Standard Im.6.10 Ep 7

[Marlys Stotesberry]

Theissues 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.

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.

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.

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 July 2019, the Centers for Medicare and Medicaid Services (CMS) issued changes to its Medicare Benefit Policy Manual [PDF] 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 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:

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.

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.

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.

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.

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, including the Practice Portal to help you get started.

ASHA maintains that SLPs are the most qualified providers for services within our scope of practice based on the knowledge and skills obtained by SLPs in their professional training. Other professional disciplines may have related education or clinical skills in their scopes of practice, such as working with patients with dysphagia and cognitive impairments in occupational therapy. SLPs work collaboratively with other disciplines and can leverage complimentary skills to optimize patient outcomes.

The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 234,000 members, certificate holders, and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology assistants; and students.

However, no clear and specific definition exists in the published literature for these components. Additionally, it is not clear to what extent these standards are met in hospital discharge summaries.

We are conducting a study designed to examine the completeness of discharge summary documentation in a large Midwestern academic hospital for patients discharged to subacute care facilities. In this paper, we provide an overview of the study methods, including definitions for the Joint Commission-mandated discharge summary components, and preliminary results regarding the prevalence of the Joint Commission-mandated components within study discharge summaries.

We identified all patients older than 18 years of age who were discharged from a single large Midwestern academic hospital (N = 612) to subacute care facilities (i.e., nursing homes or rehabilitation centers) with primary diagnoses of lung/colorectal/breast/prostate cancer, stroke, or pelvis/hip/femur fracture during the years 2003, 2004, and 2005. We focused on the subacute care patient population because they represent a vulnerable group of patients who are often unable to advocate for themselves and who are at high risk for adverse outcomes.7

Major cancers, stroke, and hip fracture were chosen because they represent some of the most common and complex diagnoses for geriatric patients in subacute care.7, 8 Eligible subjects with discharges to subacute care facilities during 2003, 2004, and 2005 were identified by use of administrative data compiled on a mandatory basis by hospital case managers for all patients in the study hospital prior to discharge. Internal testing of this system by the study hospital found approximately 99 percent reliability of this field.

A small number of subjects experienced more than one hospitalization meeting eligibility criteria during the 2003 to 2005 timeframe. Each of these hospitalizations was treated as a separate event (17 subjects contributed 2 discharge summaries to the study). During the abstraction process, patients were excluded if they did not have a discharge summary (N = 5) or if the abstractor deemed that it was clear from the discharge summary that the patient did not go to a subacute care facility (N = 5); did not have primary diagnoses of cancer, stroke, or hip fracture (N = 2); or if the patient had been discharged on hospice (N = 1). One cancer patient, eight stroke patients, and four hip fracture patients were excluded.

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