COVID-19 Practical Considerations for Oregon Chiropractors (03/25/2020)

We have received numerous phone calls and emails from practitioners who are trying to determine what their responsibilities and rights are in the midst of several confusing and often changing orders and guidelines related to the current COVID-19 crisis. We understand you have many concerns, including patient and staff safety, providing needed care to your patients without abandoning them, and the viability of your practices. Following are some general practical considerations we recommend you review, and in no way should be considered individualized legal advice tailored to your needs. Please consult with your own attorney prior to making any decision.


NEITHER THE GOVERNOR NOR THE OBCE ARE SAYING YOU MUST CLOSE YOUR OFFICE.
 

However, the Board IS saying that each individual practice/practitioner must perform a self-assessment to determine what care they can continue to provide at this time. The outcome of that assessment will determine to what extent your specific practice can remain open. There is no one-size-fits-all answer for the practice of chiropractic amid the current COVID-19 and determination must be made on a case-by-case basis. Further, we recommend that each practice establish policies regarding when it is appropriate to see patients and enforce them.
 

Here are a few things to consider while you navigate the ever-changing landscape of chiropractic:

1.  Communicate clearly with your patients regarding your clinic’s status (open/closed/moved to telehealth), available care and         new policies.

  • If you are unable to stay physically open and your patients require in person care, we recommend having a plan to refer them to other local chiropractic providers who are able to assist, or their PCP.

2. Anything that can be done via telehealth, should be conducted via HIPAA compliant telehealth. For example, can your                  nutritional consultations or rehabilitative exercises be supervised via video conferencing?

  • Remember that telehealth does not change your requirements for clinical justification and record keeping. Telehealth is a delivery method, not alteration to standard of care.

  • Check with your biller and respective insurance companies regarding billing of telehealth

3. You cannot provide elective or non-urgent care IF that care would normally require Personal Protective Equipment (PPE).              PPE is reserved for diagnosis and treatment of COVID-19 and urgent care as determined by OHA. According to the OBCE,          none of the exceptions to this restriction apply to chiropractic.

  • If you already have scheduled elective or non-urgent procedures which require the use of PPE, you must cancel and reschedule those procedures for a date no earlier than June 15, 2020.

4. Understand the purpose of the restrictions is to minimize contact to decrease the risk of spreading of COVID-19 and                     preserve vital resources for treatment of critical or emergency care. Remember the risk of infection which can lead to                   serious illness or death is what you are trying to minimize, therefore we recommend you consider the benefits of the care             you provide when weighed against the risk and your ability to mitigate that exposure. See OHA’s Interim Guidance for                   Elective and Non-Urgent Healthcare Procedures (which applies to Chiropractic):  

  • Consider limiting direct physical care to those individuals who demonstrate a clear clinical necessity.

  • Consider rescheduling in office maintenance or other types of preventative care appointments to telehealth or a later date.

5. Consider strong screening measures for both patients and staff BEFORE they enter your office. Policies for screening should        be clear and all staff trained appropriately.

  • Inquire whether staff or patients have traveled in the past 14 days and where.

  • Screen staff daily (it could be as simple as temperature reading and a sign-in stating that they have not experienced any cold or flu like symptoms). If they run a fever, have shortness of breath, a cough or won’t sign an acknowledgement that they (or to the best of their knowledge anyone they had contact with) have not had any relevant symptoms, then they should not be allowed to enter the clinic. If they have had direct contact with any individual with cold or flu like symptoms, they should not come to work for a minimum of 14 days regardless of whether they develop symptoms or not.

  • Call patients BEFORE their appointment to confirm that they have not experienced any cold or flu like symptoms, and that no one in their family (or other contacts they have had) have experienced cold or flu like symptoms for 14 days prior to the visit. Have a staff person at the door taking temperatures and obtaining patients’ consent to enter the office.

      - Document pre-appointment screening in the patient’s chart
      - Unless a minor or otherwise vulnerable person, no visitors should accompany the patient
      - Patients who the CDC has identified to be in the high-risk category should have their treatment deferred if it cannot be                  provided via telehealth https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html and                    https://www.cdc.gov/coronavirus/2019-ncov/hcp/underlying-conditions.html

6. All CDC and OHA requirements for sanitation and staff hygiene must be strictly followed:

  • This requires among other things, adding effective cleaning of equipment, counters and personnel between each patient visit. You must have proper and sufficient supplies to comply with sanitation requirements.

  • Consider having changes of clothing available if unexpected contact occurs. Alternatively, consider utilizing gowns over clothing if they are available.

  • Space appointments in such a way to allow cleaning of the treatment room and equipment.

7. Do your best to create social distancing and eliminate contact with shared surfaces and between individuals. Following are          some of our ideas on how to achieve that:

  • If possible, keeping outer clinic doors open minimizes contact with surface areas

  • Remove all magazines and toys from the waiting area and treatment rooms

  • When patients arrive, or if they arrive early, ask them to wait in their cars until they are ready to be seen. Do not have more than one person in the waiting room at a time (ideally everyone waits outside), unless patients and staff can observe at least 6 feet of separation from one another.

  • Conduct all patient care to the extent possible in the same room, and do not switch back and forth between patients when delivering care.

  • Payment, copays or deductibles can be processed before or after the care electronically or telephonically in order to minimize the contact with surfaces and time in the clinic.

  • Only staff or doctors should open and close interior doors. Patients can be escorted to the treatment room and they should be discouraged from touching any surface areas in the clinic.

  • If a patient needs x-rays or must use the restroom during their visit, those areas should  subsequently be immediately disinfected.

  • Put all social distancing parameters in place for patients and staff (clearly manual therapies cannot be delivered 6 feet apart, but you should consider alternative means of delivering necessary treatment which minimizes the physical contact and closeness)

       - Consider the least risky (in terms of exposure) forms of adjustment to reduce contact. For example, can the adjustment               be performed effectively with the patient facing away from you? Can you utilize equipment instead of some of the
         manual therapies?

8. Consider utilizing a High-Risk Informed Consent – it would be a good idea to have your patients sign consent to treat based        on the ongoing health epidemic. Realistically, even if you put all the above policies and procedures into application, you              cannot guarantee the safety of your patients. People without symptoms can still have and share COVID-19 and therefore, you      should not treat patients who refuse to assume the risk of the exposure. You cannot have them waive liability for your                    professional negligence in providing the care, but if you do everything you can to screen and sanitize, there still remains risk        of infection and you must disclose that risk to the patients and obtain their consent to treat.

9. If you discover that you, a member of your staff, or one of the patients you treated is diagnosed with COVID-19 you should          immediately discontinue offering care and analyze whether the clinic can stay open and under what conditions. Consider            other reporting requirements.

10. Contact your malpractice carrier and inquire into coverage for telehealth.

11. Contact your general business insurance and inquire into interruption of business and loss profits coverage in case you                need to temporarily close or drastically reduce your business.

12. If you are licensed in more than one state or more than one discipline, you may have different or additional regulations that          apply. Please review all relevant orders and guidelines.

13. Finally, at no time should you offer or advertise any asserted prevention or treatment to COVID-19. All marketing and                    advertisement rules apply and are strictly enforced by the OBCE.
 

Employment Considerations
Separate, but equally important, are the employment considerations during this time. Are your staff reasonably safe in your clinic environment? Can they refuse to work? Are you obligated to pay sick leave?

See OHA’s guidance for Employers
https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le2266.pdf and the 3/14/20 message sent
to employers by the Secretary of State and Labor Commissioner regarding Oregon laws on sick leave.


We are here for you
The benefit/risk analysis and standard of care has changed in this current climate and you must remain diligent in checking the updates from OHA, OBCE, CDC, Department of Labor, etc., and incorporate that into your analysis and your patient encounters. The orders and guidelines are constantly updating, and additional changes could impact your practice. If you need more tailored practice advice our team has extensive experience in regulatory compliance, practice management, risk and liability assessment and prevention, business and employment. We are fully operational but in compliance with current orders
and out of concern for our staff, clients and our communities, we are teleworking for our valued clients.

Stay healthy and remember this too shall pass!

© 2020 Matasaru Law P.C.