This federal regulation (F826) requires that specialized rehabilitative services in nursing facilities—including physical, occupational, respiratory, and speech-language therapy—be provided under a physician's written order and delivered by appropriately licensed or certified personnel. Facilities must employ or contract qualified therapists and support staff whose competencies align with residents' assessed needs and care plans. Supervisory requirements mandate that only physical therapists supervise PTAs and only occupational therapists supervise OTAs, with the stricter of federal or state supervision standards applying. Surveyors cite deficiencies when facilities fail to obtain required physician orders or use unqualified personnel.
View official sourceF826 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.65(b) Qualifications Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel. DEFINITIONS §483.65(b) “Qualified Personnel” means a physical therapist, occupational therapist, respiratory therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to furnish therapy services. Qualified personnel may also include a physical therapist assistant (PTA), or an occupational therapy assistant (OTA) when furnishing services under the supervision of a qualified therapist. GUIDANCE §483.65(b) The facility must employ either directly or contract with an outside resource the appropriate qualified personnel as defined above, and additional support staff to ensure the needs of the residents are met in accordance with their comprehensive plan of care. In addition to meeting the specific competency requirements as part of their license and certification requirements defined under State law or regulations, these personnel must have the training, competencies and skill sets to care for residents as identified through resident assessments, and described in the plan of care. NOTE: For residents receiving physical therapy (PT), occupational therapy (OT) and/or speech-language pathology (SLP) services under the Medicare Part B benefit, an order is not required An order from a physician may substitute for the required plan of care (although orders from therapists are not recognized). Although §483.30(e)(3) allows a resident’s attending physician to delegate the task of writing therapy orders to a qualified therapist, Medicare Part B does not currently recognize an order written by a therapist. Under current Part B requirements, when a therapy order is written by a qualified therapist, for that therapy to be covered and paid under the Part B benefit, a physician or recognized non-physician practitioner including a nurse practitioner, clinical nurse specialist or physician assistant – not a therapist − must sign and date the PT, OT, or SLP plan of care which may be established by the therapist. In situations where there are differences between federal and state supervision requirements, the requirement with the greater level of supervision will apply. Only physical therapists may supervise physical therapy assistants, and only occupational therapists may supervise occupational therapy assistants. All speech-language pathology services must be provided by a licensed speech-language pathologist, or by a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to furnish therapy services. PROCEDURES §483.65(b) During the record review, determine that these services are provided under the written order of a physician (or therapist as delegated by the physician in accordance with §483.30(e)(3)) and provided by qualified personnel. If individuals providing specialized rehabilitative services, i.e., physical, occupational, speech or respiratory therapy are not qualified cite here. If a problem in a resident’s care or services is related to the qualifications, competencies or training, of personnel (i.e., facility staff, contractors, temporary staff, etc.), also refer to: • Nursing services not related to behavioral health care or dementia care, tag F725 or 726, §483.35(a),(c); • Any staff caring for residents with dementia or a history of trauma and/or post- traumatic stress disorder, tag F741, §483.40; • Administration, tag F839, §483.70(e). If there are any problems in quality of care related to restoring, maintaining or improving a resident’s functional abilities, determine if these problems are attributable in part to the qualifications, competencies or training of specialized rehabilitative services staff. Also refer to §483.25 (Quality of Care) and §483.24 (Quality of Life). KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F826, the surveyor's investigation will generally show that the facility failed to do any one or more of the following: • Obtain a written order from a physician (or therapist as delegated by the physician in accordance with §483.30(e)(3)), except as otherwise permitted with regard to residents receiving these services under the Medicare Part B benefit (as explained above); OR, • Ensure that services were provided by qualified personnel.