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Practice FAQ

Service Delivery

   Scroll down for the following FAQ subjects (in order):
  • Make-up sessions for holidays celebrated on Monday.
  • Are outside agencies, such as home health, allowed to provide their services within the school setting?
  • Should an OTR/COTA provide oral-motor feeding therapy in the school setting?
  • Reasonable caseloads for therapists in the school system.
  • Documentation of progress by OTAs or PTAs on 9-week progress reports.
  • What does “integrated services” mean?
  • Clarify school-based v. medical model.
  • Can we count motor lab time as part of direct services time for our students? 
  • Should we give teachers and administrators weighted vests and other sensory items for students who are not receiving OT services?  
  • Can OT be provided to a student who only has an SI disability designation?
  • Can an OT provide services without a medical prescription or referral?
  • Help on explaining the integrated model of service to teachers.
  • What is best practice for Data Collection in school setting?
  • How long are medical referrals for related service, including PT and OT, good?
  • Can adaptive chairs be used with students for reasons other than to improve positioning?
  • How do I handle physician orders for stretching and range of motion?
  • Which OT services are considered "Medically Necessary" for SHARS billing?

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If students are seen on a regular basis (for example every Monday), do we have to provide make-up sessions for Labor Day Monday or if it falls on a Professional Development/ Student holiday? 

 

Your obligation to serve the student takes priority. For example, Mondays are often holidays, so students scheduled by the therapist on Monday will miss visits that would not be missed if they were scheduled another day.

It is your obligation to make sure the services documented in the IEP are provided, so you will need to see the student on another day of the week when that occurs.  
 
For more about when missed visits must be made up, read our featured article, "It's About Time."
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Are outside agencies, such as home health, allowed to provide their services within the school setting? Does it depend on if the student is receiving school-based therapy services or not?

 
Most school districts have board policy that addresses this issue, and it typically prohibits this sort of thing from happening. Rationale for the prohibition includes 1) the interference created with instruction that is critical to the teaching and learning process, and 2) insurance prohibitions due to liability concerns. Neither of these rationale are impacted by whether the student is receiving any school-based therapy services or not. Another issue that arises when outside services are allowed into the school is the confusion that may ensue among campus personnel, e.g., if outsideres are coming in, does that mean that the school isn't providing enough or the right therapy? 
 
I strongly suggest that you investigate with your administrators what your district's board policy is on this issue. If they do not have a policy, they may want to consult with their general counsel and consider putting one in place. 
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Should an OTR/COTA provide feeding therapy (oral-motor therapy for swallowing/chewing) in the school setting?


If the IEP team feels feeding is an issue that needs to be addressed in order for the student to benefit from his/her special education, then it should be addressed. Who provides the intervention depends on who has the required skills and expertise. Because that is not something typically included in preservice education for either speech-language pathologists or occupational therapists, it depends on who has received training via professional development. If neither provider on the campus has the training, one of them should seek the required knowledge and expertise by reading up on the topic and attending in-services, conference sessions or webcasts on the subject.

It is important to be certain the presentation(s) you attend are evidence-based. Oral-motor techniques, while popular over the years with some pediatric clinicians, have limited support for improving feeding outcomes in professional literature. Take the time to do a literature search so you know which feeding strategies are most likely to get the result you seek.
 
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I am seeking support regarding guidelines for reasonable caseloads for therapists in our school system. I know the AOTA has papers regarding shift from caseload to workload and ASHA has calculations to help determine realistic work/caseloads, but we therapists need some guidance in how to determine a caseload limit in order to help educate our administration.
 
As attractive as the concept is, there is no existing formula or mathematical calculation that can identify what "reasonable" is or should be. There are just too many variables to consider. My agency provides therapy to 20-25 school districts, special education cooperatives and charter schools annually, and every district has a different array of services they want their therapists to provide. Some want therapist time spent only on IEP services to special education students, some involve their therapists in their early intervening/RtI activities and some want their therapists tracking materials and/or equipment inventories. Some districts don’t want their therapists in staffings and IEP meetings; others want them at EVERY staffing and IEP meeting. One district in our area requires a full evaluation before a student can be discharged, while others do not. Each constellation of activities is unique to the ISD culture and preferences of the administrative leadership.
 
What might be most helpful is for 1) for you and your colleagues to do a time study to determine how each of you are currently spending your time (a week or two of data is important), and 2) for your administrative leadership to determine what are the priority activities for therapists in your district. The time study can be very helpful in showing what can and cannot be done in the time available. That, along with the priorities set, can provide insight into what level of staffing is necessary to accomplish district priorities.
 
A few other things to consider:
-- the extent to which services are integrated into natural environments and daily
routines
-- whether students with disabilities are primarily served in general education or self-contained classrooms
-- cultural patterns of time, frequency and duration for students with IEP services
-- the workload capacity of each therapist involved (for one, 40 kiddos with IEPs is too much – for another it may not be enough to keep them busy)
 
Ours is not a "cookbook" practice and there are no linear solutions that will fit all situations. Together with your administration, take a comprehensive look at all these variables and the answer will become clear to you all.  
 
Resources that may be helpful:
 
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Our OTA's write daily notes each time they see a student. Question: Progress reports are due each 9 weeks; how should our progress on our goals be documented? 1. Do they need to say per .... OT in the 9 weeks progress report card even though this is not a daily note? 2. Do the OTA and OT need to sit down and write the 9 weeks progress report together and have both sign their name? 3 Can this communication of progress be completed without face to face contact, e. g., OTA writes note/OTR reviews? 
 
First of all, the issues you are referring to are about compliance with laws and regulations under IDEA and state policies for special education, rather than adherence to specific TBOTE or TBPTE Rules. Having said that, there are some things worth considering from our licensure.
 
First, let’s clarify terms. For the purpose of this FAQ, let’s use the term "session note" to indicate notes written about an individual intervention session provided to a student. Let’s use the term "progress report" to indicate the report of progress toward IEP goals that is due to the parent/guardian at the same interval as school report cards. Let’s also make this applicable to PTAs, as the issue is the same.
 
Now, let’s look at each of your questions separately:
 
1) Educational progress reports at grading periods for students with an IEP are to reflect the student’s progress on their goals and objectives, much like a report card does for students who do not have an IEP. It is not a report of a specific visit or "session" of OT or PT intervention. If the OT or PT is a collaborator with school personnel on goals, it is typical for the teacher to write the progress report (the OT or PT should know what is being said and be in agreement with it). If the goals are only "OT goals" or "PT goals" (not best practice, by the way), the OT or PT will be responsible for sending the educational progress report home. If the OTA or PTA is writing the progress report, the supervising therapist should have reviewed it to ensure he/she agrees with what is being reported. However, since it is not a session note, an educational progress report is not required to say "per ____" or "supervised by ______," as is required by TBOTE and TBPTE for session notes written by OTAs and PTAs.
 
2) Although sitting down together is ideal, it is also fine for the OTA to draft the progress report and then have the OT review it and suggest edits, additions, etc. It is not necessary for both to sign, but it is not a bad idea (it indicates both have contributed to the content and are jointly reporting).
 
3) Yes. It could be done via Email, over the phone, etc. If I were the OT in this case I would make a note of what I approved and when.
 
Just remember that as the supervising OT or PT, you are ultimately responsible for all aspects of service delivery, including documentation of student progress. 

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What do OT and PT mean when they write "Integrated" services?
 
"Integrated services" is a term that describes both direct and indirect services that are embedded in natural environments during daily routines (where and when the participation or performance issue occurs). This approach is based on evidence reflected in the literature from the various related services disciplines that stresses the importance of 1) working in context, and 2) applying interventions in the environment where the problem occurs and to the actual activity/task in question. An integrated approach doesn’t assume the barrier to success is in the child with the disability, but acknowledges that the problem is just as likely to be due to factors in the environment and/or activity design.
 
TEA presented the terms direct and indirect in their 2009 related services FAQ. They were not meant to be mutually exclusive, and are both legitimate ways of providing intervention in support of an IEP. However, that was not said expressly in the document and many folks think you have to decide between them. Complicating the picture are the IEP management software companies -- they took a linear design approach in their software such that their drop down menus tend to require a forced choice (direct OR indirect). This has led folks to believe services must be indicated in the IEP as either one way or another. In actual fact, best practices for OT and PT include provision of both approaches, that is, an "integrated" approach where services are provided in the context of the natural environment during daily routines.
 
One last issue that muddies the waters is Medicaid. Some districts only want their providers to specify direct services in the IEP time so that it will all be reimbursable by SHARS. However, they need to remember that indirect services are a critical component to positive student outcomes and need to be included in students’ IEP time.
 
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Can you please clarify school-based v. medical model?

As regards explanations of educational need v. medical necessity, there are many resources that can be found on the internet. With just a quick search using Google.com, for example, I found these documents on the topic:   ​

Although TxSpot doesn’t endorse any particular description, you should be able to get what you need from these efforts or similar ones available at other state or local school websites. 

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Our therapists have posed the question of counting motor lab time as part of direct services time for our students.  Do you have any guidance on this topic?


Motor lab time is only appropriate to count toward the time specified in the IEP if the activities are designed to provide the intervention needed to support progress toward IEP goals/objectives. In other words, it is fine to address student IEP goals in group activities, including motor lab, but it is not fine to do a motor lab unrelated to the goals/objectives OT or PT is supposed to support and call it “ARDed time.” Keep in mind that TEA wants to be certain parents and school personnel know how services will be provided, so be sure to explain to all (and document in the IEP minutes) the various ways services will be provided (e.g., “OT will spend time working with the student during snack time, will work with the student in group activities, and will work with the teacher to plan and implement accommodations in the classroom to promote participation.").

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Teachers and administrators are asking for weighted vests and other sensory items for students that are not receiving OT services. They want to take responsibility for the items. Should I give them these supplies?  

Texas OT Rule Chapter 374.4 Code of Ethics includes principles of Beneficence and Nonmaleficence that apply. Adherence to these principles ensures the safety and well-being of the recipients of our services. Under these principles, it would be unethical for you to issue therapeutic equipment for student use unless you are officially involved in the student’s IEP or 504 plan, e.g., unless you have formally evaluated the student, recommended the use of the equipment to support goals/objectives of the IEP or 504 Plan, are documenting progress, and are providing training/overseeing/monitoring the use of the equipment at school.
 
Of course school personnel have access to all kinds of things through the internet and catalogue sales. We cannot control what they order for their classroom or for that matter what a parent sends to school with a student. If you become aware of unsupervised therapeutic equipment in use, it would be a good idea to visit with campus personnel to make sure they are aware of any risks/precautions associated with the equipment and to provide them with resources they could access regarding appropriate use of the equipment.  
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I have a question about OT supporting speech only students in the schools. Can OT be provided to a student who only has an SI disability designation? What would this look like written as a collaborative objective between Speech and OT?
 
During a not-too-distant period in our state’s history, it was the perception/belief of educators in some settings that young children with "speech only" disabilities were entitled to speech therapy services, but did not require access to the full scope of special education and related services. We now know this perception/belief is incorrect.
 
When a student is identified as having a speech impairment, rules for evaluation and development of the IEP are the same as for any of the other disability category under IDEA and the Texas Special Education Rules and Regulations. If the student is suspected of needing a related service such as occupational therapy an evaluation must be conducted and a decision made by the IEP team as to whether there is an educational need for services.
 
If the IEP team determines OT services are needed, the IEP team must develop goals/objectives, or add OT to existing goals/objectives, as appropriate. In all cases, best practice is for team collaboration, such that the student’s goals/objectives would be supported by speech, OT and instruction or any combination appropriate to that student.
 
In cases where the issues are pre-writing or written expression (depending on the student), development of a communication goal/objective(s) can work well, with speech taking the lead on verbal expression and OT taking the lead on written expression components. Otherwise, as with all students in need of special education and related services, goals/objectives must be developed to target desired outcomes for the student for the next 12 months.
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Can an OT provide services without a medical prescription or referral?
 
In accordance with Occupational Therapy Rule 372.1 (a) Provision of Services from the Texas Board of Occupational Therapy Examiners (TBOTE), an OT may evaluate to determine the need for services without a referral. However, intervention for a student with a medical condition (as defined in TBOTE Rule 362.1 (24)) requires a referral from a licensed referral source. If you look at Rule 372.1 (b) you will see that students with nonmedical conditions do not require a referral (again, see definition in 362.1(27).
 
However, in school settings, we are also governed by provisions in IDEA and the Texas Education Code. School districts and charter schools must provide notice to parents and seek consent prior to initiating an evaluation (see IDEA regulations 300.300 and 300.304). Do not initiate an evaluation or reevaluation until these provisions have been satisfied and/or your school district directs you to go ahead with your evaluation.
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I am in the process of assisting a school district that I recently contracted to, in transitioning to a integrated IEP approach for OT, whereas OT will not have separate goals. We are receiving lots of resistance as the teachers do not understand why OT will no longer be pulling the students out to work on handwriting. They don't see how working with the child in class and providing recommendations as needed is direct service. Need help on explaining this model of OT service to the teachers.
 
I can certainly appreciate your challenge. Change is a very stressful process for most, and it takes time. What has been effective for me is to provide training to all involved – therapists, diagnosticians, speech paths, school leadership, teachers, and parents. Use the evidence as your platform – because we have a mandate from IDEA and ESEA (NCLB) for practices based on scientific research, we must be knowledgeable of what is published and employ it in practice. Evidence tells us of the importance of context – both in terms of understanding the facilitators and barriers to learning and participation, and in the provision of strategies to overcome the barriers. If our services at school target remediation/treatment of aspects of impairment alone in an effort to close some developmental delay, etc., we are unlikely to help performance and participation in the classroom. In meeting a standard of educational need, our evaluations, interventions and support need to be in natural environments during daily routines.
 
You will find resources to support your assertions in the International Classification of Function and the World Health Organization model for persons with disabilities that emphasize that what is disabling is just as likely to be in the environment or activity/task design as a result of the person’s disability. You will also find resources in AOTA publications and evidence- based resource online, in the Journal of Occupational Therapy, Early Intervention and Schools, and in speech therapy, counseling and education literature as well. You are also welcome to use any of the questions and answers in our FAQ section on the TxSpot site that might apply.
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I am currently involved in a challenging IEP/ARD process with a child with AU and a parent who is challenging every aspect of the previous and currently proposed IEP. The parent continues to demand all "OT Data collection" which should reflect all interventions including sensory therapy/strategies provided to the student. What is the best practice for OT Data Collection in school setting? Currently we use daily contact notes or soap notes.
 
Although progress notes each time you have seen a student remain a professional standard, the collection of quantitative data to 1) determine the effectiveness of interventions and/or 2) track student progress on IEP goals and objectives has become important in all school districts. Here are some typical practices to include in your progress monitoring that appear in professional literature or are recommended by the legal community: 
  • Collaborate with the campus team in the development of measurable goals and objectives that will indicate progress toward the behaviors desired from the student in the time period specified. Determine a means for quantifying what you will measure (frequency, number, etc.) and under what conditions. 
  • Identify intervals for measurement (daily, weekly, every 2 weeks . . . ) and which team members will collect the data
  • Develop a means for documenting the data collected (graph, spreadsheet, matrix or the like)
  • To ensure fidelity of data collection (consistency across team members), write down and distribute to all involved a procedure that outlines the data collection process.
  • Collect baseline data
  • Adhere to interval schedule for data collection
  • Schedule a period for data analysis (every 8 weeks, for example)
  • Make needed changes in interventions in response to analysis
Remember, there are two areas where data-collection should be occurring. One is focused on the effectiveness of the specific strategies/techniques various providers have introduced, and the other is focused more globally on the student’s progress toward the goal. 　
　
Because so many of the students served for OT and PT are (or may become) Medicaid eligible under the School Health and Related Services (SHARS) program, it has also become customary in most districts to adhere to Medicaid’s requirements for anecdotal progress notes when direct services are provided, including start and end times of the visit, a notation of which IEP goal/objective(s) were addressed, the activities the student engaged in, and the student’s response to the activity.
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I have been told physician referrals for related service including, PT and OT are good for 3 years, and from other sources, I have heard 1 year, as for homebound teachers. Can someone please clarify this issue? 
 

According to the PT practice FAQ in the TBPTE section on the ECPTOTE website, there is no specified amount of time that a physician referral is good for unless stated by the physician on the referral.  Here are the answers to two questions from the PT Practice FAQ that may help:

When does a referral expire?  The Board does not set a time limit on referrals for initial treatment.  If you are concerned for any reason about how long it has been since the referral was made, you should consult with the referring practitioner before beginning treatment. There are time limits and requirements for treating patients who have had a prior referral for the same condition. See the Board rules, §322.1(a)

Is there a limit on how long a referral is valid? There is NO specific length of time a referral is valid or good; the Board leaves it to the professional judgment of the PT to determine whether the referral is valid. If you have doubts, you should contact the referral source, as the Board has no rules addressing this question. 

According to OT licensure rules, you need a physician referral to treat patients who have a medical condition.  Here is the answer to a question from the OT Practice FAQ in the TBOTE section on the ECPTOTE website that may help: Do I need a referral for school practice?

The TBOTE Rules do not require a referral for OT for non-medical conditions. Based on the definition in the Rules, this would include ADHD. Other examples of non-medical conditions would be cerebral palsy, learning disabilities, autism, and spina bifida. This is not an exhaustive list, and in all cases the presumption is that the child with the disability is otherwise healthy. In each of these cases, the disability is static, not acute or progressive. Many folks take medication to help manage symptoms (antihistamines, decongestants, seizure meds, stimulants for ADHD etc.). It is important to know if the child is taking a medication so precautions can be adhered to, but just the fact that someone takes medication does not require the OT to get a referral.

Examples of medical conditions that would require a referral would be for a student with cancer, rheumatoid arthritis, muscular dystrophy (might not be needed during times of stability, but would be needed during times where the student is clearly degenerating and functional or medical status is changing), or when a child with CP has a rhizotomy or gets a baclofen pump. The flu or another virus is not cause for a medical referral, but significant change in medical status or functional condition would be. At some facilities, a medical referral is requested on an annual basis, but the Rules do not specify a frequency.

That being said, I have found that it is typical for therapists working in school districts to obtain a new referral for students (at least for those for whom our licensure rules require it) each school year.  In my opinion, it is a good idea to obtain a new physician referral each year as children change and grow over time and regular communication with their physician will help the therapist stay abreast of any new medical information that may be needed in order to provide the best care for the student.  

If your question has more to do with SHARS Medicaid billing, here is the SHARS rule for services provided by OT or PT:  “The expiration date for the physician prescription is the earlier of either the physician’s designated expiration date on the prescription or three years, in accordance with the IDEA three-year re-evaluation requirement.” See the SHARS handbook for further information:

School Health and Related Services Provider's Handbook

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Can adaptive chairs be used with students for reasons other than to improve positioning? Our department is getting asked to recommend using adaptive chairs for students with autism, hyperactivity, etc. to assist with visual attention and focus. Can we recommend? Do we need a seating schedule? What schedule do you recommend? Also, where can we find more concrete written information on this issue to share with other school staff?

Typically, occupational therapists and physical therapists in school practice recommend seating for students who have neurological or musculoskeletal conditions that result in their needing additional physical support to assume and maintain a position conducive to learning in the classroom.  While some students with autism or ADHD may benefit from additional supports to help them remain seated and focus, utilizing supports such as trays or straps that restrict a child’s movement in this way would be considered mechanical restraint.  If you are recommending equipment for this purpose, be sure to follow your district’s guidelines for the use of mechanical restraints.  Additionally, you will want to ensure that the student’s IEP reflects the need for the equipment and how it will be used as well as a behavior plan designed to decrease the student’s need for mechanical restraints over time.

Here is a link to information provided by one equipment company that provides information related to this topic:

 
 
The parent of one of the students assigned to me has brought physician orders regarding stretching and range of motion (ROM) for the student. How do I handle this request at school?
 
As a matter of legality, the ARD/IEP team is not automatically required to follow the doctor's orders, however the committee IS required to consider whether there is an educational need to include stretching and ROM in the student's IEP, reflecting on how limitations in flexibility and/or ROM may or may not affect the student during school routines.
 
First, review with committee members the role of occupational therapy and/or physical therapy as related services supporting the student's special education in the school setting. Then, help facilitate a discussion about how the student is participating in various curriculum activities, as well as how he/she is managing self-help (ADL) activities and social activities at school. Data from instruction, therapy and other team members will help inform the discussion. Including the student in the discussion is ideal, allowing the team to understand his/her perception and how he/she is overcoming any barriers due to flexibility and/or ROM issues.
 
The discussion will yield whether there is a need to address stretching and ROM during the school day, and will identify which activities may need accommodation so that full participation is possible in the meantime. The therapist can collaborate to develop strategies for embedding activities for stretching and ROM when in PE or adapted PE, when on the playground, or during the daily routine.
 
 
 In reviewing the Electronic Signature Certification statement for SHARS billing, the OTs are questioning which of our services are considered "medically necessary" and how this is determined. Is handwriting or other classroom-based fine motor tasks ever considered "medically necessary?"  
The Texas Medicaid and Healthcare Partnership (TMHP) describes medically necessary occupational therapy services as goal-directed activities performed by an Occupational Therapist to evaluate, prevent, or correct physical dysfunction or to maximize function (perform the tasks of living) in a person’s life. Medicaid or SHARS billing is intended to provide reimbursement to school districts for “the skilled treatment of clients whose ability to function in life roles is impaired.” It is no different from a child who goes to outpatient occupational therapy for fine motor or handwriting concerns and whose services are covered by insurance.
 
According to the Texas Education Agency (TEA) and the Health and Human Services Commission (HHSC), documentation of medical necessity includes information about a person’s diagnoses and disability. Generally speaking, medical necessity can be thought of as a need that requires the skill of an Occupational (or Physical) Therapist. So, services to a person who has a disability AND has needs that require the skill of an occupational therapist would be considered medically necessary. So, to answer your question, any services provided directly by the Occupational Therapist to a student who has a disability to assist him/her to perform the tasks of living would be medically necessary.
 
Please refer also to the links below for this and other information about SHARS/Medicaid billing. Hope this helps!
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