State Board of Physical Therapy (SBPT) complaints may be filed against a physical therapist (PT) by a patient, colleague, employer, and/or other regulatory agency, such as the State Department of Health. Complaints are subsequently investigated by the SBPT to ensure that licensed PTs are practicing safely, professionally, and ethically. SBPT investigations may lead to outcomes ranging from no action against the PT to revocation of the PT’s license to practice. This license protection case study, presented by HPSO, involves a licensed PT who worked at and partly owned a physical therapy clinic which employed other PTs, Physical Therapy Assistants (PTAs), Licensed Massage Therapists and Acupuncturists.
Summary
The insured physical therapist (PT) was the clinical director and part owner of a physical therapy clinic for approximately eight years at the time of the incident. The clinic advertised that, along with physical therapy services, a patient could schedule massage therapy or acupuncture sessions as part of the physical therapy plan of care.
The patient was a 66-year-old male who was referred for physical therapy following a motor vehicle accident. At the first visit, the patient was initially greeted at the clinic by the PT who then introduced the patient to the PTA and advised that the “PTA would conduct the initial evaluation and take good care of you.” Although the PT mentioned he would check back with the patient, he did not.
During the initial evaluation, the patient described for the PTA the issues they were having after the accident which included low back pain, neck pain, and stiffness. The patient said they felt as if their joints would “lock up” and wanted to address not only the conditions from the accident but also wanted to have better mobility in their neck and better posture.
After discussing the patient’s conditions with the PT, the PTA was told to perform high-velocity low-amplitude (HVLA) manipulation to help with the patient’s stiff joints and increase the patient’s range of motion in the neck. The PT delegated this treatment to the PTA but never examined the patient. The PT also recommended dry needling or acupuncture as part of the treatment plan and delegated this treatment to the employed acupuncturist. The patient asked to speak with the PT about dry needling and acupuncture because they had never had this type of treatment. The PT wasn’t available for not only this session but several other subsequent sessions where the patient had questions. The patient felt the PT never seemed available.
The PTA’s documentation of the initial session and subsequent sessions was described in just a few words, such as ‘treatment provided’, ‘initial evaluation’, or ‘administered therapy to trapezius.’ These notes lacked required details including technique, intensity, duration, and repetitions of the treatment performed. The PT signed off on the PTA’s documentation including the initial evaluation, treatment plan developed by the PTA, and subsequent treatment sessions. Some notes were signed by the PT up to seven weeks after the treatment sessions.
On the day of the incident, the patient was returning after a one-month lapse in treatment due to a fall. During this session, the patient reported to the PTA that he had an increase in pain. The PTA documented that “Patient had a significant change in status from ED visit.” However, the PT did not re-evaluate the patient. The patient asked to speak to the PT but was told that the PT was at an offsite meeting and that the patient could call the PT later when they returned to the clinic. Because it had been a month since their last visit, the patient asked if they could speak to anyone else in charge at the clinic, but there wasn’t another provider onsite that day. The patient did not feel that they had access to the appropriate staff and filed a complaint with the SBPT, which opened an investigation into the clinic and the PT’s conduct.
The Board’s Investigation
The SBPT identified multiple concerning issues. Firstly, it was found that the clinic was delegating care to PTAs, including work that was required to be done by PTs, such as initial patient evaluations, re-evaluations on later visits, and development of treatment plans. Treatment was also delegated to massage therapists and acupuncturists. The Board opined PTs generally cannot delegate acupuncture to an acupuncturist.
Upon seeing a lack of detail in the documented notes from this patient’s sessions, the Board requested that all patient documentation within the past year be sent to them for their investigation. The Board’s investigation revealed that patient notes were co-signed by the director or another PT, even if they had never examined or treated the patient. The Board noted over 75 instances of such conduct across at least 12 patients. In over 40 patient healthcare information records,, the notes seemed to have been written up to six weeks after the treatment was performed. The Board also found that, in many instances, notes were copied verbatim from previous sessions, even with gaps in treatment sessions, like the patient who suffered the fall. Most of the patient notes were completed by a PTA, and later co-signed by the director or another PT.
According to SBPT interviews with the PT, he first explained to the Board that he thought delegation and the multi-disciplinary process he supervised was an acceptable practice. When the Board questioned him about the specific circumstances of his delegation, he admitted that he did not evaluate whether or not the staff member was competent to perform the activity safely and effectively, per accepted guidelines. The PT admitted that he allowed staff to treat areas of the body that had not been examined or re-examined, in some cases, by a physical therapist. Additionally, the PT admitted that on some occasions he failed to provide on-site supervision to staff.
Resolution
The State Board found that the insured PT had:
- Engaged in the performance of substandard care due to negligence or failure to act, regardless of any injury to a patient or lack thereof. Specifically, failing to conduct initial evaluations of patients and any re-evaluations necessary due to a patient’s change in condition or time away from treatment sessions.
- Failed to supervise PTAs as required.
- Failed to maintain adequate patient records.
- Advertised and provided treatment unwarranted by the condition of the patient.
- Delegated tasks to personnel outside of the scope of practice for a physical therapist.
The Board ordered the PT to surrender his license, and he was blocked from reapplying for licensure for three years. The PT was also required to pay a civil penalty of $10,000. The total cost incurred to defend this matter was $25,000.
(Note: Monetary amounts represent solely the legal defense expenses paid on behalf of the insured PT.)
The SBPT opined that proper documentation ensures that a patient’s healthcare information records fully and accurately detail the patient’s treatment history, indicate what interventions have been and have not been effective, allow future physical therapists and other health care professionals to know the type and extent of treatments that have been attempted, and allow insurance companies or other third-party payers to reimburse for treatment as necessary. Documentation is not only a requirement of the profession but also should be done in an objective, timely, accurate, complete, and appropriate manner.
Risk Control Recommendations for Physical Therapists
Know and understand your state’s scope of practice. Only perform interventions and make clinical decisions that are within your legal and professional boundaries. Never delegate tasks that are reserved exclusively for physical therapists, such as evaluation, diagnosis, prognosis, and plan of care development.
Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, and appropriate manner. Documentation should support the treatment plan and satisfy board regulatory and third-party billing requirements. When more than one requirement applies, adhere to the most stringent policy. An accurate, complete, and comprehensive patient record of care is the primary tool for tracking the patient’s clinical history and evaluating the quality and effectiveness of care It is also the first line of defense against allegations of negligence.
Comply with legal, regulatory, and facility policies when documenting late entries. Indicating the entry as “Late” or “Addendum” helps differentiate it from contemporaneous documentation. Reference the date and time of the original event being documented. Explain the Reason for the late entry, briefly state why the entry is being made after the fact, and do not alter or backdate the original record. Sign (and, if required, electronically authenticate) the late entry as you would any other clinical note, including your credentials.
Know your employer’s policies and procedures related to clinical practices and delegation. To ensure that assistive personnel do not attempt to provide clinical care outside their competency or beyond regulatory limits, providers and practices alike should adhere to and have policies and procedures on delegation, including:
- Prior to delegating tasks, be aware of the knowledge and skills, training, and experience of the individual to whom you are delegating elements of care. Use good clinical judgement, which includes the complexity of the patient as well as the availability and competence of the delegatee prior to delegating patient care.
- Adhere to state practice acts regarding limits of delegation.
- Monitor the implementation of the delegated task as well as the performance of the delegatee to the overall patient plan of care, including patient responses to their care, and provide feedback for improvement, if needed.
- Conduct routine observations and audits of delegated tasks.
- Remember: The supervising physical therapist remains ultimately responsible and accountable for the patient's care.
To strengthen the defense of the delegation process, healthcare information records should contain a description of the nature of the assigned task, objective patient assessment findings, observations by assigned personnel, and progress notes by the delegator, along with co-signatures where required, indicating that the delegatee was closely supervised and the process as a whole is coordinated.
References
- American Physical Therapy Association (APTA). 2020. Code of Ethics for the Physical Therapist. https://www.apta.org/apta-and-you/leadership-and-governance/policies/code-of-ethics-for-the-physical-therapist
- American Physical Therapy Association (APTA). 2020. Standards of Ethical Conduct for the Physical Therapist Assistant. https://www.apta.org/apta-and-you/leadership-and-governance/policies/standards-of-ethical-conduct-for-the-physical-therapist-assistant
- American Physical Therapy Association (APTA). 2017. Physical Therapist's Scope of Practice. https://www.apta.org/apta-and-you/leadership-and-governance/policies/position-scope-of-practice
- American Physical Therapy Association (APTA). 2022. Supervision and Teamwork. https://www.apta.org/your-practice/supervision-teamwork
- CNA. 2025. Delegation: A Brief Guide to Safely Transferring Healthcare Tasks. https://www.cna.com/sites/default/files/assets/182be6e2-8562-4894-b0bd-111084197b6e/rc-cna-inbrief-2025-delegation-brief-guide-safely-transferring-healthcare-tasks.pdf?fid
- American Physical Therapy Association (APTA). 2018. Interventions Performed Exclusively By Physical Therapists. https://www.apta.org/apta-and-you/leadership-and-governance/policies/interventions-performed-exclusively-by-physical-therapists
- American Physical Therapy Association (APTA). 2022. Direction And Supervision Of The Physical Therapist Assistant. https://www.apta.org/apta-and-you/leadership-and-governance/policies/direction-supervision-pta
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2025 CNA. All rights reserved.
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