Physical therapists (PTs) often delegate to physical therapy assistants (PTAs) and students, requiring appropriate supervision once a task is assigned. Thanks to a recent change by the Center for Medicare & Medicaid Services (CMS), PTs can now provide general supervision of PTAs in outpatient settings; previously, direct supervision was required.
According to the American Physical Therapy Association (APTA), this change is expected to help broaden access to physical therapy care, particularly in underserved areas, by enabling greater workforce flexibility. However, regardless of the level of oversight, PTs need to follow basic principles of delegation and supervision to reduce the risk of legal action in the event a patient is harmed.
General vs. direct supervision
According to the final rule of the 2025 Medicare Physician Fee Schedule, a PT can engage in general, rather than direct, supervision in the outpatient setting. With general supervision, a PT only needs to be available by telecommunication, as opposed to being physically present and immediately available, as is the case with direct supervision.
The change reflects the fact that, as of December 2024, 44 states permit general supervision of PTAs in all settings, and five states allow it with restrictions: Florida, Georgia, North Dakota, Pennsylvania, and West Virginia.
To ensure they supervise effectively, PTs must first understand how to delegate effectively.
Nature of delegation
A PT can delegate certain tasks or procedures to a PTA but keeps overall responsibility for the patient (sidebar #1). The PT is responsible for supervising the PTA: If a PT fails to provide proper supervision, they can be held liable if patient harm occurs.
What can be delegated depends on the scope of practice for each role. PTs need to know their state’s practice act to ensure they delegate only appropriate activities, and PTAs need to know what types of activities they are permitted to engage in.
According to Medicare policies, PTAs can’t provide evaluative or assessment services; make clinical judgements or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service. PTs should be knowledgeable of commercial insurer contracts as they may have their own supervision requirements, which will affect delegation.
Both the delegator (PT) and the delegatee (PTA) have responsibilities related to delegation.
- The PT is responsible for determining the patient's needs (in terms of complexity and acuity), assessing whether the delegatee is competent for the task, considering the type of setting in which care is provided, complying with federal and state laws/regulations, and communicating instructions clearly. It is important to match the patient's needs with the delegatee’s competence.
- The PTA should only accept tasks that fall within their competence. Other important factors include the accessibility of the PT and their availability in case of emergencies, as well as the complexity of the patient. PTAs also need to notify the delegator promptly if they encounter challenges.
Employers should have policies that guide delegation and reflect legal and regulatory requirements. The policies should include documentation requirements, since complete documentation is vital not only for ensuring quality patient care, but also for providing protection in the event of legal action.
It is also crucial for PTs to understand their responsibilities in supervising PT students (sidebar #2).
Supervising effectively
PTs can take several steps to supervise effectively and avoid related legal risks.
Be aware of state standards. For example, 36 states limit how many people a PT can supervise at a given time (e.g., PTAs, students, therapy aides). Ratios range from 1 PT to 2 PTAs to 1 PT to 4 PTAs.
Develop detailed protocols. The protocols should include when direct and general supervision are appropriate, parameters for when the PT should check in with the PTA, and when the PTA should contact the PT. Regular case reviews are essential for facilitating effective communication.
Protocols must align with Medicare and other regulatory requirements. For example, in rehabilitation settings where a PTA is providing services, a qualified PT must make an on-site visit at least once every 30 days (or more often if required by state or local laws/regulations). Information in protocols should also adhere to APTA requirements (sidebar #3).
Ensure that communication is effective and private. Protected health information should not be shared on non-secure devices.
Provide supervision-related education. PTs need to know how to delegate both directly and remotely, and PTAs need to understand that although they may have more autonomy, they must be vigilant in reaching out to PTs for help as needed.
A valuable tool
Delegation is a valuable tool for PTs in their work, but it must be done appropriately by considering the task at hand, who is permitted to perform the task, and the individual’s qualifications and competencies. When they delegate, PTs should follow principles of supervision, whether that supervision is direct or general.
Thoughtful delegation combined with appropriate supervision will help PTs avoid legal liability that could occur if a patient is harmed.
Cynthia Saver, MS, RN, of CLS Development, is a medical writer in Columbia, Md.
Sidebar #1
Physical therapist responsibilities
The American Physical Therapy Association states that these are the sole responsibility of the PT:
- Interpretation of referrals
- Initial examination and reexamination
- Evaluation, diagnosis, and prognosis
- Development or modification and management of the plan of care, which is based on the initial examination or reexamination and includes the physical therapy goals and outcomes
- Determination of when the expertise and decision-making capability of a PT therapist requires a PT to personally render services, and when it may be appropriate to use a PTA
- Revision of the management plan and plan of care when indicated
- Conclusion of an episode of care
- Responsibility for any “hand-off” communication
- Oversight of all documentation for services rendered to each patient or client
- Consultation
Source: American Physical Therapy Association. Direction and supervision of the physical therapist assistant. 2022.
Sidebar #2
Delegating to physical therapy students
As is the case with PTAs, PTs must consider the student's ability before delegating a task. The American Physical Therapy Association notes the following:
- PT students should only provide services under a PT’s direct supervision.
- PTA students should only provide services under the direct supervision of a PT or a PT and PTA working as a team.
Source: American Physical Therapy Association. Student physical therapist and physical therapist assistant provision of services. 2019.
Sidebar #3
Supervision of physical therapist assistants off-site
The American Physical Therapy Association statement on the direction and supervision of PTAs lists the following requirements related to PT supervision of a PTA off-site:
- A PT must be accessible by telecommunication to the PTA at all times while the PTA is providing service to patients and clients.
- There must be regularly scheduled and documented collaboration with the PTA regarding patients and clients; the frequency of this collaboration is determined by the needs of the patient or client and the needs of the PTA.
In addition, in situations in which a PTA is involved in the care of a patient or client, the statement outlines when a supervisory visit by the PT is to be made (e.g., the PTA requests a reexamination), how often it should be made (at least once a month or more often, when established by the PT, in line with the patient’s needs), and what it should include (e.g., onsite review of the plan of care with appropriate revision or termination).
Source: American Physical Therapy Association. Direction and supervision of the physical therapist assistant. 2022.
References