(a) Medical Conditions.

(1) Occupational therapists may evaluate the client to determine the need for occupational therapy services without a referral. However, a referral must be requested at any time during the evaluation process when necessary to ensure the safety and welfare of the client.

(2) Intervention for a medical condition by an occupational therapy practitioner requires a referral from a licensed referral source.

(b) Non-Medical Conditions. The evaluation or intervention for a non-medical condition does not require a referral. However, a referral must be requested at any time during the evaluation or intervention process when necessary to ensure the safety and welfare of the client.

(c) Methods of Referral. The referral must be from a licensed referral source in accordance with the Occupational Therapy Practice Act §454.213 (relating to Accepted Practice; Practitioner's Referral) and may be transmitted in the following ways:

(1) by a written document, including paper or electronic information/communications technologies;

(2) verbally, either in person or by electronic information/communications technologies. If a referral is transmitted verbally, it must be documented by the authorized personnel who receives the referral. In this subsection, "authorized personnel" means staff members authorized by the employer or occupational therapist to receive referrals transmitted verbally; or

(3) by an occupational therapy plan of care, developed according to the requirements of this section, that is signed by the licensed referral source.

(d) Screening, Consultation, and Monitored Services. A screening, consultation, or monitored services may be performed by an occupational therapy practitioner without a referral.

(e) Evaluation.

(1) The occupational therapist is responsible for determining whether an evaluation is needed and if a referral is required for an occupational therapy evaluation.

(2) Only an occupational therapist may perform an initial evaluation or any re-evaluations.

(3) An occupational therapy plan of care must be based on an occupational therapy evaluation.

(4) The occupational therapist is responsible for determining whether any aspect of the evaluation may be conducted via telehealth or must be conducted in person.

(5) The occupational therapist must have contact with the client during the evaluation. The contact must be synchronous audio and synchronous visual contact that is in person, via telehealth, or via a combination of in-person contact and telehealth. Other telecommunications or information technology may be used to aid in the evaluation but may not be the primary means of contact or communication.

(6) The occupational therapist may delegate to an occupational therapy assistant the collection of data for the evaluation. The occupational therapist is responsible for the accuracy of the data collected by the occupational therapy assistant.

(f) Plan of Care.

(1) Only an occupational therapist may initiate, develop, modify, or complete an occupational therapy plan of care. It is a violation of the Occupational Therapy Practice Act for anyone other than the occupational therapist to dictate, or attempt to dictate, when occupational therapy services should or should not be provided, the nature and frequency of services that are provided, when the client should be discharged, or any other aspect of the provision of occupational therapy as set out in the Occupational Therapy Practice Act and Rules.

(2) Modifications to the plan of care must be documented.

(3) An occupational therapy plan of care may be integrated into an interdisciplinary plan of care, but the occupational therapy goals or objectives must be easily identifiable in the plan of care.

(4) Only occupational therapy practitioners may implement the written plan of care once it is completed by the occupational therapist.

(5) Only the occupational therapy practitioner may train non-licensed personnel or family members to carry out specific tasks that support the occupational therapy plan of care.

(6) The occupational therapist is responsible for determining whether intervention is needed and if a referral is required for occupational therapy intervention.

(7) Except where otherwise restricted by rule, the occupational therapy practitioner is responsible for determining whether any aspect of the intervention session may be conducted via telehealth or must be conducted in person.

(8) The occupational therapy practitioner must have contact with the client during the intervention session. (A) The contact must be either: (i) synchronous audio and synchronous visual contact that is in person, via telehealth, or via a combination of in-person contact and telehealth; or (ii) synchronous audio contact, provided that the occupational therapy practitioner makes use of store-and-forward technology in preparation for or during the intervention session. The synchronous audio contact may be in person and/or via telehealth. In this subsection, "store-and-forward technology" means technology that stores and transmits or grants access to a client's clinical information for review by an occupational therapy practitioner at a different physical location than the client. (B) Other telecommunications or information technology may be used to aid in the intervention session but may not be the primary means of contact or communication.

(9) Except where otherwise restricted by rule, the supervising occupational therapist may only delegate to an occupational therapy assistant tasks that they both agree are within the competency level of that occupational therapy assistant.

(g) Documentation.

(1) The client's records include the medical referral, if required; the initial evaluation; the plan of care, including the goals and any updates or change of the goals; the documentation of each intervention session by the OT or OTA providing the service; progress notes and any re-evaluations, if required; any patient related documents; and the discharge or discontinuation of occupational therapy services documentation.

(2) The licensee providing occupational therapy services must document for each intervention session. The documentation must accurately reflect the intervention, decline of intervention, and modalities provided.

(3) In each intervention note, the occupational therapy assistant must include the name of an occupational therapist who is readily available to answer questions about the client's intervention at the time of the provision of services. The occupational therapist in the intervention note may be different from the occupational therapist who wrote the plan of care. The occupational therapy assistant may not provide services unless this requirement is met.

(h) Discharge or Discontinuation of Occupational Therapy Services.

(1) Only an occupational therapist has the authority to discharge clients from occupational therapy services. The discharge or discontinuation of occupational therapy services is based on whether the client has achieved predetermined goals, has achieved maximum benefit from occupational therapy services, or when other circumstances warrant discontinuation of occupational therapy services.

(2) The occupational therapist must review any information from the occupational therapy assistant(s), determine if goals were met or not, complete and sign the discharge or discontinuation of occupational therapy services documentation, and/or make recommendations for any further needs of the client in another continuum of care.

Source Note: The provisions of this §372.1 adopted to be effective October 11, 1994, 19 TexReg 7717; amended to be effective August 31, 1995, 20 TexReg 6337; amended to be effective May 8, 1996, 21 TexReg 3716; amended to be effective November 4, 1997, 22 TexReg 10752; amended to be effective October 25, 1998, 23 TexReg 10912; amended to be effective August 21, 2000, 25 TexReg 8063; amended to be effective July 22, 2001, 26 TexReg 5442; amended to be effective July 22, 2002, 27 TexReg 6546; amended to be effective February 27, 2005, 30 TexReg 910; amended to be effective December 4, 2005, 30 TexReg 7892; amended to be effective February 25, 2008, 33 TexReg 1604;amended to be effective September 7, 2009, 34 TexReg 6124; amended to be effective January 9, 2012, 37 TexReg 69; amended to be effective October 6, 2013, 38 TexReg 6931; amended to be effective July 1, 2016, 41 TexReg 4050; amended to be effective March 1, 2017, 42 TexReg 696; amended to be effective March 1, 2018, 43 TexReg 902; amended to be effective June 1, 2019, 44 TexReg 2465; amended to be effective June 1, 2022, 47 TexReg 3064