Frequently Asked Questions: SLPs Working in Health Care
Is it within my scope of practice to perform additional tasks, such as taking blood pressures, suctioning, or gathering information for intake assessments that do not just address speech-language pathology issues?
The issues of multiskilling and cost containment present new challenges for members to perform activities that were not previously expected of them. The SLP Scope of Practice is written in broad terms and specific activities, such as suctioning or taking blood pressures, are not mentioned. However, some of these activities are not considered "skilled" and are also taught to family members and technicians. Other activities, such as completing functional assessments, require SLPs to score items about a patient's status that they may not feel trained to evaluate. SLPs may complete these tasks as a function of their job responsibilities. ASHA's Code of Ethics states that clinicians must be competent by virtue of training, education and experience to perform any activities. Thus, appropriate training and support is necessary for an SLP to undertake any activity in which they are not already competent. It may be advisable for your facility to develop a written policy that addresses the level of involvement and training that SLPs will have, and a mechanism for verifying their competency.
States may have guidance on issues such as suctioning. For example, Maryland has determined that tracheal suctioning is within the Scope of Practice of SLPs. Other states may or may not have such specific guidance.
See ASHA's position statement and technical report on multiskilling.
Our hospital is preparing for a Joint Commission survey. What do I need to do?
Your facility has most likely already designated an administrator to coordinate preparation for your survey, and that individual will let you know what you will need to do. Personnel files for all speech-language pathologists (including outside contractors who provide services in your facility) should contain evidence of their licensure and certification, as well as demonstration of competencies that involve high volume/high risk within the facility. This can be accomplished by various means, including checklists of skill areas, documentation of attendance at continuing education programs or successful completion of self-study programs. ASHA has developed a product called Guide to Verifying Competencies in Speech-Language Pathology, which displays in checklist format all the knowledge and skills statements contained in ASHA policy documents. Samples of the competency checklists for swallowing [PDF], videofluoroscopy [PDF], and endoscopy [PDF] are available online.
An additional area targeted by the Joint Commission is age-related competencies, which require demonstrated knowledge of developmental, physical and psychosocial aspects of all age groups that may be treated in your facility.
Does ASHA have productivity standards? What are"typical" productivity requirements in a hospital or skilled nursing facility?
ASHA does not specify productivity standards in health care settings because productivity can be influenced by a number of variables, including the severity level of the disorders, the patient population, setting, etc. However, ASHA collected information about productivity through the SLP Health Care Survey.
For the purposes of this survey, productivity was defined at the number of hours in direct patient care divided by the number of hours worked. Fifty nine percent of respondents across settings indicated that their facility had a productivity requirement. Overall, the mean productivity requirement was 77%, equating roughly to 6 hours of direct treatment per 8 hour day. A complete breakdown of productivity by setting (general medical hospital, pediatric hospital, skilled nursing facility, etc.) is available in the Survey Summary Report [PDF] of the 2009 Health Care Survey. In 2011, productivity was further broken down by individual and group treatment, as well as documentation and an "other" category. Results for direct treatment (individual and group) remained consistent at approximately 75%, with documentation taking up an additional 19% of the average clinician's time.
Do I need a physician's order to see a patient? Can I write in the orders section of a patient's chart for the physician to sign?
The professions of speech-language pathology and audiology are autonomous and a physician's order is not required to provide services. However, in health care settings, the physician's orders are used as a mechanism to initiate referrals, and are required by many payers for reimbursement purposes. Check your facility's policy and the requirements of both public and private reimbursement sources. In May, 2005, the Centers for Medicare and Medicaid Services (CMS) issued changes to its Medicare Benefit Policy Manual that stated that a physician's order is not required for SLP services to be provided to a beneficiary. Payment for services is contingent on physician certification of the plan of care.
In some facilities, SLPs may be asked to write verbal orders from the physician in the chart, or to write diet-texture recommendations or other orders for the physician to sign. In some cases, the physician countersignature may not be required. ASHA has no policies prohibiting the practice of SLPs writing orders. Contact the state agency governing health care to determine what state regulations allow. The facility also should make a determination as to whether this best serves patient care and is an acceptable liability risk. Policies should be written to document the agreed-upon procedure.
The Joint Commission on Accreditation of Healthcare Organizations does not specify in their accreditation standards which personnel are able to write orders in the medical chart. The following excerpt from the 2007 Comprehensive Accreditation Manual for Hospitals (CAMH), Management of Information chapter (page IM-12), indicates that the facility should define which personnel are authorized to write in the medical record:
- Standard IM.6.10
The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served.
- Elements of Performance for IM.6.10
Only authorized individuals make entries into the medical record.
The hospital defines which entries made by non-independent practitioners require countersigning consistent with law or regulation (page IM-12).
(Comprehensive Accreditation Manual for Hospitals: The Official Handbook. (2007). Oakbrook Terrace, IL: Joint Commission Resources, Inc.)
A related question has to do with who can write an order for SLP services (e.g., a medical doctor, dentist, nurse practitioner, etc.). Since ASHA does not require an SLP to get an order, ASHA also does not define from whom an SLP can take an order. Medicare allows physicians, physician assistants, and nurse practitioners to write orders. Other payers may have their own guidelines about who can write orders or authorize treatment.
The Joint Commission has patient safety regulations about taking verbal orders and abbreviations that are prohibited in medical charts that should be considered in any policy.
See ASHA's policy document on autonomy.
When I write an order for a diet texture change, may I also include the dietary restrictions, such as low sodium or low fat?
If you are allowed to write orders, based on applicable state laws and other regulations, you should be careful about how you take or write orders for things that fall outside your scope of practice. For example, if you need to change a patient's diet to mechanical soft and that patient is also on a low sodium diet, the order will most likely need to address both issues-texture and dietary restrictions. There is no ASHA policy prohibiting an SLP from writing such orders, but care must be taken to ensure that the order is correct and that it is clear that the SLP is not the one requesting the dietary restrictions, which falls outside the SLP's scope of practice.
In some facilities, members have reported using language such as "Mechanical soft diet with low sodium restriction, as per physician/dietary order dated XXXX" or "Mechanical soft diet, continue dietary restrictions previously in place." In others, physicians are writing broad orders, such as "diet as determined by speech pathology," which allows the SLP to request a diet without it being written as an order. There should be a policy in place that outlines the agreed-upon procedure for writing such orders.
Recently, a question came up about Medicare's regulations on ordering "therapeutic diets," which they define as "a diet ordered by a health care practitioner as part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet (e.g., sodium or potassium), or to provide mechanically altered food when indicated" (Tag F325 of the SNF Surveyors Manual). According to the hospital Medicare conditions of participation for food and dietetic services [42 section 482.28(b)(1)], "therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients." For Medicare, these practitioners include physicians, physician assistants, and nurse practitioners, not speech-language pathologists. It is not clear how these regulations are being interpreted and enforced, but clinicians should be aware of this issue when considering policies regarding writing diet orders.
I know that Medicare and other payers want to see evidence of "medical necessity" in my documentation. What exactly do they mean by this, and how can I make sure I am documenting this correctly?
The term "medical necessity" has been used by health plans for many years to define limits of coverage, despite a lack of agreement on what constitutes medical necessity. Over the years, the term has evolved from a health plan concept directed by physicians to a cost-saving measure used by health plan administrators and medical directors.
Medicare defines medical necessity as a "service that is reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member." The service must be consistent with the symptoms of the illness or injury, be provided within generally acceptable professional medical standards, not performed for the convenience of the patient or physician, and furnished at a safe level and in a setting appropriate to the patient's medical needs. Some private payers define the term even further, so there may be differences in payer expectations and requirements.
Speech-language pathologists must document how the services they provide meet the requirement to treat various types of disorders in children and adults. To assist members with this sometimes elusive concept, ASHA has developed an excellent resource, Medical Necessity for Speech-Language Pathology and Audiology Services [PDF]. In addition, a number of resources available on ASHA's billing and reimbursement site include information about medical necessity and documentation.
Is there an accepted standard for how many treatment sessions or length of sessions that speech-language pathologists should provide for specific disorders?
ASHA's National Outcomes Measurement System (NOMS) is collecting data from members to answer this question for both adults and children. Currently, reports are available that list how much improvement was achieved based on the amount of treatment time (reported in terms of overall time, rather than number of treatment sessions). ASHA members can sign up and receive training to collect patient data using Functional Communication Measures (FCMs) for NOMS. They will then receive quarterly reports, as well as national data against which to benchmark their services. Ultimately, this will lead to evidence-based data regarding the efficacy of speech-language pathology treatment and typical range of sessions.
What is ASHA's position on telepractice?
Telepractice is defined in ASHA's position statement as "the application of telecommunications technology to delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation."
ASHA's position is that telepractice is an appropriate model of service delivery for speech-language pathology and audiology. Policy documents, a telepractice report, survey, and other information is available in the telepractice section of ASHA's website.
I am interested in attending a conference about a new therapy technique but am wondering whether it is worth my time and money. What does ASHA say about conferences and products offered for speech-language pathologists?
ASHA does not endorse any conference material, therapy technique or procedure or product marketed to members. CEUs may be offered from ASHA for a particular program, not to imply endorsement of the content, but to recognize that the program meets the educational activity requirements set by ASHA. To assist ASHA members in determining the value of a product or program, ASHA has developed a resource entitled What To Ask When Evaluating Any Treatment Procedure, Product, or Program.
My caseload has become increasingly diverse. What tools are available to help me provide the best care to a culturally and linguistically diverse population?
Working with a culturally and linguistically diverse (CLD) population requires that you adapt your services to meet the needs of each individual. The federal government has mandated that all federally funded organizations must have written policies on how to provide equal access to services for limited English proficient individuals. In this age of HIPAA, however, it is important that patient and client records and communication not include information that may reasonably lead to identification of that individual by others. In facilities with a limited CLD population, information about a person's ethnicity, culture, or language may reasonably lead someone to identify them and may violate HIPAA. Keep this in mind when developing privacy policies and sending information from your facility.
ASHA's Office of Multicultural Affairs has developed a number of resources to help clinicians working with CLD populations.
How can I get information about specific medical conditions or disorders?
One way to find such information is to search ASHA's website database. You can do this by using the search engine. You may also find medical information, in abstract form, by searching the National Institutes of Health database. With an emphasis on evidence-based practice in today's society, locating information about disorders and treatment efficacy is vital. Links to literature review sites and evidence-based practice tools are available on ASHA's Evidence-Based Practice webpage. This site includes the Compendium of Evidence-Based Guidelines and Systematic Reviews on a wide variety of speech, language, and swallowing disorders.
I am returning to work after being home with my family for a few years. What can I do to get back "up to speed"?
Depending on how long you have been away from practice, things may have changed a little or a lot. You want to make sure that you are up to date on clinical practice, of course, but also may need updates on work requirements in different health care settings (documentation, billing, interdisciplinary teaming, etc.). First, you need to determine the areas in which you are in need of training. You can read current literature, attend professional development programs, work with mentors, and more to establish/reestablish competency in the areas of practice you have identified. ASHA has a number of resources to help you get started.
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