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Frequently Asked Questions about Ethics

Occupational Therapy Code of Ethics and Ethics Standards (2010) 

Q: When was the Occupational Therapy Code of Ethics (2005) 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 new Code integrates the three previous documents that comprised the Ethics Standards (theOccupational Therapy Code of Ethics (2005)Guidelines to the Occupational Therapy Code of Ethics, and Core Values and Attitudes of Occupational Therapy Practice) into one comprehensive document, now titled the Occupational Therapy Code of Ethics and Ethics Standards (2010) (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 at AOTA’s Web site (www.aota.org) under “Ethics Documents” in the Ethics section of “Practitioners," “Educators/Researchers,” and “Students.” It can also be found in the "About Occupational Therapy" section of AOTA's Web site, which makes it available to nonmembers as well. You can also find it in the Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards, which will be available for purchase in fall 2010. 

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 may be purchased through AOTA, beginning in fall 2010. (See previous question.) 

Q: Does 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 it is intended to guide professional behavior, occupational therapy personnel should be cognizant of how personal interactions and choices may impact the public perception of the profession and occupational therapy clients in all spheres.

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

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

A: AOTA is a voluntary professional membership association. The National Board for Certification in Occupational Therapy, Inc. (NBCOT®) is a separate credentialing agency that provides certification for the occupational therapy profession. It is responsible for the initial certification of 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.

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

Q: What is the process for filing a complaint?

A: The specific process is detailed within Section 2 of theEnforcement 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: Before you address the situation, carefully document what occurred, so that information is available when you proceed. First discuss the situation with the person involved, as soon after the episode as is reasonably possible. Doing this will help you to clarify whether unethical behavior has actually occurred. If your perception appears to be correct, discuss your concerns with the individual and if that is ineffective, proceed with reporting them to the supervisor. Should the supervisor fail to take action, you may wish to contact the compliance officer within your organization. If your colleague broke a law (or violated the professional conduct regulations in the state practice act), also contact the regulatory board for that profession and/or the Centers for Medicare & Medicaid Services hotline at the Office of the Inspector General—OIG depending upon the legal issue involved. If the situation was a breach of ethics without a legal component, you may wish to contact the professional organization for that discipline (see the Web sites of professions with which practitioners frequently interact below). In the case of a school employee, the complaint should go to the teacher, then the principal, and then the director of special education or school superintendent (or equivalent) if the issue is not resolved at the school level.

Principle 7 of the Code and Ethics Standards states that “Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity (Fidelity),” which applies to all situations.

Links to Other Professions’ Web Sites:

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 he or she should subsequently take. The student has a responsibility to utilize internal resources to “…discourage, prevent, expose, and correct breaches of the Code and Ethics Standards…” (Principle 7C), and to employ conflict resolution techniques in doing so (Principle 7G).These techniques should include following departmental and university grievance procedures if the potential offense involves university faculty, and contacting the academic fieldwork coordinator if the potential offense relates to conduct by the clinical instructor in the facility. If these strategies are ineffective and the issue remains unresolved, the student should determine whether the violation falls within the jurisdiction of the Ethics Commission by answering the following questions: Is the person who allegedly acted unethically a member of AOTA? Is the behavior a violation of specific principles/language in the Code and Ethics Standards that can be identified? If the answers to these questions are yes, follow the procedures (Enforcement Procedures) for filing a complaint (Complaint Form) with the Ethics Commission

For additional information, contact ethics@aota.org.

Q: How do I report unethical conduct in my facility?

A: Depending on the nature of the incident and the setting, there are several options for reporting. Unethical conduct by an individual OT or OTA can be reported to:

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

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 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.

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” in the Reference Guide to the Occupational Therapy Code of Ethics and Ethics Standards 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: Contact NBCOT at 301-990-7979 about the policies and procedures related to this issue and the SRB in the state(s) in which you anticipate practicing.

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. The employer usually determines the length of time for records management.

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. Code and Ethics Standards principles to consider: Principles 3H, 5, and 5C.

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. However, pediatric records must be retained until the age of majority plus the statute of limitations. 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 and Medicaid Services (CMS) requires patient records for Medicare beneficiaries to be retained for a period of 5 years (see42CFR482.24 (b)). Medicaid requirements vary by state.

Laws regarding record retention are passed by the state legislature. You can search your state’s Web site to find applicable laws or your state’s Department of Health Web site. You can also contact a lawyer knowledgeable about federal and state medical record laws. Another resource for guidance about record retention may be your state licensure board.

In addition, the American Health Information Management Association (AHIMA) has published recommended retention standards, as well as created summaries of accreditation agency and federal health record retention requirements. This information is available on their Web site.

Skilled-Nursing Facility Refusal of Equipment to Clients 

Q: Can a skilled nursing facility under the prospective payment system refuse to provide needed equipment to a patient?

A: Individuals providing service should get informed consent from the patient to provide the needed service. Businesses have a right to not provide an adaptive device or equipment that is not medically necessary. However, if something is medically necessary, the facility must provide the service. Check with the appropriate state and federal agencies regarding patient rights and facility obligations.Code and Ethics Standards principles to consider: Principles 3A, 4D, 4E, and 5O.

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 provide physical agent modalities (PAMs)? What resources can guide me?

A: OTAs work under the supervision of an OT. Be sure to check your state regulations for specific language related to 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.

In evaluating a client, the OTA may, if permitted by state licensure regulations, perform designated parts of an evaluation as delegated by the supervising OT and based on competency. 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."

In addition, as outlined in the AOTA document “Physical Agent Modalities: A Position Paper,” the OT must be competent in PAMs prior to delegating this modality to an OTA (who has demonstrated competence in PAMs) for intervention with a patient. 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 regulatory requirements and ensure that preparation, application, and documentation are based on service competency. That is, only occupational therapists with service competency in this area may supervise the use of PAMs by occupational therapy assistants (p. 343).

The Occupational Therapy Code of Ethics and Ethics Standards (2010) mandates safe and competent practice within the practitioner’s scope of practice (Principle 1E). In addition, the Code and Ethics Standards reinforce that delegated duties must match qualifications and scope of practice, and that practitioners must adhere to guidelines and applicable laws related to appropriate supervision (Principles 5G and 5H).

Q: I am an occupational therapy assistant, and my supervisor is requiring me to write initial evaluations. Will I get into trouble? Is this legal or ethical?

A: If you are in a state requiring licensure to practice, you should check with your licensure board. AOTA’s Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy and the Standards of Practice for Occupational Therapy also provide guidance. Code and Ethics Standards principles to consider: Principles 1E, 5, 5F, 5G, and 6.

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, the services should be billed as occupational therapy. If the billing takes place under another discipline, it is not a skilled occupational therapy service. Individuals also should check the reimbursement guidelines of payers and state regulations regarding scope of practice. Code and Ethics Standards principles to consider: Principles 5,5O, and 6 B–D.

Q: My supervisor has been promoted, and I have taken over her caseload. I have discovered that she has been billing for patients when she has been 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 Web site. You may first wish to speak with the parties involved and get the facts. After doing so, confidentially speak to someone in authority 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. Code and Ethics Standards principles to consider: 5A, 5D, 6B, and 6D.

Q: As an OT, can I provide and bill for PT services while the PT 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 boards, and who hold valid and active state licensure in their discipline, when required to do so. When certain conditions are met, Medicare and other health care insurers will reimburse for therapy services as long as they are rendered by personnel who are qualified and hold the proper credentials in their discipline. Professionals are individually licensed, and these licenses are not interchangeable. Code and Ethics Standards principles to consider: 1E, 1J, 5E, 5G, 6A, and 6E.

Additional resources are available on the Reimbursement Pages of AOTA’s Website

Documentation

Q: I am new to my facility, and I have been asked to re-create notes on a patient of another occupational therapy practitioner. Is this ok?

A: The Code and Ethics Standards speaks to occupational therapy personnel about fabricating or falsifying documentation. You may only document on services that you have personally provided. Your signature on the documentation attests to the accuracy of the information contained in that note. Code and Ethics Standards principle to consider: 6C.

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. 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. 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. Code and Ethics Standards principle to consider: 6C.<>

Americans with Disabilities Act (ADA) 

Q: I’m an OT educator. Do I have to accept a student with a disability?

A: Section 504 of the Rehabilitation Act of 1973 is designed to eliminate discrimination on the basis of handicap in any program receiving federal financial assistance. For the purposes of the act, institutions of higher education are considered to receive federal financial assistance through student aid.

The act covers physical or mental impairment such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.

At the postsecondary education level, the recipient is required to provide students with appropriate academic adjustments and auxiliary aids and services that are necessary to afford an individual with a disability an equal opportunity to participate in a school’s program. Recipients are not required to make adjustments or provide aids or services that would result in a fundamental alteration of a recipient’s program or impose an undue burden.

The term reasonable is interpreted broadly, and undue burden does not include financial burden. There have been instances where the financial burden of providing accommodations exceeded the tuition income of the program; but it cannot alter the academic program.

During the admissions process the applicant is not required to disclose, nor are schools allowed to ask about, any disability. If the applicant meets the academic and technical standards required for admission or participation in the program, then the assessment of appropriate and reasonable accommodations is made after the applicant becomes a student in the program.

An exception is made if the disability does not meet bona fide occupational qualifications, meaning that the disability would prevent the student from performing the essential functions of the profession.

For more information, see the advisory opinion Ethical Considerations for Professional Education of Students with Disabilities.

Q: Are there any resources about the ADA that I could review to help me ensure that my practice and facility are in compliance?

A: Yes. The Job Accommodation Network is an outstanding resource that not only provides a thorough review of the ADA but also numerous tools about accessibility, FAQs, manuals and guidebooks, a glossary, an accessibility checklist, and other helpful information. Another resource to consider is the AOTA Position PaperOccupational Therapy's Commitment to Nondiscrimination and Inclusion.

Q: I am working with a client who is deaf and uses the services of an American Sign Language interpreter to communicate. The interpreter regularly talks with me about the client during the treatment session when no communication is being shared between me and the client. Is it ethical practice for me to participate in that communication?

A: No. You should immediately bring to the patient’s attention that you would like to know how he or she would like you to proceed regarding communications coming from the interpreter. This will cue the patient that such communications are taking place and allow him or her to correct the situation with the interpreter. The client may choose to permit the extraneous communication, or the client might choose to dismiss the interpreter. The choice about all communication with clients using interpreters lies exclusively with clients.

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 OT personnel and a right of the patient. When making information available to other practitioners involved in the patient’s care, consent for disclosure, although implied, is required from the patient. However, there are situations when maintaining confidentiality may be in conflict with a duty to tell the truth. 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 a third party outside of the provider/patient relationship. Examples of such conflicts may include, but are not limited to, emergency situations involving a patient, including patients with psychiatric illness who exhibit violent tendencies; mandatory reporting of suspected abuse; information required by law during court proceedings; and documentation of communicable diseases to public health agencies.

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

October 2010