Supervision 101: Important considerations for supervisors and supervisees

AOTA receives many questions from occupational therapy practitioners (OTPs), students, and other health care providers about supervision in the context of occupational therapy service delivery. If you are currently providing supervision (a supervisor) or receiving supervision (a supervisee) or thinking about either, there are many considerations and requirements to be aware of.

Supervision, Generally

Supervision is a collaborative process between the supervisor and the supervisee and ensures “the safe and effective delivery of occupational therapy services and [fosters] professional competence and professional development” (American Occupational Therapy Association [AOTA], 2020, p. 1).

Supervision should be tailored to account for various factors such as the practice setting, needs of the clients, or supervisor or supervisee experience and training, but also state licensing agency requirements and individual facility requirements. Additionally, health insurers may have their own supervision requirements that must be followed, in addition to state-level policies. For instance, under Medicare Part B, the supervising therapist must directly treat clients seen primarily by assistants at least every 10 visits and write a supervisory note regarding the client’s progress (Centers for Medicare & Medicaid Services [CMS], n.d.; Karr, 2024.). Supervisors and supervisees take on the responsibility of becoming familiar with all applicable standards when they enter a supervisory relationship.

It is also worth noting that there is a difference between clinical supervision and administrative supervision (AOTA, 2023). Clinical supervision is required to be provided to certain trained participants as part of the occupational therapy service delivery process. Administrative supervision involves tasks such as addressing staffing issues, ensuring facility compliance, or caseload assignment. It is provided outside the service delivery process and may involve health care providers other than OTPs.

Occupational Therapy Assistant (OTA) Supervision

OTAs are regulated by state licensing agencies, so supervisors and supervisees need to follow applicable requirements in statute and regulation. Failure to follow these requirements could result in disciplinary action from your state’s occupational therapy licensing agency.

Many states provide flexibility to tailor supervision based on various factors as recommended in AOTA’s (2020) Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services. Some states might not allow an occupational therapist (OT) to supervise until they have been licensed for a certain amount of time or might require OTAs new to practice to be more closely supervised than those with more experience.

It is incumbent upon an OT to determine whether they are qualified to provide supervision, and the OT is ultimately responsible for the services being provided by their supervisees. If an OT is unable to provide the required supervision, even if temporarily, they need to notify their supervisees so an alternate supervisor can be found, and so the OTA can continue providing services. For example, Texas regulation requires such a notification within at least 14 days of the supervisor’s separation from employment.

It is important to remember an OTA’s role is to contribute to, but not direct the evaluation process. The OTA executes the treatment plan developed in collaboration with the OT based on client goals, clinical knowledge, and experience. The OTA provides services delegated to them by the OT and in which they have shown service competency.

OTAs can provide supervision to OT personnel, but this depends upon the OTA’s demonstrated service competency, state requirements, and facility requirements.

Supervision of Temporary License/Limited Permit Holders

A holder of a temporary license or limited permit is, in most of the states that offer such a credential, a recent graduate who is providing occupational therapy services under supervision of a full licensee while waiting to hear if they passed the national certification exam administered by the National Board for Certification in Occupational Therapy (NBCOT^®). Like OTs and OTAs, they are regulated by their state licensing entity and so must comply with the applicable requirements in state law or regulation.

In some states, the holder might be restricted from providing certain interventions the state licensing agency has determined require more experience or training beyond what is required for a license.

Student Supervision

Students of OT and OTA academic programs can provide occupational therapy services to clients to complete their fieldwork or capstone requirements, but they are not required to be licensed or credentialed to do so. Student supervisors should consult their state’s occupational therapy practice act and regulations to ensure they’re following student supervision standards. Payers may also have additional policies that must be adhered to regarding the level of supervision required during client interventions.

Supervision standards for students can be found in the Accreditation Council for Occupational Therapy Education (ACOTE®) standards for academic programs and students should adhere to the requirements of their academic program. For example, Level II fieldwork supervision is required to be direct and then to decrease based on the practice setting, the condition of clients, and “the ability of the student to support progression toward entry-level competence” (ACOTE, 2023, p. 41).

OT Aide Supervision

Occupational therapy aides provide supportive, unskilled services to OTPs (AOTA, 2020). Like students, they are not licensed by the state occupational therapy licensing agency. A supervisor may delegate certain tasks to aides based on specific factors, such as whether the outcome is predictable, whether the client’s condition is stable, and the aide’s demonstrated service competency (AOTA, 2020). As previously stated, supervisors should check if their state’s practice act and regulations impose specific requirements on aide supervision.

Other Considerations

Supervision Ratios

Some states impose a numerical limit on the number of supervisees to which a supervisor may provide supervision. In Utah, for example, an OT can supervise no more than two full-time OTAs at a time or four part-time OTAs for certain circumstances. There is no recognized magic number for the maximum number of supervisees that can be supervised. However, it is ultimately the responsibility of the OT to ensure that all supervisees in their charge are receiving the supervision they require, and that all clients on their supervisees’ caseload are receiving high-quality services.

Documentation

Supervision documentation requirements also vary. For example, California allows for various methods of documenting supervision, including documenting client care or co-signing the OTA’s documentation; whereas New York requires a formal supervision plan that includes specific information, although there has been a general movement away from practices determined to be labor intensive, such as maintaining supervision logs. A state licensing agency may provide a suggested supervision form or contract that must be completed by all parties and returned to the agency to document compliance. If state law or regulation does not specify a required method for documenting supervision, a facility or employer may establish their own.

Supervision Methods

Telehealth is considered a “model of health care delivery” rather than a method of treatment (AOTA, 2018, p. 1). With the proliferation of telehealth platforms, many states allow for virtual supervision of OTAs or temporary permit holders, provided the communication is live and in real-time, but others might require face-to-face interactions where both parties are physically together. An OTA can provide services to a client without their OT supervisor being physically present, but only if the OTA has demonstrated that they are competent to do so. Other types of supervision methods include observation, co-treatment, discussions, and teaching (AOTA, 2020).

The supervision process may prompt questions, but if approached with your clients’ and colleagues’ best interests in mind, it can be educational and rewarding and ensure that everyone involved becomes a better OTP.

References

Accreditation Council for Occupational Therapy Education. (2023). 2023 Accreditation Council for Occupational Therapy Education (ACOTE^®) Standards and Interpretive Guide. https://acoteonline.org/accreditation-explained/standards/

American Occupational Therapy Association. (2018). Telehealth in occupational therapy. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410059. https://doi.org/10.5014/ajot.2018.72S219

American Occupational Therapy Association. (2020). Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410020. https://doi.org/10.5014/ajot.2020.74S3004

American Occupational Therapy Association. (2023). AOTA ethics advisory opinion: Supervision and collaboration between occupational therapists and occupational therapy assistants. https://www.aota.org/practice/practice-essentials/ethics

Centers for Medicare & Medicaid Services. (n.d.). Covered medical and other health services (chapter 15). In Medicare Benefit Policy Manual, pp. 100–102). https://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/bp102c15.pdf

Karr, K. (2024, November 11). Finalized 2025 Medicare Physician Fee Schedule impact on OT. https://www.aota.org/advocacy/advocacy-news/2024/finalized-2025-medicare-physician-fee-schedule-impact-on-ot.

Kristen Neville is AOTA’s Manager, State Affairs.