working together gearsThe relationship between a Therapist and a Therapist Assistant can be like a well-oiled machine, a squeaky dysfunctional mess or anywhere in between. If you are a physical or occupational therapist and have not yet had the pleasure of working with a seasoned Assistant {PTA or COTA} then you are missing out!

Therapists and Assistants have been working together to provide care to patients since the 60’s. Since that time, the professions of physical and occupational therapy have seen significant growth…and with that growth came change in both the structure and function of this dynamic duo.

But change is good, right? Sure, we all love change!

Sometimes change happens and we don’t stop and take notice at the time, only to be hit with the effects of it later on. Let’s take a moment to stop…and look at where we are today with the role of the Physical Therapist Assistant (PTA) and the Certified Occupational Therapy Assistant (COTA). You will be glad you did…your license may depend on it.

Let’s look at the roles, rules and regulations pertaining to PTA’s and COTA’s in the long term care setting. We each have a defined role and need to not only know our own role, but also know the role of those we work with. We are in this together!

State Practice Acts Are Where It’s At

When looking at the rules that govern our practice, we must recognize that regulations come from different entities, and that we must follow the most stringent guideline.  Our state Practice Act {and each state has one} is what governs our practice {with laws}. Some state Practice Acts are more stringent than federal regulations. Practice Act supervision standards for Assistants can be more stringent than Medicare laws and regulations. In these cases, the state Practice Act trumps Medicare regulation. Unfortunately, we don’t get to pick the rules we like best.

Here is an example: In a skilled nursing facility (SNF) in New York or New Jersey, a physical therapist must be on the premises when skilled services are furnished by a physical therapist assistant despite the fact that Medicare requires general supervision. New York and New Jersey’s state Practice Act requires direct supervision rather than general supervision, and therefore, the physical therapist and physical therapist assistant would have to comply with this state requirement {or would be breaking the law}. State trumps Medicare.

These laws vary considerably from state to state, so it is important for Therapists and Assistants to be familiar with the laws in their state. Click here for a link to the PT and OT State Practice Acts for all 50 states, just in case you  need a refresher on yours.

Money Makes The Rules

Payer regulations, or the rules dictated by “insurance” companies, also direct the supervision and function of Therapists and Assistants. It is important that all facilities have a system in place to obtain updates on these regulations as they change. As we all know, Medicare rules change all the time!

Some of the rules are so convoluted that it’s tough to keep up. Medicare, for example, has different rules for itself depending on the practice setting (inpatient, outpatient, skilled nursing, home care) and the type of Medicare (Part A, Part B). Payers may also specify what interventions and tasks may or may not be directed to an Assistant. For example, Medicare specifically indicates that tasks that require ongoing evaluation must be provided by Therapists. Although most payers do not specify, some payers may have payment differentials according to who is providing the intervention. Some payers will not pay for services provided by an Assistant.

True or False?

In a SNF, a PTA or COTA can treat a Medicare Part A resident for both skilled restorative therapy and skilled maintenance therapy.  True

In a SNF, a PTA or COTA can treat a Medicare Part B resident for both skilled restorative therapy and skilled maintenance therapy. False! A PTA and COTA, under Medicare Part B, cannot provide skilled maintenance therapy. This regulation was updated by Medicare in January 2014. Catch up on the rules around skilled maintenance therapy here in this article.

What Is True…Above All Else

  • PTA’s and COTA’s work as part of a team to provide physical and occupational therapy services under the direction and supervision of physical or occupational therapists
  • The PT and OT are responsible for the services provided by the PTA and COTA
  • Therapists are legally and ethically responsible for the Assistants under their direction and supervision
  • The level and frequency of supervision differs by practice setting and state practice act
  • In patient management, Assistants assist with the intervention component only. Examination, evaluation, diagnosis, prognosis, and outcomes are the sole responsibility of the Therapist
  • Assistants are responsible for following the plan of care established by the Therapist, including ensuring patient comfort and safety during the intervention and related data collection
  • Only a PT can supervise a PTA; Only an OT can supervise a COTA
  • PT’s and OT’s can only delegate patient care based on the complexity of the patient and the competency of the Assistant

Common Questions

Can an Assistant write a Progress Report? This question may be answered differently based on: 1- Your State Practice Act; 2- Insurance Payer Regulations. For example, under Medicare regulations as outlined in the Medicare Benefit Policy Manual for Part B services, a Progress Report must be written by a Therapist. The Manual {actually} says “and not an Assistant.” Pretty clear, huh?

Can an Assistant add new goals? As noted above, in patient management, Assistants assist with the intervention component only. Examination, evaluation, diagnosis, prognosis and outcomes are the sole responsibility of the Therapist. Goal setting implies evaluation, prognosis and establishment of projected outcomes. Does this mean that an Assistant can’t approach a Therapist, discuss the patient’s status and provide input for goal setting? Absolutely not – in fact, this is what collaboration is all about. This is what should happen. Assistants may have insight into the patient’s care that the Therapist may not have.

Can an Assistant write a Discharge Summary? Again, based on what is noted above, the answer is no. In Chapter 15 of the Medicare Benefit Policy Manual, Medicare defines a discharge summary as a “progress report” that finalizes and summarizes the course of care. For Part B, if Medicare says a progress report must be written by a Therapist, then a “discharge progress report” must also be written by a Therapist. Again, this may differ based on insurance payer regulations.

Click here to visit our JustAsk! Q&A Forum and read the full answers to these questions and others about Medicare Part A and Part B in the SNF – including what documentation is required, and if Assistants are permitted to complete it. For detailed information on this topic, consider our Documentation course (click here to read the course details) or visit our Therapist Toolbox to print out the SNF Documentation Fact Sheet.

On The Lighter Side:

Top 10 Ways Assistants Know They Are In A Dysfunctional Therapist Relationship:

  1. You have NO IDEA who your supervising Therapist is – and staff run when you ask
  2. Your PT calls to tell you he/she will be late and tells you to “get started” on the day
  3. You “split” the resident caseload with the Therapist and never discuss each others “half”
  4. You write the progress notes and discharge summaries and a Therapist co-signs them
  5. You tell the Therapist what to document and he/she does WITHOUT looking at the patient
  6. Your supervising Therapist has NEVER observed you treat a patient or provided feedback
  7. You do not have regular meetings with the Therapists
  8. You NEVER discuss your roles as Therapist-Assistant
  9.  You report directly to the Rehab Manger – and skip the therapist altogether
  10. You show this blog to your supervising Therapist and they WON’T read it


Therapists and Assistants have successfully provided patient care for almost 50 years black board working togethertogether.  The relationship is a team approach. Both the Therapist and Assistant benefit when the roles are clear and communication is open and ongoing.  There is much to be learned from eachother. In the end, a solid relationship ultimately benefits the patient…  and that’s why we are all here.

In Your Corner,


Dolores Montero, PT, DPT, GCS, RAC-CT, RAC-CTA

SNF Therapy & MDS Compliance Team @

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