Conduct Matters: December 2024 — College of Physiotherapists of Alberta

Quarterly report of all closed conduct files from July 1 – Sept 30, 2024.

Disclaimer: Decisions may vary depending on the circumstances. The reasons for a decision must be considered in light of the evidence and the actual issues pertaining to the allegation.

Case 1

Allegations

The physiotherapist failed to do the following on one assessment date:

Safely and appropriately assess and treat the patient, causing increased symptoms and pain to the patient’s head, neck, shoulders, and back.
Communicate respectfully to the patient when providing physiotherapy services.
Clearly communicate the applicable physiotherapy fees to the patient prior to providing physiotherapy services.

Investigation

The allegations centered around the interactions between the patient and the physiotherapist during an assessment for neck pain and vertigo, and the subsequent interactions and information provided by the physiotherapist to patient and clinic employees. The investigation focused on the following:

Written submission from the physiotherapist.
Review of photographs of the clinic waiting room, hallways and treatment rooms/cubicles.
Review of the physiotherapy record and the patient’s medical record.
Interviews of the patient, the physiotherapist, three employees, and a witness to a portion of the interactions between the patient, the physiotherapist and clinic employees.
Review of assessment techniques and test.
Review of the clinic’s advertising.

Decision

The Complaints Director determined after careful consideration of the submitted complaint and the evidence presented in the investigation report, that there was insufficient evidence specific to the investigated allegations to support a finding of unprofessional conduct by a hearing tribunal. The complaint was dismissed and was not referred to a hearing.

While the evidence did not support referring this complaint for a hearing, the evidence did support that the physiotherapist did not consistently and fully meet the following Standards of Practice:

Client Assessment, Diagnosis and Intervention
Client Centered Care
Communication
Fees and Billing

The Complaints Director provided recommendations to the physiotherapist to improve future practice. It was strongly recommended that the physiotherapist undertake each of the recommendations. The recommendations were:

Review in detail and implement into daily practice the following Standards of Practice:

Review in detail the CPTA Consent Guide and implement it into daily practice.
Read the CPTA Good Practice: Fees and Billing FAQs article and implement recommendations.
Complete a risk management continuing education course.
Undertake regular continuing education regarding the assessment and treatment of dizziness, vestibular and balance concerns, and concussion management.

It was also noted that any future complaint of a similar nature may result in a referral to a hearing.

Case 2

Allegation

By continuing to provide services, the investigated person represented or held out that they were a regulated member and in good standing following cancellation of their practice permit.

Investigation

The investigated person, via legal counsel, admitted to providing physiotherapy services without a valid practice permit.

The investigated person demonstrated remorse and admitted to a lack of judgment and appreciated the risk to patients and the profession when an unlicensed individual provides physiotherapy services.

Decision

Given the investigated person’s admission, there was strong evidence of unprofessional conduct to warrant sending this matter for a hearing.

The Complaints Director chose, in this case, to offer facilitated resolution rather than refer this matter for a hearing tribunal. The investigated person agreed to this process. Facilitated resolution results in a formal and binding agreement between the investigated person and the College. The terms of the agreement are typically similar to orders the College would seek if the matter was referred for a hearing and the physiotherapist was found guilty of unprofessional conduct. Facilitated resolution is only an option if deemed appropriate by the Complaints Director and agreed to by all parties. As such, the individual in this case must complete the following conditions to resolve the matter without it being sent for a hearing:

Review and reflect on the College’s Legislative Responsibilities Standard of Practice in its entirety.
Review and reflect on the College’s Code of Ethical Conduct in its entirety.
Pay a $500 fine for practicing when not authorized.
Complete a course, approved by the Complaints Director, specific to professionalism and ethics for health-care professionals.

In accordance with s. 119 of the Health Professions Act (HPA), each condition is placed on the physiotherapist’s practice permit and available on the Public Registry until the matter is resolved. Each condition is removed from the practice permit when the Complaints Director is satisfied the condition is met.

Case 3

Allegation

By engaging in benefits fraud through Alberta Blue Cross the physiotherapist violated the following sections of the CPTA Code of Ethical Conduct:

* B. 1. Conduct and present themselves with integrity and professionalism.

* C. 3. Act honestly, transparently and with integrity in all professional and business practices to uphold the reputation of the profession.

Investigation

The physiotherapist admitted they engaged in benefits fraud through Alberta Blue Cross for services that did not occur or could not be verified and this is unprofessional conduct as defined in section 1(1)(pp)(ii) of the HPA.

Specifically, the physiotherapist admitted they violated the following sections of the College’s Code of Ethical Conduct:

B.1. Conduct and present themselves with integrity and professionalism. Physiotherapists have an ethical responsibility to conduct themselves with integrity and professionalism.

C.3. Act honestly, transparently and with integrity in all professional and business practices to uphold the reputation of the profession.

Decision

Given the physiotherapist’s admission, there was strong evidence of unprofessional conduct to warrant sending this matter for a hearing.

The Complaints Director chose, in this case, to offer facilitated resolution rather than refer this matter for a hearing. The physiotherapist agreed to this process. Facilitated resolution results in a formal and binding agreement between the physiotherapist and the College. The terms of the agreement are typically similar to orders the College would seek if the matter was referred for a hearing and the physiotherapist was found guilty of unprofessional conduct. Facilitated resolution is only an option if deemed appropriate by the Complaints Director and agreed to by both the individual reporting the incident and the physiotherapist. As such, the physiotherapist in this case must complete the following conditions to resolve the matter without it being referred for a hearing:

Review the College’s Code of Ethical Conduct.
Enroll in and successfully complete the College of Physiotherapists of Ontario Ethics E-Learning Module.
Write an original 2000-word reflection paper that addresses the importance of ethical conduct of physiotherapists in Alberta and demonstrates how their past conduct, the ethical learnings from the Ethics E-Learning Modules and reading the College’s Code of Ethical Conduct will affect their behaviour in the future to ensure this conduct does not happen again.

Case 4

Allegation

Was there evidence that the physiotherapist is not maintaining accurate and complete physiotherapy records sufficient to allow the patient to be managed by another physiotherapist?

Investigation

The investigation consisted of a random chart audit of nine client physiotherapy records from the physiotherapist’s primary practice location, a private practice physiotherapy clinic.

Decision

The investigation revealed an overall lack of documentation in the reviewed records. This made it challenging for the investigator to evaluate the physiotherapist’s clinical reasoning.

In six of the nine charts reviewed, there was no documentation after the initial assessment other than billing information.

The Complaints Director determined that there was strong evidence to support a finding of unprofessional conduct in that the physiotherapist was not documenting sufficient information to allow another physiotherapist to manage the clients’ conditions.

The Complaints Director proposed that the physiotherapist enter into a facilitated resolution with the Complaints Director rather than referring this matter for a hearing. The physiotherapist agreed to this process. As a result, the physiotherapist must:

Agree that they failed to meet the College’s Documentation and Record Keeping Standard of Practice while providing physiotherapy services.
At their own expense, complete a course, approved by the Complaints Director, specific to health professional documentation and record keeping.
Participate in three chart audits over a minimum of 18 months to ensure that the physiotherapist consistently meets the Documentation and Record Keeping Standard.
Meet the minimum audit criteria established by the Complaints Director for each chart audit.
Provide payment to the College for partial cost of each chart audit.

Case 5

Allegations

The patient client presented for assessment with a complex and lengthy history of previous injuries and overall pain.

The College investigated two allegations:

During an initial assessment, the physiotherapist failed to develop a realistic intervention plan that addressed the patient’s goals by failing to appropriately assess the patient’s presenting condition.
During an initial assessment, the physiotherapist failed to involve the patient in their care plan in a compassionate, respectful, and dignified manner.

Investigation

The investigation involved interviews with the patient, the physiotherapist, and a clinic staff member. It also involved a review of the physiotherapy treatment record and records of conversations between the patient, the physiotherapist, and clinic staff.

The investigation revealed that the patient placed a much greater emphasis and relevance on their prior diagnostic imaging results than the physiotherapist did. Despite the physiotherapist’s willingness to evaluate these imaging results, the therapeutic relationship was affected by this decision to not immediately address the prior imaging results.

Decision

The evidence showed that the physiotherapist performed a complete physiotherapy assessment, discussed the findings with the patient, set treatment goals in consultation with the patient, and had a plan in place to review the prior diagnostic imaging results at a future date.

There was no evidence presented that the interactions between the patient and the physiotherapist were not compassionate, respectful, or dignified.

The complaint was dismissed with no evidence of unprofessional conduct found for either allegation.

Case 6

Allegations

The College investigated two allegations following a patient complaint regarding lack of assessment and improper prescription of pushups.

Did the physiotherapist conduct a physiotherapy assessment and arrive at a physiotherapy diagnosis based on the patient's presenting condition including an upper quadrant, upper extremity scan?
Was the treatment plan requiring the patient to do pushups consistent with the physiotherapy diagnosis?

Investigation

The investigation involved a review of the physiotherapy record, interviews, and written submissions from the patient and physiotherapist.

The investigation revealed the physiotherapist was the fourth physiotherapist to be seen by the patient during one specific episode of care. The physiotherapist was providing coverage for other physiotherapists and only provided physiotherapy services to the patient on one occasion.

Decision

There was no evidence that the physiotherapist performed a complete assessment. However, given that the physiotherapist was continuing a plan of care established by other physiotherapists and treatment by alternate therapists within a clinic for continuation of services is not uncommon clinical practice, this alone does not generally trigger a comprehensive new intake assessment.

The patient reported no significant changes in subjective status that would have warranted a comprehensive new or re-assessment, nor were any substantive objective changes noted in the re-assessment performed by the physiotherapist on the day physiotherapy services were provided to the patient.

Regarding the appropriateness of pushups in the physiotherapy treatment plan, no evidence was presented to warrant removal of pushups from the treatment plan on the day the patient was treated by the physiotherapist. Pushups had been prescribed previously and were being continued as part of the treatment plan for the patient. Sound critical thinking and rationale was provided by the physiotherapist for including pushups in the treatment plan for the patient.

There was no evidence to support a finding of unprofessional conduct on either allegation investigated. The complaint was dismissed.

Case 7

Allegations

The College investigated three allegations:

The physiotherapist failed to obtain the patient’s consent before initiating physiotherapy services.
The physiotherapist failed to provide the patient with information regarding fees before initiating physiotherapy services.
The physiotherapist posted a recording of the patient performing exercises on a social media service without the patient’s consent.

Investigation

The investigation involved reviewing the physiotherapy treatment record and the physiotherapist's written submission. The patient declined to be interviewed. Information from the Alberta Office of the Information and Privacy Commissioner was also collected to inform the privacy allegation.

Decision

The physiotherapy treatment record provided evidence that the physiotherapist obtained and documented the patient’s verbal consent for each treatment session. The record also showed that the physiotherapist provided information about fees and the billing process. These two allegations were dismissed.

Evidence showed that the physiotherapist did not obtain the patient’s consent to post the video. Consent to disclose is required under the Personal Information Protection Act if the video includes personal information. The Alberta Office of the Information and Privacy Commissioner Order in order P2006-008 states, “If an individual in the frame can be identified, then the captured image is “information about an identifiable individual”. The Complaints Director did not indicate whether the image in the video is identifiable, as that decision lies with the Office of the Information and Privacy Commissioner of Alberta.

This allegation was dismissed, however; the Complaints Director provided the physiotherapist with recommendations for improved practice.

Review the consent section of the Personal Information Protection Act.
Review the College’s Social Media Guide.
Obtain each patient’s consent for using and disclosing their personal information before posting on social media, even if their face and head are not included.

Case 8

The patient was involved in a motor vehicle collision and attended a clinic nine times and was treated by a physiotherapist and a chiropractor. The patient made allegations that encompassed the following Standards of Practice:

Sexual Abuse and Sexual Misconduct
Client Assessment, Diagnosis, Interventions
Client-Centered Care
Performance of Restricted Activities
Consent
Fees and Billing
Legislative Responsibilities

Seven allegations were put forward by the Complaints Director and an extensive investigation occurred. The investigation consisted of several interviews: the patient, the physiotherapist, and several of the physiotherapist’s colleagues. The investigation reviewed several documents including:

Submissions from the patient, the physiotherapist, several of the physiotherapist’s colleagues, the patient’s motor vehicle insurers and legal counsel, and two of the patient’s physicians
Physiotherapy, medical, massage therapy, and chiropractic records from multiple sites

Decision

Pursuant to section 66(3) of the Health Professions Act, the role of the Complaints Director in all investigated complaints is to determine if the allegations in the complaint will be referred for a hearing or be dismissed.

The threshold for referring an allegation for a hearing is two-fold:

It is the Complaints Director’s opinion that there is a reasonable prospect of establishing the facts necessary to prove the allegation before a Hearing Tribunal.
Having determined that the first threshold test is met, the Complaints Director

must then have significant concerns about the physiotherapist’s competence or ethics, or there is a significant risk to public protection if the physiotherapist continues the alleged practice or behaviour.

Seven allegations were investigated. Two allegations could not be proven on a balance of probabilities. Five allegations were dismissed as there was no evidence to support each allegation. The evidence for each allegation was weighed and assessed and each allegation was dismissed as there was no evidence to support each individual allegation.

Case 9

Allegations

On or about February 11, 2023, Khairmode failed to perform appropriate assessments in relation to client P.B. prior to initiating moist heat treatment with a hot pack (“MHP treatment”), including one or more of the following:
1. failed to conduct a pain sensitivity assessment;
2. failed to conduct a thermal sensitivity assessment.
On or about February 11, 2023, Khairmode failed to have and/or document a therapeutic justification for applying MHP treatment to client P.B.’s buttocks.
On or about February 11, 2023, Khairmode failed to implement patient P.B.’s MHP treatment in a safe and/or competent manner, including one or more of the following:
1. failed to consider information about client P.B.’s health, including that they had sensory loss in the gluteal and sacral regions;
2. failed to determine potential risks to client P.B.;
3. placed the hot pack underneath client P.B.’s buttocks while they were laying in the modified crook lying position;
4. failed to wrap the heat pad with sufficient towels and/or covers, considering the placement of the hot pack underneath client P.B.’s buttocks.
On or about February 11, 2023, Khairmode failed to adequately monitor client P.B. during the MHP treatment, including one or more of the following:
1. inappropriately relied on P.B.’s verbal response instead of conducting a visual assessment of client P.B.’s gluteal region;
2. failed to conduct assessments of client P.B. with sufficient frequency.
Between February 12, 2023, and March 2, 2023, Khairmode failed to respond to client P.B.’s concerns in an appropriate and/or professional manner, including one or more of the following:
1. failed to demonstrate sensitivity and/or accountability to client P.B. when you were notified about client P.B.’s burns over the phone;
2. failed to document an incident report in a timely manner after being notified about client P.B.’s burns on February 13, 2023.

Investigation

The evidence obtained during the investigation supported referral of this matter for a hearing.

Findings

Hearing Tribunal accepted the admissions of unprofessional conduct and determined that all the allegations set out in the Notice of Hearing were proven and constituted unprofessional conduct.

Orders

Khairmode’s Practice Permit will be suspended for a period of thirty (30) days.
Khairmode shall pay 25% of the costs of the investigation and hearing.
Within thirty (30) days of receiving the Decision, Khairmode shall:
1. Review the College’s Patient Safety and Risk Management Guide
2. Prepare a self-directed reflection on the Guide and considering the

Hearing Tribunal’s decision

Decision of the Hearing Tribunal on allegations and sanctions (posted August 28, 2024)

Case 10

Allegation

The patient sustained a burn injury on their back following cupping.

Investigation

The investigation focused on the physiotherapist's training in the use of cupping, consent discussions, and education surrounding the use of cupping as a physiotherapy intervention, benefits and risks associated with its use, and the management of a patient safety incident.

Decision

The investigation revealed evidence of post-cupping blisters, not burns.

The physiotherapist had appropriate education regarding using cupping as an intervention and chose to use cupping as an intervention upon the patient’s request. Cupping was indicated as an intervention in this case. Precautions and contraindications were considered. There was no evidence to support or refute how long the cupping cups were in place on the patient’s skin.

There was limited evidence of the depth of the discussion between the physiotherapist and the patient regarding the risks of cupping as an intervention.

There was evidence that the cups used were cleaned but not disinfected between client uses. Cupping cups are classified as non-critical items that require cleaning and disinfection between uses.

While there was evidence of a patient safety event, it did not rise to the level of unprofessional conduct.

The physiotherapist informed the investigation of steps taken to improve their practice because of the complaint, including reviewing all policies and procedures regarding cupping and taking a certification course in cupping.

The physiotherapist was encouraged to:

Review and reflect on the methods used to inform clients about the potential risks of cupping as an intervention and consider incorporating written information to improve consistency in messaging to clients.
Review and reflect on the amount of detail documented regarding consent discussions.
Review and update cleaning and disinfecting policies and procedures for non-critical items.

Case 11

Allegations

The patient had surgery on their left knee and was referred to the physiotherapist to do post-operative rehabilitation.

The College investigated three allegations:

Physiotherapy treatment resulted in an injury to the patient’s right knee.
The physiotherapist failed to obtain informed consent and respect the patient’s concerns about performing exercises.
The physiotherapist failed to provide physiotherapy treatment to the patient’s left knee.

Investigation

There is no evidence tying the patient’s report of right knee symptoms to any activity reported during the physiotherapy sessions. There is evidence to support that the physiotherapist modified the patient’s exercise program when they reported an increase in symptoms. The treatment record reflects an improvement in the patient’s function based on an outcome measure completed by the patient.

The treatment record indicates that consent for treatment was obtained for all sessions. However, how this consent was obtained and how much information the physiotherapist provided to the patient is not captured. The treatment record does demonstrate that exercises were modified, and interventions adjusted following the patient’s report of increased symptoms, demonstrating that the physiotherapist modified the physiotherapy services delivered based on patient’s feedback and subjective report.

No evidence was presented that the physiotherapy services provided were not done so in a safe manner. There was a lack of distinction between left, right, or both knees in the treatment record which was problematic. This made it difficult to determine what occurred during the provision of physiotherapy services.

Decision

There was insufficient evidence specific to the investigated allegations to support a finding of unprofessional conduct by a hearing tribunal. The complaint was dismissed. The physiotherapist was provided with the following recommendations to improve practice:

Complete the College’s Documentation Module
Review and reflect on the College’s Documentation and Record Keeping Standard of Practice.

Page updated: 05/12/2024

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