Physical Therapy Board Complaint Case Study: Unprofessional Conduct

Background

This case study involves a licensed physical therapist (PT) who served as both the owner and an employee of her physical therapy private practice. She had been in practice for over twenty years and owned the practice for the last ten years. She reported strong professional relationships with staff, clients, and referring providers. Over the past ten years, the PT acquired a valuable referral source among local specialty orthopedic surgeons due to her training and experience.

Following a complaint made to the State Board of Physical Therapy (SBPT) related to billing and documentation practices, a Board-appointed PT expert consultant (consultant) conducted an on-site visit at the insured’s practice. During the visit, the consultant observed the PT and two physical therapy aides actively working with patients in the gym area, with multiple patients receiving treatment simultaneously. Interviews with the PT and aides were conducted after they completed patient care; however, patients continued their exercises and new patients arrived during the PT interview.

The consultant also observed that both aides were providing treatments to different patients at the same time. For example, one aide assisted a patient who was performing resistance band exercises while, at the same time, the other aide guarded a different patient during tandem walking. The owner was the only PT on the premises at the time of the site visit.

When the PT was interviewed about her use of aides and the documentation of their competencies, she stated that the aides did not independently perform treatments on patients. She reported that the training/competency records were maintained in a binder in her office; however, she was unable to locate the binder or access any training records at the time of the site visit. 

The consultant also observed that the PT was not wearing a name badge. When asked about the name badge, the PT stated that it was not her typical practice to wear one as she felt it could injure a patient. The consultant noted that the PT’s license was displayed behind the registration desk, but it was not visible to patients as it was blocked from view by a poster and bookshelf.

The consultant reviewed five patient medical records during the visit. None of the records documented who  provided the patient treatment, what treatments were administered, patients’ response to the treatment or outcomes. When asked about the lack of documentation, the PT stated that because she was the sole PT and the owner of the practice, she knew who provided the treatment and did not feel it was necessary to fully document  that information. 
 

Board Notice, Accusations and Disciplinary Considerations

One month later, the PT received a letter from the SBPT outlining their accusations against the PT and her practice. The allegations of  unprofessional conduct included:

• The failure to maintain adequate and accurate medical records relating to the provision of services to  patients.
• The failure to evaluate competencies of physical therapy aides.
• The failure to produce competency records of physical therapy aides.
• The failure to adequately supervise physical therapy aides and to allow them to act outside of their scope of practice.
• The failure to wear a name badge and to properly display her PT license.

While the complaint began as an issue with billing and documentation practices, the SBPT also identified that the PT had a history of recurring violations. There were two prior and separate disciplinary actions brought against her in 2009 and 2015, both of which the Board had considered resolved.  
In 2015, the SBPT fined the PT $300 due to the following violations found during a visit:

• The failure of an employed aide to wear a name badge.
• The failure to evaluate/document each aide’s competency and make those records available.     

In 2009, the SBPT publicly reproved the PT‘s license, required her to complete and pass a written examination on the laws and regulations governing the practice of physical therapy, and ordered her to reimburse the SBPT for prosecutorial costs. The violations at that time included:

• The failure to properly supervise and/or ensure proper supervision of all physical therapy services provided by physical therapy assistants (PTAs) and PT aides.
• The failure to conduct regularly scheduled and documented case conferences between the supervising PT and the PTAs and PT aides rendering physical therapy services.

Due to the prior violations and what the SBPT deemed as a blatant disregard for patient safety, the SBPT issued a decision to revoke and/or suspend the PT’s license and ordered her to reimburse all costs related to the investigation incurred by the SBPT. The costs claimed by the SBPT were in excess of $40,000.

 

Resolution

The PT, through legal representation, was able to negotiate a reduced disciplinary action. Without the assistance of qualified legal representation, negotiating the SBPT to a lesser disciplinary action would likely not have occurred. Following  negotiations, the SBPT issued the following final disciplinary actions:

• License probation for three years.
• Responsibility for payment of all fines imposed by the SBPT, reimbursement of the SBPT’s investigative costs, fees related to probation monitoring program and costs associated with the required examination. Total fines and recovery costs totaling over $30,000 were required to be paid in full 180 days prior to completion of probation.
• Requirement to attend regular interviews with the SBPT.
• Mandatory compliance with probation monitoring program.
• Prohibition from working for a temporary service agency during the probationary period.
• Prohibition from supervising physical therapy students, interns or foreign educated physical therapist license applicants while on probation.
• Prohibition from supervising PTAs and physical therapy aides until one full year of probation compliance had been completed.
• Requirement to successfully pass the SBPT’s written examination on the state laws and regulations governing PT practice within 90 days of signed agreement.    

 This matter was resolved with an incurred amount of more than $7,500 in legal defense expenses.
 

Risk Management Recommendations

• Know and understand the scope of practice for your profession and/or licensure in your state and understand the standard of care to which you will be held. Not only is it the responsibility of the physical therapist to know and understand the regulations governing the practice of physical therapy in each state where they practice, but also the policies and protocols of their organization.
• Ensure that clinical practices comply with the standards promulgated by physical therapy professional associations, state practice acts and facility protocols.
• Understand the importance of complete, appropriate, timely, legible and accurate documentation regardless of  whether records are in the electronic or handwritten form. Remember that the electronic health record (EHR) provides a date and time stamp for each entry, providing a clear documentation trail. At a minimum, records should include:
  • Date, time and signature for each entry
  • Findings of initial and ongoing patient assessments
  • Patient response to therapy
  • Discussions regarding diagnosis, treatment options, and expected outcomes with the patient, family and healthcare team members
  • Patient education and discharge instructions, including assessment of the patient’s ability to demonstrate self-care and to repeat instructions 
• Ensure that patient billing reflects the services provided and is in accordance with the physical therapy professional associations, state practice acts and facility protocols.
• Delegate patient therapy services only to the appropriate level of staff and provide appropriate supervision for all delegated patient services.
  • Unless allowed by the regulations governing the practice of physical therapy, a physical therapist should not leave the therapy area when the patient is receiving services from lower levels of staff.
  • Periodically assess the staff member’s technique and the patient’s response to the delegated service throughout the session, and document supervisory findings.
• Acknowledge that physical therapy supervisors provide guidance to and monitor the performance of physical therapy staff. This ensures physical therapy staff follow regulatory compliance requirements and meet the standard of care.
• Ensure that all physical therapy aides, applicants, students and interns performing patient related tasks under the supervision of licensed PTs display their name and working title on a name tag in at least 18-point font while working.
  • If a physical therapist or physical therapist assistant in a practice or an office does not wish to wear a name badge, their license must be prominently displayed in that practice/office.
• Retain copies of clinical competencies, staff education and current licenses in an area that is secure and readily accessible.
• Maintain compliance with all agreed upon SBPT disciplinary actions. If ongoing compliance becomes difficult or burdensome, contact an attorney experienced with SBPT defense for assistance.

 
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