NEW JERSEY REGISTER
Adopted New Rules: N.J.A.C. 13:44K-9 and 10
Proposed: July 16, 2001 at 33 N.J.R. 2417(a).
Adopted: July 1, 2002 by Reni Erdos, Director, Division of Consumer Affairs.
Filed: July 12, 2002 as R.2002 d.257, without change.
Authority: N.J.S.A. 45:9-37.51 et seq., specifically 45:9-37.75.
Effective Date: August 5, 2002.
Federal Standards Statement
A Federal standards analysis is not required because the adopted 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.
Full text of the adoption follows:
SUBCHAPTERS 5. THROUGH 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 occupational therapists 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 thebasis 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 the treatment;
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 nothave control over or authority to release client records pursuant to agency policy.