NEW JERSEY REGISTER
VOLUME 33, NUMBER 14
MONDAY, JULY 16, 2001
RULE PROPOSAL
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
OCCUPATIONAL THERAPY ADVISORY COUNCIL
BUSINESS PRACTICES; PROFESSIONAL CONDUCT; CLIENT RECORDS

Additions are indicated by <<+ Text +>>; deletions by <<- Text ->>.
Changes in tables are made but not highlighted.

Proposed New Rules: N.J.A.C. 13:44K-9 and 10

Authorized By: Mark S. Herr, Director, Division of Consumer Affairs

Authority: N.J.S.A. 45:9-37.51 et seq., specifically 45:9-37.75.

Proposal Number: PRN 2001-283.

Submit comments by August 15, 2001 to:

Laura Anderson, Executive Director

Occupational Therapy Advisory Council

124 Halsey Street

PO Box 45037

Newark, New Jersey 07101

The agency proposal follows:

Summary

Pursuant to the Occupational Therapy Licensing Act, P.L. 1993, c.85, N.J.S.A. 45:9-37.51 et seq., (the Act), the Director of the Division of Consumer Affairs (the Director), in consultation with the Occupational Therapy Advisory Council (the Council), proposes two new subchapters which delineate a licensee's duties regarding appropriate business practices and the maintenance and release of client records. The Director believes that the proposed new rules are necessary in order to promote the health, welfare and safety of consumers seeking occupational therapy services in New Jersey.

Proposed N.J.A.C. 13:44K-9.1(a) provides that all licensed occupational therapists and occupational therapy assistants must make their licenses available to clients upon request. Licensees may obtain duplicate licenses by paying the fee set forth in N.J.A.C. 13:44K-11. Proposed subsection (b) requires occupational therapists and occupational therapy assistants to display notices, in any office or facility where they provide services, to advise clients that information about fees will be provided to them upon request. Licensees must also display a notice regarding how clients may contact the Council in order to report complaints. In addition, subsection (c) prohibits a licensee from altering or obscuring any information contained on his or her license. The Director proposes this new rule in order to ensure that consumers who wish to receive occupational therapy services are able to verify, in a timely and efficient manner, that the person performing such services is licensed by the Council.

Proposed N.J.A.C. 13:44K-9.2 sets forth the requirements for any financial arrangements to be entered into between licensees and clients and/or third party payors. N.J.A.C. 13:44K-9.2(a) provides that all fees for occupational therapy services must be reasonable, and must be commensurate with the experience of an occupational therapist offering the services. The fees charged by licensees must not be excessive, consistent with the provisions of N.J.A.C. 13:44K-9.4. In addition, subsection (b) requires that prior to beginning occupational therapy treatment, an occupational therapist, or someone designated by the occupational therapist, must explain to the client the financial arrangements for the services that will be provided. An occupational therapist must tell the client what the charges for his or her services will be, or how the charges will be calculated, and whether the licensee will accept installment payments or assignment of benefits from a third party payor. An occupational therapist must also tell the client that insurance coverage may not be available in all circumstances and the financial consequences, if any, of missed appointments with the licensee. In addition, subsection (c) prohibits an occupational therapist from requiring a client or third party payor to pay a fee for preparing insurance claim forms or for occupational therapy services not documented in the client record. Moreover, an occupational therapist may not charge a fee for unkept appointments or collect interest on unpaid accounts, unless the client has been notified in writing of these policies prior to receiving treatment from the licensee. Subsection (d) requires an occupational therapist to maintain a written list of current fees for standard services, which must be provided to clients upon request. The list must include information regarding whether Medicare, Medicaid or other third party payor plans are accepted, whether insurance payments are accepted as payment in full, and whether special fees are available for designated groups, such as senior citizens. Subsections (e) and (f) require an occupational therapist to provide a copy of a written fee schedule to any interested party upon request, and to include on all bills to a client or third party, his or her license number. The Director proposes this new rule in order to ensure that consumers are afforded detailed information regarding the costs associated with obtaining occupational therapy services prior to beginning such treatment. The Director believes that such information is necessary to allow consumers to make an informed choice regarding their occupational therapy treatment options. In addition, the Director believes that the proposed new rule is necessary to provide guidance to licensees concerning the circumstances under which the charging of fees will be deemed inappropriate by the Council.

Proposed N.J.A.C. 13:44K-9.3(a) requires an occupational therapist or an occupational therapy assistant to advise a client, or the client's legal guardian, of the nature and purpose of the occupational therapy services he or she will be providing to the client. The occupational therapist must also advise the client about the limits and obligations associated with such services. The Director believes that the proposed new rule is necessary in order to ensure that clients are made aware of the nature of the services they will be receiving, as well as the parties' obligations regarding such services, prior to beginning treatment. Subsection (b) also prohibits a licensee from providing occupationaltherapy services while under the influence of alcohol or mind altering drugs which adversely impact the delivery of services.

Proposed new rule N.J.A.C. 13:44K-9.4 sets forth the factors that the Council may consider in determining whether a fee charged by a licensee for his or her services is excessive. These factors include the time, effort and skill required to perform the services, the nature and length of the relationship between the licensee and the client, the experience of the licensee and the circumstances under which services are provided and whether the fees are set by an agency for whom the licensee performs the services. An analysis of such factors, the Director believes, will provide the Council with sufficient information to determine whether the fees charged by licensees are reasonable.

Proposed N.J.A.C. 13:44K-9.5 concerns the termination of services. Subsection (a) provides that an occupational therapist must terminate services to a client when the client has achieved the predetermined goals established in the plan of care or when the services no longer meet the client's needs or interests. Subsection (b) requires a licensee who is unable to provide continued services to make all reasonable efforts to assist the client in obtaining services from another licensee, before he or she terminates the client. The Director believes that the proposed new rule is necessary in order to ensure that clients who are terminated by a licensee will, nevertheless, be assisted in obtaining services from other healthcare practitioners.

Proposed new rule N.J.A.C. 13:44K-10.1 sets forth the requirements for the preparation and maintenance of client records. The Director proposes this new rule to delineate for licensees their obligation to maintain accurate and detailed client records. The Director believes that such records are necessary in order to ensure that clients receive appropriate treatment. Subsection (a) requires an occupational therapist, or an occupational therapy assistant acting under the supervision of a licensed occupational therapist, to maintain a permanent record for each client. The record must be contemporaneous with the services provided, regardless of the client's treatment setting. Pursuant to subsection (b), the record must contain the name and license number of the licensee providing the service, and the name and license number of the designated supervisor, if applicable, as well as an indication whether the licensee providing the service is an occupational therapist or occupational therapy assistant. The record must also include: the client's name, address and telephone number; the location and dates of all treatments; findings upon initial evaluation, including the client history and test results; the plan of care created by the licensee, including the type of treatment to be rendered; periodic reassessments of the client's status; information regarding referrals; a discharge summary; and fees charged to and paid by the client, unless a separate financial record is kept by the licensee. The client record must also include progress notes from each day of treatment, which provide a description of the type of treatment provided to the client and notations on the client's status. All progress notes that are created by an occupational therapy assistant, a temporary licensed occupational therapist, a temporary licensed occupational therapy assistant, or an occupational therapy student fulfilling the required fieldwork component of his or her educational training, must be countersigned by the supervising occupational therapist. The Director proposes the requirement of a countersignature in order to ensure that the occupational therapist responsible for the overall treatment of the client is aware, at all times, of the nature of the care being provided to that client. Subsection (c) requires an occupational therapist to periodically review and update the client's plan of care. The permanent client record must be retained for at least seven years from the date of last entry, pursuant to subsection (d). If the client is a minor at the time of the last patient visit, however, the occupational therapist must retain the client record until the minor reaches the age of 25. Pursuant to N.J.A.C. 13:44K-10.1(e), all occupational therapists, or occupational therapy assistants working under the direction of an occupational therapist, must comply with the recordkeeping requirements of the proposed new rule, notwithstanding the recordkeeping requirements of a licensee's employer.

Proposed N.J.A.C. 13:44K-10.2 sets forth the requirements applicable to client records maintained on a computer. The Director proposes these requirements so that client records maintained in this manner are adequately protected against unauthorized access and inappropriate alteration. Subsection (a) requires a licensee who maintains client records solely on a computer to use a write-protected program which contains an internal permanently activated date and time recording for all entries and which automatically prepares a back-up copy of the file. The program must also be designed in such a manner that after the licensee uses his or her confidential personal code, the entry cannot be changed. Subsection (b) requires the licensee to include at least two forms of client identification in the record, such as a name and record number. Subsection (c) requires the licensee to finalize all entries made in the record by means of his or her confidential personal code. Subsection (c) further requires that all notes made in the client record by an occupational therapy assistant, a temporary licensed occupational therapist, a temporary licensed occupational therapy assistant, or an occupational therapy student, must be countersigned by the supervising occupational therapist. Any addenda or corrections to the client record must be made in a separately dated, signed and timed note, pursuant to N.J.A.C. 13:44K-10.2(d).

Proposed N.J.A.C. 13:44K-10.3 concerns the release of client records. Subsection (a) requires an occupational therapist to provide a client with a copy of his or her record within 30 days of a written request by the client, the client's guardian or another person designated by the client or the guardian. N.J.A.C. 13:44K-10.3(b) provides that an occupational therapist may charge a fee for the reproduction of a client record. The fee may be no greater than $1.00 per page, or $100.00 for the entire record, whichever is less. If the client record is less than 10 pages, the licensee may charge up to $10.00 in order to cover postage and the miscellaneous costs associated with retrieval of the record. Pursuant to subsection (c), however, an occupational therapist may provide the client with a summary of the client record, if the summary adequately reflects the history of the occupational therapy services provided to the client. If the licensee provides the client with a summary, the cost of the summary may not exceed $1.00 per page or $100.00, for the entire summary, whichever is less. If the summary is less than 10 pages, the licensee may charge the client up to $10.00 for the compilation of the summary. The Director proposes this new rule in order to ensure clients access to their records, and to provide guidance to licensees concerning under what circumstances they may charge fees for the reproduction of a client record or the compilation of a summary or a report, and how much they may charge for the performance of such services. Subsection (d) provides that an occupational therapist may charge a reasonable fee for the completion of reports other than a record summary. The fee charged for such reports must be consistent with N.J.A.C. 13:44K-9.4, which prohibits excessive fees. In addition, subsection (e) prohibits an occupational therapist from requiring advance payment of such fees when the report is needed to enable a client to receive ongoing care by another practitioner or is needed for use in a judicial proceeding. An occupational therapist, however, may require the advance payment of the fee to release a report he or she prepared for the occupational therapist's ownuse as an expert witness on behalf of the client. Subsection (f) provides that the requirements imposed upon licensees regarding the release of client records does not apply to an occupational therapist who offers services in connection with a medical, health, educational or social agency, when the occupational therapist does not have authority to release such records pursuant to agency policy.

Social Impact

The Director believes that the proposed new rules of subchapters 9 and 10 will have a positive impact upon licensees and consumers who seek occupational therapy services. The proposed new rules will have a positive impact upon consumers to the extent that the rules will help to ensure that occupational therapy clients will be provided with sufficient information regarding the type of services that will be provided, including the obligations of licensees and the limitation of such services, as well as information regarding fees and charges. Such information, the Director believes, will enable consumers to make informed decisions regarding occupational therapy treatment options. The proposed new rules will also have a positive impact upon licensees by clarifying the information which licensees must provide to consumers prior to beginning occupational therapy services, as well as the criteria the Council will use to determine if the fees charged by licensees are reasonable. The proposed new rules will also clarify for both licensees and consumers the circumstances under which client records and/or reports may be released, and what fees, if any, may be charged for their release.

Economic Impact

The Director believes that the proposed new rules may have an economic impact upon licensees and the consumers they serve. Proposed N.J.A.C. 13:44K-9.1 may have an impact upon licensees who provide services in more than one practice location. If each facility in which the licensee practices requires the licensee to permanently post his or her license in that facility, the licensee will be obligated to obtain a duplicate license for each facility in which he or she practices. In order to obtain a duplicate license, a licensee must pay the fee set forth in N.J.A.C. 13:44K-11. Licensees may also incur additional administrative expenses as a result of the proposed new rule because, pursuant to subsection (b), they must obtain and post notices regarding their services and fees.

In addition, proposed new rule N.J.A.C. 13:44K-9.2 may also have an economic impact upon licensees, to the extent that proposed subsection (a) limits the amount that may be charged because the rule requires licensees to charge fees that are both reasonable and commensurate with the status and experience of an occupational therapist offering like services in the same geographic area. Moreover, N.J.A.C. 13:44K-9.2(c) may also have an economic impact upon licensees and consumers because the subsection prohibits a licensee from charging a client or the client's third party payor a fee for preparing insurance claim forms or for occupational therapy services not documented in the client record. Additionally, a licensee may not charge a fee for unkept appointments or collect interest on unpaid accounts, unless the client has been notified in writing of these polices prior to receiving occupational therapy treatment. Subsection (d) of proposed new rule N.J.A.C. 13:44K-9.2 may cause a licensee to incur the economic costs associated with having to produce and maintain a current list of fees for standard services he or she provides. In addition, the proposed new rule at N.J.A.C. 13:44K-9.5 regarding termination of services, may have an economic impact upon licensees, to the extent that licensees must assist clients in obtaining alternate services when the licensee is unable to provide continued professional services.

The rules in proposed subchapter 10 may have an economic impact upon licensees and consumers. Proposed new rule N.J.A.C. 13:44K-10.1, which requires a licensee to keep an accurate and contemporaneous record of services provided to clients, may cause licensees to incur administrative costs associated with creating and maintaining a client record system. Specifically, subsection (d), which requires a licensee to retain client records for at least seven years for adult clients, and until a client who is a minor at the last patient visit reaches the age of 25, may cause licensees to incur costs associated with the proper storage of such records for the required period of time. Moreover, N.J.A.C. 13:44K-10.2, which imposes various requirements upon licensees who maintain a client record solely on a computer, may impose additional costs upon licensees who maintain their records in this manner. Such licensees may be required to upgrade their existing computer programs, or purchase new programs, in order to ensure that their client record system complies with the requirements of the proposed new rule.

N.J.A.C. 13:44K-10.3, concerning release of client records, may also have an impact upon licensees and consumers, to the extent that licensees may charge a fee for the reproduction of a client record, for the compilation of a summary of the client record, or for the creation of a report regarding the client's treatment.

The Director believes that any adverse economic impact to licensees as a result of the proposed new rules is outweighed by the need to promote the health, welfare and safety of consumers in the performance of occupational therapy services.

Federal Standards Statement

A Federal standards analysis is not required because the proposed new rules are governed by N.J.S.A. 45:9-37.51 et seq. and are not subject to any Federal standards or requirements.

Jobs Impact

The Director does not anticipate that the proposed new rules will result in the creation or loss of jobs in the State.

Agriculture Industry Impact

The Director does not believe that the proposed new rules will have any impact on the agriculture industry of the State.

Regulatory Flexibility Analysis

The Regulatory Flexibility Act (the Act), N.J.S.A. 52:14B-16 et seq., requires the Director to give a description of the types and an estimate of the number of small businesses to which the proposed new rules will apply. Approximately 1,450 individuals are expected to initially apply for licensure. If, for the purposes of the Act, the aforementioned individuals are deemed "small businesses" within the meaning of the Act, then the following analysis applies.

The Act requires the Director to set forth the reporting, recordkeeping and other compliance requirements of the proposed new rules, including the kinds of professional services likely to be needed to comply with the requirements. The Act further requires the Director to estimate the initial and annual compliance costs of the proposed new rules, to outline the manner in which it has designed the rules to minimize any adverse economic impact upon small businesses, and to set forth whether the rules establish differing compliance requirements for small businesses.

The proposed new rules do not impose any reporting requirements upon licensees. The proposed new rules, however, do impose various recordkeeping and compliance requirements upon licensees. N.J.A.C. 13:44K-9.1(a) requires all occupational therapists and occupational therapy assistants to make their licenses available to clients upon request. N.J.A.C. 13:44K-9.1(b) requires all licensees to ensure that information regarding the Council, as well as the professional fees that may be charged for a licensee's services, are prominently displayed in the office or facility where the occupational therapy services are provided. In addition, N.J.A.C. 13:44K-9.1(c) prohibits a licensee from altering in any manner the information contained on his or her license.

N.J.A.C. 13:44K-9.2 (a) and (b) require a licensee to establish reasonable fees for the services he or she provides and to explain to a client the financial arrangements surrounding the provision of such services. N.J.A.C. 13:44K-9.2(c) prohibits an occupational therapist from requiring a client or a third party payor to pay a fee for preparing an insurance claim form or for any service not documented in the client's record. Subsection (c) further prohibits a licensee from charging interest on an unpaid account or from collecting a fee for unkept appointments, unless the client was notified, in writing, of such policies before beginning occupational therapy treatment. N.J.A.C. 13:44K- 9.2(d) and (e) require an occupational therapist to maintain a written list of current fees for standard services, which must be provided to clients or other interested persons upon request. The list must include information regarding whether Medicare, Medicaid or other third party payor plans are accepted, and whether insurance payments are accepted as payment in full. The list must also specify whether any special fee categories are available. N.J.A.C. 13:44K- 9.2(f) requires an occupational therapist who is directly billing a client or third party payor for his or her services to include his or her license number on all bills submitted.

N.J.A.C. 13:44K-9.3(a) provides that an occupational therapist or occupational therapy assistant must advise a client, or the client's legal guardian, of the nature of the services to be provided, as well as the limits and obligations associated with such services. N.J.A.C. 13:44K-9.3(b) prohibits an occupational therapist or occupational therapy assistant from providing occupational therapy services while under the influence of alcohol or any mind altering drug that impairs the licensee's ability to provide services. N.J.A.C. 13:44K-9.4 prohibits an occupational therapist from charging excessive fees. N.J.A.C. 13:44k-9.5(a) requires an occupational therapist to terminate services to a client when the client has achieved the predetermined goals established in the client's plan of care, or when the occupational therapy services provided by the licensee no longer meet the client's needs. N.J.A.C. 13:44K-9.5(b) requires an occupational therapist who is unable to provide continued professional services to notify the client of the termination after making a reasonable effort to assist the client in obtaining services from another qualified licensee.

N.J.A.C. 13:44K-10.1 requires an occupational therapist to prepare and maintain a permanent, contemporaneous client record for each client to whom he or she provides services, regardless of the treatment setting. The client record must include: the name, license number and license status of the licensee providing service, and the name of the licensee's supervisor, if applicable; the client name, address and telephone number; the location and dates of all treatments; all findings upon initial evaluation; the plan of care created by the licensee; progress notes from each day of treatment; periodic reassessments of the client's status; information regarding referrals; a discharge summary; and fees charged to and paid by the client, unless a separate financial record is kept by the licensee. All progress notes created by an occupational therapy assistant, a temporary licensed occupational therapist or occupational therapy assistant, or an occupational therapy student fulfilling the required fieldwork component of his or her educational training, must be countersigned by the supervising occupational therapist.

N.J.A.C. 13:44K-10.1(c) requires the occupational therapist to periodically review and update the client's plan of care. N.J.A.C. 13:44K-10.1(d) requires the licensee to retain the client record for at least seven years from the date of last entry. If the client is a minor, the licensee must retain the record until the minor reaches the age of 25. In addition, N.J.A.C. 13:44K- 10.1(e) requires a licensee to comply with the recordkeeping rule notwithstanding his or her employer's individual recordkeeping requirements.

N.J.A.C. 13:44K-10.2(a) requires a licensee who prepares a client record which is maintained solely on a computer to use a "write-protected" program that contains a permanently activated date and time recording for all entries and that automatically prepares a back-up copy of the file. The program must also limit access to the system to those persons with confidential personal codes. Pursuant to N.J.A.C. 13:44K-10.2(b), the licensee must include in the client record at least two forms of identification and must finalize all entries through use of the confidential personal code. N.J.A.C. 13:44K- 10.2(c) provides that all entries into the client record must be finalized by means of the confidential personal code of the person accessing the record. In addition, all notes made in the client record by a licensed occupational therapy assistant, a temporary licensed occupational therapist or occupational therapy assistant, or an occupational therapy student, must be countersigned by the supervising occupational therapist. N.J.A.C. 13:44K-10.2(d) requires an occupational therapist or occupational therapy assistant to document any addenda or corrections to a client's record in a separately dated, signed and timed note.

N.J.A.C. 13:44K-10.3(a) requires an occupational therapist to provide a client with a copy of his or her record of occupational therapy services provided by the licensee, within 30 days of a written request by the client, the client's guardian, or a person designated by the client or guardian. An occupational therapist may not charge a client more than $1.00 per page or $100.00 for the entire client record, whichever is less, pursuant to N.J.A.C. 13:44K-10.3(b). If the record is less than 10 pages, an occupational therapist may charge up to $10.00 to cover postage and miscellaneous costs. N.J.A.C. 13:44K-10.3(c) provides that an occupational therapist may charge a client for a summary of the record. The charge for the summary may, likewise, be no more than $1.00 per page or $100.00, for the entire client record, whichever is less, or may be up to $10.00, if the record is less than 10 pages.

Pursuant to N.J.A.C. 13:44K-10.3(d), an occupational therapist may charge a client a fee for the production of reports, other than a summary of the client record. N.J.A.C. 13:44K-10.3(e), however, prohibits a licensee from requiring advanced payment as a condition for releasing a report when the report is needed to enable the client to receive ongoing care by another practitioner or is needed for use in a judicial proceeding. Lastly, N.J.A.C. 13:44K-10.3(f) provides that an occupational therapist who performs occupational therapy services in connection with a medical, health, educational or social agency, does not have to comply with the provisions of N.J.A.C. 13:44K-10.3, if the occupational therapist does not have authority from the agency to release client records.

No additional professional services will be needed to comply with the proposed new rules. The costs of compliance with the proposed new rules are discussed in the Economic Impact above. The Director believes that the proposed new rules should be uniformly applied to all occupational therapy licensees in order to ensure the public's health, safety and welfare in the provision of occupational therapy services, and, therefore, no differing compliance requirements for any licensees are provided based on the size of the business.

Full text of the proposed new rules follows:

SUBCHAPTERS 5. THROUGH <<-10->><<+8+>>. (RESERVED)

<<+SUBCHAPTER 9. BUSINESS PRACTICES; PROFESSIONAL CONDUCT+>>

<< NJ ADC 13:44K-9.1 >>

<<+13:44K-9.1 Display of notice of licensure; duplicate license; notification of availability of fee information+>>

<<+(a) All licensed occupational therapists and occupational therapy assistants shall make their licenses available to clients upon request. Duplicate licenses may be obtained upon payment of the fees provided in N.J.A.C. 13:44K-11.1(a)10 and 11.+>>

<<+(b) All licensed occupationaltherapists and occupational therapy assistants shall ensure that the following notices are prominently displayed in a public area in any office or facility at which the licensee practices occupational therapy services:+>>

<<+1. "Occupational therapists and occupational therapy assistants are licensed by the Occupational Therapy Advisory Council, an agency of the Division of Consumer Affairs. Any member of the public may notify the Council of any complaint relative to the practice conducted by an occupational therapist or an occupational therapy assistant. The Council address is: Division of Consumer Affairs, Occupational Therapy Advisory Council, PO Box 45037, 124 Halsey Street, Newark, New Jersey 07101."+>>

<<+2. "INFORMATION ON PROFESSIONAL FEES IS AVAILABLE TO YOU UPON REQUEST."+>>

<<+(c) A licensee shall not alter or obscure any information on the biennial license in any manner.+>>

<< NJ ADC 13:44K-9.2 >>

<<+13:44K-9.2 Financial arrangements with clients and third party payors+>>

<<+(a) Fees for occupational therapy services shall be reasonable and commensurate with the status and experience of the occupational therapist offering like services or treatment in the geographic area and shall be consistent with the provisions of N.J.A.C. 13:44K-9.4 prohibiting excessive fees.+>>

<<+(b) Prior to the initiation of occupational therapy services, the occupational therapist or his or her designee shall explain to the client in an understandable manner the financial arrangements for the services that will be provided. The information provided to the client shall include the following:+>>

<<+1. The fee for services or the basis for determining the fee to be charged;+>>

<<+2. Whether the licensee will accept installment payments or assignment of benefits from a third party payor;+>>

<<+3. That insurance coverage may not be available in all circumstances; and+>>

<<+4. The financial consequences, if any, of missed sessions.+>>

<<+(c) An occupational therapist shall not require a client or a third party payor to pay:+>>

<<+1. A fee for preparing an insurance claim form;+>>

<<+2. Interest on an unpaid account unless the client has been notified of this policy, in writing, prior to the initiation of occupational therapy services;+>>

<<+3. A full or partial fee for unkept appointments unless the client has been notified of this policy, in writing, prior to the initiation of occupational therapy services; or+>>

<<+4. A fee for any occupational therapy service not documented in a client record in a manner consistent with N.J.A.C. 13:44K-10.1.+>>

<<+(d) An occupational therapist shall prepare and maintain a written list of current fees for standard services and, upon request, shall provide the list to clients. The list shall include the following information:+>>

<<+1. Whether Medicaid clients are accepted;+>>

<<+2. Whether Medicare clients are accepted;+>>

<<+3. Whether other third party payor plans are accepted;+>>

<<+4. Whether insurance payments (excluding deductible and copay) are accepted as payment in full; and+>>

<<+5. Whether special fee categories are available, such as for senior citizens or for members of designated groups, such as preferred provider plan members.+>>

<<+(e) An occupational therapist shall provide a copy of a written fee schedule to any interested person upon request.+>>

<<+(f) An occupational therapist who is directly billing the client or third party payor for his or her services shall include on all bills submitted to a client or third party payor the occupational therapist's current license number.+>>

<< NJ ADC 13:44K-9.3 >>

<<+13:44K-9.3 Professional interactions with clients+>>

<<+(a) An occupational therapist or occupational therapy assistant shall advise the client or the client's legal guardian, in terms the client or the guardian can understand, of the nature and purpose of the services to be rendered and the limits and obligations associated with such services.+>>

<<+(b) An occupational therapist or occupational therapy assistant shall not provide occupational therapy services while under the influence of alcohol or any mind altering drug that impairs the delivery of services.+>>

<< NJ ADC 13:44K-9.4 >>

<<+13:44K-9.4 Prohibition on excessive fees+>>

<<+(a) An occupational therapist shall not charge an excessive fee for services. Factors which the Council may consider in determining whether a fee is excessive include the following:+>>

<<+1. The time or effort required to perform the services;+>>

<<+2. The skill required to properly perform the services;+>>

<<+3. The nature and length of the professional relationship with the client;+>>

<<+4. The experience, reputation and ability of the licensee performing the services;+>>

<<+5. The nature and circumstances under which services are provided; and+>>

<<+6. Whether the fee is set by a medical, health, educational or social agency.+>>

<< NJ ADC 13:44K-9.5 >>

<<+13:44K-9.5 Termination of services+>>

<<+(a) A licensed occupational therapist shall terminate services to a client when the client has achieved the predetermined goals established in the plan of care or when such services no longer meet the client's needs or interests.+>>

<<+(b) A licensed occupational therapist who is unable to provide continued professional services to a client shall terminate such services to the client and shall promptly notify the client of the termination only after making reasonable efforts to assist the client in obtaining such services from another licensee qualified to meet the needs or interests of the client.+>>

<<+SUBCHAPTER 10. CLIENT RECORDS+>>

<< NJ ADC 13:44K-10.1 >>

<<+13:44K-10.1 Preparation and maintenance of client records+>>

<<+(a) An occupational therapist, or a licensed occupational therapy assistant acting under the supervision of a licensed occupational therapist, shall prepare and maintain for each client a contemporaneous, permanent client record that accurately reflects the client's contact with the occupational therapist or the occupational therapy assistant, whether in an office, hospital or other treatment, evaluation or consultative setting.+>>

<<+(b) An occupational therapist, or an occupational therapy assistant, acting under the supervision of an occupational therapist, shall include at least the following information in the client record:+>>

<<+1. The full name, as it appears on the license, of the licensee who rendered care, identification of licensure status as either an occupational therapist or occupational therapy assistant, license number and designated supervisor, if applicable. This information shall be legible and shall appear at least once on each page of the client record;+>>

<<+2. The client's name, address and telephone number. The client's name shall appear on each page of the record;+>>

<<+3. The location and dates of all treatments, evaluations or consultations;+>>

<<+4. Findings upon initial evaluation, including the client's relevant history and results of appropriate tests and examinations conducted;+>>

<<+5. A plan of care establishing measurable goals of the treatment program, including the type of treatment to be rendered and the frequency and expected duration of thetreatment;+>>

<<+6. Progress notes for each day of treatment. Progress notes shall include, at a minimum, the date the client received treatment, a description of the treatment rendered, the name of the licensee or other person rendering treatment, and notations of the client's status regardless of whether significant changes have occurred since the last date of treatment.+>>

<<+i. An occupational therapist may dictate progress or session notes for later transcription provided the transcription is dated and identified as preliminary pending the occupational therapist's final review and approval; and+>>

<<+ii. All progress notes that are created by a licensed occupational therapy assistant, temporary licensed occupational therapist, temporary licensed occupational therapy assistant or an occupational therapy student fulfilling the required fieldwork component of his or her educational training, consistent with the provisions of N.J.A.C. 13:44K-5.3, shall be countersigned by the supervising occupational therapist, notwithstanding the delegation of supervision responsibilities to a licensed occupational therapy assistant pursuant to N.J.A.C. 13:44K-6.4;+>>

<<+7. Periodic reassessment of the client's status consistent with the goals set forth in the treatment plan;+>>

<<+8. Information regarding referrals to other professionals and any reports and records provided by other professionals;+>>

<<+9. A discharge summary which includes the reason for discharge from and outcome of occupational therapy services relevant to established goals at the time of discharge; and+>>

<<+10. Fees charged by the occupational therapist and paid by the client, unless a separate financial record is kept.+>>

<<+(c) A licensed occupational therapist shall periodically review and update the client's plan of care.+>>

<<+(d) The permanent client record of occupational therapy services shall be retained for at least seven years from the date of the last entry, unless otherwise provided by law, or in the case of a client who is a minor at the time of the last date of treatment, the licensee shall retain the record until the minor reaches the age of 25.+>>

<<+(e) A licensed occupational therapist, or a licensed occupational therapy assistant acting under the direction of a licensed occupational therapist, shall comply with the provisions of this section notwithstanding an employer's recordkeeping requirements.+>>

<< NJ ADC 13:44K-10.2 >>

<<+13:44K-10.2 Use of computer to prepare client records+>>

<<+(a) A licensee who prepares a client record maintained solely on a personal or other computer shall use a write-protected program which:+>>

<<+1. Contains an internal permanently activated date and time recordation for all entries;+>>

<<+2. Automatically prepares a back-up copy of the file; and+>>

<<+3. Is designed in such manner that, after the occupational therapist or occupational therapy assistant "signs" by means of a confidential personal code ("CPC"), the entry cannot be changed in any manner.+>>

<<+(b) An occupational therapist or occupational therapy assistant shall include in the client record at least two forms of identification; for example, name and record number or any other specific identifying information.+>>

<<+(c) An occupational therapist or occupational therapy assistant shall finalize or "sign" the entry by means of a CPC. Where more than one individual is authorized to make entries into the computer file of any client record, the occupational therapist or occupational therapy assistant responsible for the practice shall assure that each such person obtains a CPC and uses the program in the same manner. All notes made in the client record by a licensed occupational therapy assistant, temporary licensed occupational therapist, temporary licensed occupational therapy assistant or an occupational therapy student fulfilling the required fieldwork component of his or her educational training, shall be countersigned by the supervising occupational therapist pursuant to N.J.A.C. 13:44K-10.1, notwithstanding the delegation of supervision responsibilities to a licensed occupational therapy assistant pursuant to N.J.A.C. 13:44K-6.4.+>>

<<+(d) An occupational therapist or occupational therapy assistant shall document any addenda or corrections to a client's record in a separately dated, signed and timed note.+>>

<< NJ ADC 13:44K-10.3 >>

<<+13:44K-10.3 Release of client records+>>

<<+(a) An occupational therapist shall provide one copy of the client record of the occupational therapy services provided by the licensee within 30 days of a written request by the client, the client's guardian or any other party designated by the client or the client's guardian.+>>

<<+(b) An occupational therapist may charge a fee for the reproduction of the client record. Such fee shall be no greater than $1.00 per page or $100.00 for the entire record, whichever is less. If the record request is less than 10 pages, the occupational therapist may charge up to $10.00 to cover postage and the miscellaneous costs associated with retrieval of the record.+>>

<<+(c) An occupational therapist may provide a summary of the client record, unless otherwise required by law, provided that the summary adequately reflects the history of the occupational therapy services provided to the client. If a summary is provided, the charge for the summary shall not exceed $1.00 per page or $100.00, whichever is less. If the summary provided is less than 10 pages, the occupational therapist may charge up to $10.00 to cover postage and the miscellaneous costs associated with producing the summary.+>>

<<+(d) An occupational therapist may charge a reasonable fee, consistent with the provisions of N.J.A.C. 13:44K-9.4, for the completion of reports, other than the summary provided for in (c) above, when a separate request for such reports is made.+>>

<<+(e) When a report is needed to enable a client to receive ongoing care by another practitioner or for use in judicial proceedings, an occupational therapist shall not require advance payment as a condition for releasing the report, except that an occupational therapist may require advance payment for release of a report prepared by the occupational therapist for use by the occupational therapist as an expert witness on behalf of the client.+>>

<<+(f) The provisions of this section shall not apply to an occupational therapist who provides or offers occupational therapy services in connection with a medical, health, educational or social agency when the occupational therapist does not have control over or authority to release client records pursuant to agency policy.+>>


Consumer Affairs Home Page

Rule Proposals

Occupational Therapy Advisory Council

Medical and Mental Health Related Professional Boards

Department of Law and Public Safety's Home Page | State of New Jersey's Home Page

Feedback

___________________________________________

Posted July 16, 2001