September 27, 2021

APTA is watching this issue closely and will provide information when it is available.

'We will not know the details of the new vaccine mandate until CMS releases the rule. It is expected mid-October. Until we see the rule, we will not know which settings are required to comply, how compliance will be tracked or if there will be any exceptions medical reasons or for small businesses etc.

We are tracking this issue closely and will issue guidance as soon as we have it. We will also be advocating that this requirement should not place undue burden on providers who already must comply with extremely complex and burdensome Medicare requirements.'

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September 15, 2021

APTA Michigan Centennial Scholar, Bana Odeh, was selected by APTA to speak at the APTA Centennial Gala held September 10 in Washington, DC.  It was quite an honor to speak and then introduce the APTA President, Sharon Dunn.

Download Bana's speech

 

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August 23, 2021

Important note:  The OSHA Emergency Temporary Standard (ETS) referenced below MAY or MAY NOT apply to non-hospital healthcare settings.  Please review this flow chart to determine whether or not the ETS applies to your setting.

If the ETS does not apply all should keep current MDHHS recommendations in consideration.  

OSHA Emergency Temporary Rule:  June 22, 2021:  Masks and other precautions are still necessary in healthcare settings.  August update continues to recommend special consideration for certain health care settings.    

Under the latest version of the MIOSHA Emergency Rules, the state’s Workplace Safety Rules are in line with the OSHA Standards. Specifically, MIOSHA’s Emergency Rules are adopted from Subpart U in the OSHA Standards. Subpart U is the COVID-19 Emergency Temporary Standard and provides standards that healthcare settings must follow. Under the latest rules, only healthcare settings have certain protocols and standards to follow. All other sectors and workplaces are encouraged to follow CDC and OSHA guidelines. The updated rules are effective today and are set to expire on December 22, 2021.

To view the latest MIOSHA Emergency Rules, please click here. To view Subpart U from the OSHA Standards, please click here. To view a press release on the new MIOSHA rules, please click here.

View the OHSA requirements here: https://www.osha.gov/coronavirus/ets   APTA additional guidance:  https://www.apta.org/news/2021/06/14/osha-covid-rules

MDHHS updated guidance effective June 22 which states:  Healthcare Facilities, such as hospitals, ambulatory care settings and surgical centers - As of now CDC healthcare guidance remains unchanged. Facilities should continue to follow CDC  guidance. https://www.michigan.gov/documents/coronavirus/MDHHS_Face_Mask_Recommendations_5.20.21_725941_7.pdf

CDC Guidance from February 2021 remains in effect for health care settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

CDC Guidance:

Implement Telehealth and Nurse-Directed Triage Protocols

  • Continue to use telehealth strategies to reduce the risk of SARS-CoV-2 transmission in healthcare settings while maintaining high quality patient care.
  • When scheduling appointments for routine medical care (e.g., annual physical, elective surgery):
    • Advise patients that they should put on their own well-fitting form of source control (see Implement Universal Source Control Measures for more details) before entering the facility.
    • Instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 within the 10 days prior to their appointment, if they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment, or if they have had close contact with someone with suspected or confirmed SARS-CoV-2 infection within 14 days prior to their scheduled appointment.
  • When scheduling appointments for patients requesting evaluation for possible SARS-CoV-2 infection, use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
    • If the patient must come in for an appointment, instruct them (or their responsible party if they are unable to communicate) to take appropriate preventive actions (e.g., follow triage procedures, put on their own well-fitting form of source control before entry and throughout their visit or, if a well-fitting form of source control cannot be tolerated, hold a tissue against their mouth and nose to contain respiratory secretions) and immediately inform triage personnel upon arrival (e.g., call from car) so they can be placed in an examination room.

Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

  • Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility
    • Post visual alerts (e.g., signs, posters pdf icon[572 KB, 1 page]) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene.
    • Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
  • Limit and monitor points of entry to the facility.
  • Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19,  or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
    • Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
      • Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival.
      • Obtaining reliable temperature readings is affected by multiple factors, including:
        • The ambient environment in which the temperature is measured: If the environment is extremely hot or cold, body temperature readings may be affected, regardless of the temperature-taking device that is used.
        • Proper calibration of the thermometers per manufacturer standards: Improper calibration can lead to incorrect temperature readings.
        • Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading.
  • Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection:
    • Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation.
    • Visitors should be restricted from entering the facility and be referred for proper evaluation.
  • Patients should be isolated in an examination room with the door closed.
  • If an examination room is not immediately available, such patients should not wait among other patients seeking care.
    • Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
    • In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
    • Depending on the level of transmission in the community, facilities might also consider designating a separate area at the facility (e.g., an ancillary building or temporary structure) or nearby location as an evaluation area where patients with symptoms of COVID-19 can seek evaluation and care.

Re-evaluate admitted patients for signs and symptoms of COVID-19

Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).

Implement Universal Source Control Measures

Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection for the wearer against exposure to infectious droplets and particles produced by infected people. Ensuring a proper fit is important to optimize both the source control and protection offered. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.

  • Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. If they do not bring their own, they should be offered an option that is equivalent to what is recommended for people in the community
    • Patients may remove their source control when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room.
    • Cloth masks, facemasks and respirators should not be placed on young children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing a mask safely, or anyone who is unconscious, incapacitated or otherwise unable to remove their cloth mask, facemask or respirator without assistance.
    • Visitors who are not able to wear source control should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection.
  • For guidance on recommended source control for HCP, refer to Implement Universal Use of Personal Protective Equipment below.
    • HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
    • To reduce the number of times HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask (extended use) throughout their entire work shift.
    • HCP should remove their respirator or facemask, perform hand hygiene, and put on their community source control when leaving the facility at the end of their shift.
  • Educate patients, visitors, and HCP about the importance of performing hand hygiene, including immediately before and after any contact with their cloth mask, facemask, or respirator.

Encourage Physical Distancing

Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Examples of how physical distancing can be implemented for patients include:

  • Limiting visitors to the facility to those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
    • Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
  • Scheduling appointments to limit the number of patients in waiting rooms, or creating a process so that patients can wait outside or in their vehicle while waiting for their appointment.
  • Arranging seating in waiting rooms so patients can sit at least 6 feet apart.
  • Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart.
    • In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:

  • Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions.
  • Emphasizing the importance of source control and physical distancing in non-patient care areas.
  • Providing family meeting areas where all individuals (e.g., visitors, HCP) can remain at least 6 feet apart from each other.
  • Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked.

Implement Universal Use of Personal Protective Equipment

Transmission from asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission.

The fit of the medical device used to cover the wearer’s mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer’s exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air.  Facemasks that conform to the wearer’s face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer’s exposure to particles in the air. Improving how a facemask fits can increase the facemask’s effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed.

PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection is described in Section 2.

HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history):

  • HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis; for example, use an N95 respirator or equivalent or higher level respirator if the patient is suspected to have tuberculosis).
  • Additionally, HCP should use PPE as described below:
    • N95 respirators or equivalent or higher-level respirators should be used for
      • All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) AND
      • All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ During the COVID-19 pandemic, are there special considerations for surgical or other procedural settings, including performance of AGPs?).
    • One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
    • Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions.

HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator.

Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19

In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure screening testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.

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June 09, 2021

On June 1, the Department of Licensing and Regulatory Affairs (LARA) announced new requirements for over 400,000 health care professionals licensed in Michigan.  Licensees who have email addresses listed with the Bureau of Health Professions/LARA should have received an email outlining the new requirement.  That message is copied below.  Licensees renewing in 2021 will not be impacted.  Those renewing in 2022 will need 2 hours of implicit bias training.  APTA Michigan is developing course content to meet this new requirement and we hope to offer both sessions at our conferences along with live webinars. 

as

Dear Licensee –

The Bureau of Professional Licensing (BPL) within the Department of Licensing and Regulatory Affairs (LARA) would like to inform you that the Public Health Code – General Rules have been revised which will require implicit bias training for your profession, effective June 1, 2022.

The new training requirements are the product of numerous workgroup meetings over the past year and represent feedback from 86 organizations including our health professional boards, insurance providers, health systems, health care associations, legislators, state agencies, higher education, and community and advocacy groups. The requirements apply to both new applicants as well as those renewing their existing licenses or registrations.

Below are the changes in the rules that pertain to the new training requirements:

  • The term “implicit bias” is defined as:

(A)n attitude or internalized stereotype that affects an individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic. (R 338.7001 (c) )

  • Specifically, the new rule (R 338.7004) requires the following:

Rule 4. (1) Beginning 1 year after promulgation of this rule, an applicant for licensure or registration under article 15 of the code, MCL 333.16101 to 333.18838, except those seeking to be licensed under part 188 of the code, MCL 333.18801 to 333.18838, shall have completed a minimum of 2 hours of implicit bias training within the 5 years immediately preceding issuance of the license or registration.

(2) Beginning 1 year after promulgation of this rule and for every renewal cycle thereafter, in addition to completing any continuing education required for renewal, an applicant for license or registration renewal under article 15 of the code, MCL 333.16101 to 333.18838, except those licensed under part 188 of the code, MCL 333.18801 to 333.18838, shall have completed a minimum of 1 hour of implicit bias training for each year of the applicant’s license or registration cycle.

(3) The implicit bias training must be related to reducing barriers and disparities in access to and delivery of health care services and meet all of the following requirements:

(a) Training content must include, but is not limited to, 1 or more of the following topics:

(i) Information on implicit bias, equitable access to health care, serving a diverse population, diversity and inclusion initiatives, and cultural sensitivity.
(ii) Strategies to remedy the negative impact of implicit bias by recognizing and understanding how it impacts perception, judgment, and actions that may result in inequitable decision making, failure to effectively communicate, and result in barriers and disparities in the access to and delivery of health care services.
(iii) The historical basis and present consequences of implicit biases based on an individual’s characteristics.
(iv) Discussion of current research on implicit bias in the access to and delivery of health care services.

(b) Training must include strategies to reduce disparities in access to and delivery of health care services and the administration of pre- and post-test implicit bias assessments.

(c) Acceptable sponsors of this training include any of the following:

(i) Training offered by a nationally-recognized or state-recognized health-related organization.
(ii) Training offered by, or in conjunction with, a state or federal agency.
(iii) Training obtained in an educational program that has been approved by any board created under article 15 of the code, MCL 333.16101 to 333.18838, except under part 188 of the code, MCL 333.18801 to 333.18838, for initial licensure or registration or for the accumulation of continuing education credits.
(iv) Training offered by an accredited college or university.
(v) An organization specializing in diversity, equity, and inclusion issues.

(d) Acceptable modalities of training include any of the following:

(i) A teleconference or webinar that permits live synchronous interaction.
(ii) A live presentation.
(iii) Interactive online instruction.

(4) Submission of an application for licensure, registration, or renewal constitutes an applicant’s certificate of compliance with the requirements of this rule. A licensee or registrant shall retain documentation of meeting the requirements of this rule for a period of 6 years from the date of applying for licensure, registration, or renewal. The department may select and audit a sample of a licensees or registrants and request documentation of proof of compliance with this rule. If audited by the department, a licensee or registrant shall provide the proof of completion of training, including either of the following:

(a) A completion certificate issued by the training program that includes the date of the training, the program sponsor’s name, the title of the program, and licensee’s or registrant’s name.

(b) A self-attestation by the licensee or registrant that includes the date of the training, the program sponsor’s name, the title of the program, and licensee’s or registrant’s name.

Please send any questions you may have about these revised rules to BPLHelp@michigan.gov .

Thank you,

Debra Gagliardi, Director
Bureau of Professional Licensing
Department of Licensing and Regulatory Affairs


LARA is an equal opportunity employer/program.

Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

BUREAU OF PROFESSIONAL LICENSING
P.O. BOX 30670· LANSING, MICHIGAN 48909
www.michigan.gov/bpl

For more information about LARA, please visit www.michigan.gov/lara

Follow us on Twitter www.twitter.com/michiganLARA

Like” us on Facebook or find us on YouTube www.youtube.com/michiganLARA

 


 

 


Update your subscriptions, modify your password or email address, or stop subscriptions at any time on your Subscriber Preferences Page. You will need to use your email address to log in. If you have questions or problems with the subscription service, please contact subscriberhelp.govdelivery.com.

This service is provided to you at no charge by Michigan Department of Licensing and Regulatory Affairs.


This email was sent to shoemami@gvsu.edu using GovDelivery Communications Cloud on behalf of: Michigan Department of Licensing and Regulatory Affairs · P.O. Box 30004 · Lansing, MI 48909

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June 09, 2021

Important Announcements and provider webinars:

Meridian Announcement  Download file

Prior Authorization Webinars Download file

Utilization Management Webinars  Download file

 

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April 24, 2017

The Physical Therapy Section of the Public Health Code has been amended to allow Advanced Practice Registered Nurses to prescribe physical therapy:

 

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****



333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

 

 

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

Section 17201:

Sec. 17201. (1) As used in this part:

(a) “Advanced practice registered nurse” or “a.p.r.n.” means a registered professional nurse who has been granted

a specialty certification under section 17210 in 1 of the following health profession specialty fields:

(i) Nurse midwifery.

(ii) Nurse practitioner.

(iii) Clinical nurse specialist.

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****

 


333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

 

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

 

 

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