SD7 - Study on the Appropriate Level of Regulation for Certified Occupational Therapy Assistants

Executive Summary:
Background for the Study

Senate Joint Resolution 153, patroned by Senator R. Edward Houck and passed by the 2000 Session of the General Assembly, requested the Virginia Department of Health Professions to study the appropriate level of regulation for Certified Occupational Therapy Assistants (COTAs). By virtue of the statutory authority of the Board of Health Professions to advise the Governor, the General Assembly, and the Department Director on matters related to the regulation and level of regulation of health care occupations and professions, the Board will conduct the study and provide recommendations through the Director and Secretary of Health and Human Resources accordingly (see § 54.1-2510 of the Code of Virginia).


The sunrise review methodology detailed in the Board of Health Professions Policies and Procedures for Evaluation of the Need to Regulate Health Occupations and Professions (1998) was employed in this study. Successful application of these methods is rooted in the following:

• The Board's ability to accurately determine the risk of harm to the public posed by the unregulated group.

• Its full understanding of the educational and training requirements for competent practice of the profession or occupation.

• Clear understanding of the level of autonomy of the practitioners of the profession or occupation.

• Comprehension of the actual scope of practice of the profession or occupation.

• An assessment of the economic impact of regulating the profession or occupation based upon economic variables which speak to costs at the level of the individual practitioner.

• An evaluation of the alternatives to state regulation.

The Board undertook the following efforts to address these issues:

• A policy literature review was conducted which relates to trends in the practice of occupational therapy with special emphasis on the oversight, both public and private, of COTAs.

• Current relevant federal and states' laws and regulations were examined.

• Disciplinary information was obtained from states regulating COTAs and from the National Board of Certification in Occupational Therapy, Inc.

• A survey of occupational therapy licensees in Virginia was conducted to obtain information related to supervision of and task delegation to COTAs.

• Available malpractice information was obtained.

• The Board solicited and received public comment in writing and through a public hearing.

Results and Conclusions

Throughout the course of the study, the following issues related to COTA practice were identified:

• There are accredited educational programs that prepare graduates for practice as occupational therapy assistants.

There are two levels of practice that are generally recognized in the field of occupational therapy. Practitioners are designated as either occupational therapists (OTs) or occupational therapy assistants (OTAs) depending on their educational preparation. Occupational therapists enter the field with either a bachelors or an entry-level master's degree from an accredited university. According to the AOTA, there are 131 accredited OT programs nationwide. Occupational therapy assistants enter the field with either an associates degree or certificate from an OTA program. Both OTs and OTAs complete supervised clinical internships during their academic preparation. The majority of OT and OTA graduates elect to take the national examination offered by the National Board of Certification in Occupational Therapy, Inc. so that they can use the recognized credentials OTR (registered occupational therapist) or COTA (certified occupational therapy assistant) respectively.

• Occupational therapist assistants must pass the NBCOT certification examination to use the COTA credential.

In this respect, title protection appears to exist for COTAs through NBCOT certification.

• Based on information from the NBCOT and information from states with regulatory processes in place, there is little evidence that public harm has occurred when OT services are rendered by a COTA.

The following chart contains information about the aggregate number of complaints and disciplinary actions involving occupational therapists and occupational therapy assistants across all responding states in an approximate time period of two years.

Number of States Responding: 28*

Total # of OTs: 32,706

Complaints OTs: 113**

Discipline OT: 23

Total # of OTA: 10,426

Complaints OTA: 40**

Discipline OTA: 9

*Of responding states, 26 regulated both OTs and OTAs and 2 regulated OTs only.
**One state reported a total of 9 complaints for both OT/OTAs without. Since 70% of occupational therapy licensees in that state were OTs, 6 complaints were classified as involving OTs and 3 as OTAs.

These findings indicate that less than one percent of OT and OTA licensees in responding states have had complaints lodged against them. For both OTs and COTAs, less than 25% of the complaints actually resulted in any disciplinary action.

• Supervision processes are addressed in the Virginia regulations governing the practice of occupational therapy. Responses on the survey conducted by the Board suggest that the frequency and nature of supervision for COTAs and occupational therapy aides is consistent with that required in the regulations.

The supervisory responsibilities of the licensed occupational therapist are specified in Board of Medicine regulation § 18 VAC 85-80-110 as follows:

A. An occupational therapist shall be responsible for supervision of occupational therapy personnel who work under his direction.
B. The occupational therapist providing clinical supervision shall meet with the occupational therapy personnel to review and evaluate treatment and progress of he individual patient at least once every fifth treatment session or 21 calendar days, whichever comes first.
C. An occupational therapist shall not provide clinical supervision for more than six occupational therapy personnel.
D. An occupational therapist shall be responsible for the direct treatment actions of persons providing occupational therapy under his clinical supervision.

The COTA provides occupational therapy services to individuals under the supervision of a registered occupational therapist (OTR).

• The NBCOT, Inc. has authority to investigate complaints issued against OTRs and COTA and, if appropriate, to take disciplinary action against the OTRs and/or COTAs certification.

In regard to complaints and felony-related matters, the NBCOT indicated that since 1993 they have received five "complaints" involving OTRs and COTAs. In addition, NBCOT has reviewed six felony related matters pertaining to applicants wishing to sit for the certification examination. The chart on page iv reflects the level of practitioner and nature and disposition of each case.

• The scope of practice of a COTA appears to be broader than that of an occupational therapy aide based on task delegation reported in the survey of occupational therapists practicing in Virginia.

• It has been reported that Trigon has denied payment for occupational therapy services rendered by a COTA due to a lack of state regulatory oversight.

There are conflicting reports regarding denial of payment by Trigon for services provided by COTAs in Virginia. In one section of their policy, Trigon states that "...unlicensed occupational therapy personnel are not covered providers under the terms of our member's contracts." However, in another section of their policy, Trigon lists covered services as those rendered by certain professionals including COTAs. Within the same section, however, the policy states "services provided by unlicensed/non-certified physical medicine personnel are not covered" (Trigon, provider contract effective 12/01/00). During the course of this study, one COTA did report denial of payment for services provided by a COTA in his agency to patients covered by Trigon (B. Litton, personal communication, August 9, 2000).

• Employment of COTAs in non-traditional settings was reported during the public hearing. Although public hearing participants indicated that supervision would still be necessary, it is likely that the COTA would practice with a greater degree of autonomy in non-traditional settings such as adult day care centers and community-based wellness programs. Employment of COTAs in these settings provides cost-savings for the employer and may result in lower consumer cost for services rendered.

Final Recommendation of the Board of Health Professions

In response to Senate Joint Resolution 153, the Board of Health Professions has recommended that no state regulatory oversight is needed for Certified Occupational Therapy Assistants at this time.