Ethical Standards in a Challenging Health Care Environment.”

Q: Can an occupational therapy assistant provide physical agent modalities (PAMs)?

A: As outlined in the AOTA document “Physical Agent Modalities: A Position Paper,” before using and recommending PAMs for clients as a treatment modality, the supervising occupational therapist must meet qualifications and be competent in PAMs prior to delegating any of the modalities. Physical agent modalities include, but are not limited to superficial thermal agents, deep thermal agents, electrotherapeutic agents, and mechanical devices. If state regulations permit, then delegating occupational therapy assistants to use PAMs is permitted. The occupational therapy assistant must also be adequately trained and demonstrate competency to use the recommended modalities. Specific language to support this ethical and professional mandate can be found in the position paper: “When an occupational therapist delegates the use of a PAM to an occupational therapy assistant, both must comply with appropriate supervision and state regulatory requirements and ensure that preparation, application and documentation are based on service competency and institutional rules. Only occupational therapists with service competency in this area may supervise the use of PAMs by occupational therapy assistants. Occupational therapy assistants may gain competency only in those modalities allowed by state and laws and regulations.” (p. 2) Occupational therapy practitioners should keep records of their PAMs training and demonstrated competency.

The Code and Ethics Standards mandates safe and competent practice within the practitioner’s scope of practice (Principle 1E). In addition, the Code and Ethics Standards reinforces that delegated duties must match qualifications and scope of practice and that practitioners must adhere to guidelines and applicable laws related to appropriate supervision.

Q: Can an occupational therapy assistant be clinically supervised by an individual who is not an occupational therapist?

A: No. Occupational therapy assistants must be clinically supervised by an occupational therapist. Occupational therapy assistants, as well as occupational therapists can report administratively to an individual from another profession but cannot be clinically supervised by him or her.

Billing Issues

Q: While working in the office of another discipline (e.g., psychologist, physical therapist), an occupational therapist is providing biofeedback services or other similar nontraditional service. Is it ethical to bill under the license of another professional?

A: No. If the occupational therapist is providing occupational therapy services, (including biofeedback therapy) the order should be written for occupational therapy and the services should be documented and billed as occupational therapy. Individuals also should check the reimbursement guidelines of payers and state regulations regarding scope of practice.

Q: As an occupational therapist, can I provide and bill for physical therapy services while the physical therapist is on vacation?

A: No. Physical, speech, respiratory, and occupational therapies must be provided by individuals who have met specific qualifications by successfully completing their respective academic programs, fieldwork placements, and national certification requirements, and who hold active state licensure (or other required regulation) in their discipline. Professionals are individually licensed, and these licenses are not interchangeable.

Q: My supervisor has been promoted, and I have taken over her caseload. I have discovered that she has been billing for patients that she could not have seen since she was sitting in her office all day. What should I do?

A: Basically, you are asking what to do about fraudulent billing. For a definition of fraud, refer to the Centers for Medicare & Medicaid Services website. You should first speak with the parties involved and get the facts. After doing so, if you still feel that fraudulent billing has occurred, speak confidentially to the compliance officer or designated administrator at your place of work about your concerns and options for action. If you are in a state that requires licensure to practice, be sure to speak to the state regulatory board. If you are unable to resolve the situation in the workplace, it is your duty to contact the appropriate authorities (e.g., CMS, state licensure board)

Additional resources are available in the Fraud and Abuse section of AOTA’s website.

Documentation

Q: I am new to my facility, and I have been asked to re-create notes on a patient I have never seen. This patient was treated by another occupational therapy practitioner who has since resigned. Is this okay?

A: No. You may only document services that you have personally provided or supervised (e.g., an occupational therapist may co-sign notes for an occupational therapy assistant they supervise if required by state law). Your signature on the documentation attests to the accuracy of the information contained in that note. The Code and Ethics Standards contains language for occupational therapy personnel about fabricating or falsifying documentation.

Q: My supervisor has asked me to go back and re-create my notes and records on a patient I saw more than 2 months ago because the facility lost the record. I do not have copies of my notes. Can I do this?

A: The Code and Ethics Standards states that you should not use any form of communication that is false, fraudulent, or deceptive. If you have billing records or notes that explain the dates and times you saw a particular patient, you can write a note stating that information but with the current date and explanation that the original documentation was lost but this note reflects what treatment was rendered based on the records that do exist. If you do not have notes and cannot remember what you did and what type of progress an individual made, then it is unethical to make something up.

Q: When can confidentiality be breached by occupational therapy personnel as part of the provider–patient relationship?

A: The provider–patient relationship entails special obligations to maintain confidentiality. Based on the principles established in the Code and Ethics Standards, confidentiality is a duty of occupational therapy personnel and a right of the patient. Subject to federal mandates (HIPAA) and state laws (practice acts), confidentiality may be breached or overridden when the safety of a patient is at risk or there is an ethical obligation to prevent foreseeable harm to self or others. Other exceptions to confidentiality include mandatory reporting of suspected abuse; information required by law during court proceedings; and documentation of communicable diseases to public health agencies.

Professional Boundaries

Q: When is it okay to date a client? I know it would be a bad idea while I am treating him, but what about after discharge?

A: When deciding whether or not a relationship with a past patient is appropriate, you should review the regulations, if any, put forth by your state regulatory board (SRB). Some states have defined time frames within which relationships with former clients are acceptable; others have declared all such relationships unethical. The Code and Ethics Standards discusses such relationships under Principle 2, Non-Maleficence. When no legal barriers apply, the prudent practitioner weighs the potential harm to the former patient and considers whether a relationship could be established on “equal footing,” considering the prior client–therapist relationship, the vulnerability of clients, and the power differentials that exist between client and therapist. Further guidance on dating and professional boundaries in general can be found in the AOTA Ethics advisory opinion “Professional Boundaries: Where to Draw the Line.”

Online Social Networking

Q: I am a Level II fieldwork student and my classmates and I have a Facebook page that we use to stay in touch and share ideas. Some of my classmates use this Facebook page to complain about their clients, their supervisors, or our university faculty. Is this ethical?

A: Ethical issues related to Facebook postings fall into three categories: confidentiality, privacy, and fidelity, or respect for others. Of utmost importance is keeping clients’ protected health information confidential in accordance with HIPAA (1996) regulations. It is important to remember that the privacy of information posted on the Internet should not be expected and is not guaranteed. This includes descriptions that could be linked to clients, even without posting names. Therefore, individuals must exercise prudence to avoid posting information that is illegal or unethical. Finally, posting negative information about others, with or without their knowledge, is unprofessional and disrespectful, and should be avoided

For additional information, see the advisory opinion “Social Networking.”

Confidentiality and Fieldwork

Q: I am a clinician and fieldwork educator (FWE) and work closely with academic fieldwork coordinators (AFCs) to support Level II fieldwork students who rotate through our facility. The AFC from our local university provides a lot of information about students prior to their starting of clinical rotations at our facility. Sometimes the information almost seems like gossip to me. What are the ethical boundaries for sharing information about fieldwork students?

A: Information about a student should be shared only for the purposes of protecting client, student, and FWE safety, and supporting the student’s successful completion of fieldwork requirements. In addition, those sharing student information need to ensure that the specific information they share is allowable under HIPAA (1996) and FERPA (1974) privacy and confidentiality statutes.

For additional information related to HIPAA and FERPA regulations, see the HIPAA and FERPA websites.

For additional information about ethical issues related to fieldwork education, see the ethics advisory opinion, “Promoting Ethically Sound Practices in Occupational Therapy Fieldwork Education.”

Telehealth

Q: I work at a regional pediatric hospital that serves children who live in rural areas from several states. For many of our clients, traveling to the hospital for therapy appointments is a hardship, resulting in kids missing appointments. Our facility administrators would like us to provide evaluation and intervention services for these kids using real-time telecommunication technology. What ethical issues do I need to address when delivering services this way?

A: First and foremost, you should apply sound clinical reasoning to determine whether providing services using telehealth technology serves the best interest of each individual client (i.e., will the services provided be safe and effective in meeting client goals?). You also need to ensure that measures are taken to protect client privacy and confidentiality during the delivery of services (e.g., ensure that technology is secure). If you are providing services to a client in a different state, you have a duty to adhere to required state licensure regulations in both your home state and in the state where services are delivered (if telehealth services are even permitted). Finally, you need to ensure that documentation accurately represents services provided and that billing for services meets third party payer standards and requirements. For additional information about service delivery using telehealth technology, see AOTA’s position paper Telehealth (2013); and for additional information about ethical issues, see the ethics advisory opinion on “Telehealth.”

Patient Abandonment

Please refer to the advisory opinion on “Patient Abandonment.”

Treating Family Members

Q: My grandmother is a patient in the skilled nursing facility where I work. Can I treat her?

A: No. The existing family relationship may jeopardize objective, professional judgment and bias in making decisions or recommendations. Maintaining professional boundaries separate from personal relationships is an important ethical tenet.

As her therapist, you might have access to information that as a family member you might not otherwise know and because of confidentiality you would be precluded from sharing the information with other family members. But you might feel conflicted if you thought they should know. There is also the possibility that as her therapist, your grandmother might withhold important information that she would normally have shared with a non-relative therapist—but because she wants to protect you she may not be as forthcoming with that information.

For more information about the Ethics Program, contact the American Occupational Therapy Association by telephone at 301-652-6611, x2206 or via email at ethics@aota.org

Copyright© 2014 American Occupational Therapy Association, Inc. All rights reserved. For personal or educational use only. All other uses require permission from AOTA. Contact: copyright@aota.org

 July 2014