The Coronavirus (COVID-19) pandemic has impacted all of us. Play Therapists may not have provided professional services over telehealth until the pandemic. Now, some of you may be transitioning to reopen your practice/clinic, you may be considering continuing telehealth, or perhaps a combination of in-person and telehealth services. Whatever you decide, keep in mind that there can be significant differences in how each of your practices may need to operate according to location. In the last few months, most states have implemented emergency orders, such as stay-at-home orders, although not all have. Some states have implemented orders allowing only businesses deemed essential to be open, and the definition of “essential” may vary widely depending on the state. There is a state-by-state compilation of emergency orders which can be accessed online and may be useful to you as you navigate through these rapidly evolving regulations.
Some states now are reopening and, in many instances, reopening portions of a state, by region, that do not have a large number of cases compared to other areas. It varies considerably. The Centers for Disease Control and Prevention (CDC) and the Federal Government have issued reopening guidelines. It is important to note that these are guidelines/recommendations, and states can determine whether they choose to follow them or not. Each state varies considerably on how they are reopening and when. States who previously reopened may also be considering slowing down their reopening, and there is also consideration on shutting down again.
From a risk management standpoint, Play Therapists should follow the current CDC guidelines, applicable state and federal regulations, review the ATP website for helpful links to resources, and depending on your area of training/practice , check your national professional organization’s website for resources. Note, federal and state regulations may differ, and it is best to follow the most restrictive applicable rules. Often, states may have stricter rules in the state and possibly in a region/county/city within the state. It can be confusing but it is important to remain up to date. The health and safety of your patients, your staff, and you, are of the utmost importance.
Prior to reopening or transitioning to reopen, many factors should be considered, and your practice may need to undergo considerable changes to implement safety measures to reduce risk. Some of these risk considerations include:
Consider Your Comfort Level When Reopening. When thinking of reopening your office, consider if you are comfortable doing so. It is important to determine your risk and that of your patients. Be aware if you are in a high-risk category, consider your own health, and the health and risk status of your patients.
Determine If You Want to Have Reduced Hours or Maintain Some Hours Via Telehealth. (See below “Consider Telehealth When Possible”).
Develop New/Revised Policies and Procedures. You will likely need to develop new or will need to revise policies and procedures for your office. Some of these may include:
- Use of PPE;
- Revised/new infection control procedures;
- Social distancing guidelines;
- How many individuals can be in the office at the same time;
- Waiting area requirements/patient check-in process;
- Phone Pre-Screening and In-Person Screening Guidelines (items such as temperature check, questions about travel to certain high-risk areas, contact with someone known to have had COVID-19, and whether the patient has been under quarantine and when);
- How staff members should notify the office if they are ill; and
- Staff protection strategies.
If Employed by a Clinic or Hospital System, Know their Policies/Procedures. If you are employed by a clinic or hospital system, their policies and procedures likely will have changed following COVID-19. There may be new polices such as no visitors allowed, no accompanying guests, or restricted visitors. If there are restrictions and as Play Therapists typically treat children/minors, you may need to make alternate arrangements such as meeting your patients at the door and accompanying them to your office. Make sure you have a system in place and communicate this to your patient’s parent/guardian prior to the appointment.
Implement Training for Staff. Prior to reopening your office, it is important to meet with all staff regarding changes in policies and procedures. Consider holding a video conference with staff prior to opening the office. Staff may be nervous, may have questions, and may also have helpful ideas/strategies. Some issues may include: use of PPE, new patient pre-screening/screening process, check-in process, cleaning equipment, handling and cleaning of devices, and a policy of how employees can notify the office if they are ill.
Screen Staff Each Workday. When your staff members arrive for work each day and prior to patients arriving, consider screening them for symptoms/travel/contacts pertaining to COVID-19. If the staff member has had exposure, follow recommendations as set forth by the CDC.
Office Practices Related to Personal Protective Equipment (PPE). Depending on your practice and current guidelines, it is important to determine if PPE may be indicated. Your state may have requirements concerning masks in public spaces or in buildings. As such, it is important to be aware of applicable regulations and require staff and patients to adhere to regulations prior to allowing their entry. In addition, the Occupational Safety and Health Administration (OSHA) has issued guidance which we suggest you review and follow.
Develop an Infectious Disease Preparedness and Response Plan. Review OSHA’s items to incorporate.
Implement a Routine Cleaning Policy. Ensure your office implements cleaning procedures to reduce the risk of spread on surfaces. Review and follow OSHA’s “Ten Steps All Workplaces Can Take to Reduce Risk of Exposure to Coronavirus.” The U.S. Environmental Protection Agency (EPA) has a list of cleaning products effective against COVID-19. Determine how the office will be sanitized (in between patients, for example). Ensure these procedures are followed routinely and that your staff is aware of and complies with the process.
Given that most of you use toys in treatment or your office has toys in the waiting area, ensure that you use toys that can be cleaned in between each patient. If you have toys that cannot be cleaned, such as books, it is best to not use them at this time. The CDC provides recommendations for cleaning and disinfecting toys, guidelines on cleaning schools (which may be applicable), and facilities. We encourage you to review these guidelines.
Ensure Your Office Knows How To Report a Potential COVID-19 Case or Exposure to Your Office. Know how to contact relevant public officials if you suspect a patient/staff member may have COVID-19, were notified that a patient/staff member was in your office and has been diagnosed with the virus, and/or there was exposure to your office. The CDC encourages businesses to coordinate with state and federal health officials so timely and accurate information can guide appropriate responses. The website provides links to state resources.
Develop and Mail a Letter to All Patients. Before you open your office, you should send a letter to all of your patients. As most of you treat minors, make sure you send the letter to the guardian/parent who has the legal authority to make decisions. This letter should outline items such as:
- Changes in your practice;
- Safety precautions that the office is taking;
- Explanation that the office will be implementing phone pre-screening for each scheduled appointment; and
- New policy for check-in, waiting area changes (including changes in removing books or toys), and screening.
When patients arrive to the office, we suggest that you have an acknowledgement document for them (or their parent/guardian) to sign, indicating they reviewed the letter. Again, as most of your patients may be minors, provide this to the person accompanying the minor. If there is an indication that he/she did not receive the letter in the mail, present him/her with another copy along with the acknowledgement document.
Update Your Website.
Post an announcement on your website including office hours, information regarding telehealth, and the letter to your patients.
Post Announcements/Notices on the Door and in the Office. Post any announcements about wearing a mask, use of hand sanitizer upon entry, or asking patients to wait to come into the office until their scheduled appointment time. The notices on the door should indicate that patients should not enter the office until the notices have been read. Make sure these notices comply with local rules and regulations (for example, some local cities require a mask whereas others do not). If regulations require a mask to enter the office, patients should be notified that they will not be allowed entry, thus, will not be seen without a mask, and their appointment will need to be rescheduled. Ensure that the notices have large enough font which will draw attention to them.
Consider Prioritizing Patients. Your office may have been closed for a period of time, and patients may have more emergent issues over others. Some may have been waiting a considerable period of time. It is important to consider prioritizing based on the need.
Implement Telephone Pre-Screening/Screening Upon Arrival. Your office should develop a set of pre-screening questions to ask the patient on the phone. To reduce risk of exposure, it is important to conduct a pre-screening prior to the patient (if the patient is a minor, the person who is accompanying him/her) coming into the office. Keep in mind, however, patients and parents/guardians can be asymptomatic but still have the virus. Remind the patient and/or parents/guardians not to come into the office if he/she has a fever, shortness of breath, coughing, gastrointestinal issues, or other symptoms associated with COVID-19. If the patient is a minor, conduct the pre-screening with the minor’s parent/guardian. Prior to leaving the house on the day of the appointment, ask the patient (if the patient is a minor, the person accompanying him/her) to take his/her temperature and indicate that he/she will need to reschedule the appointment if experiencing any symptoms or have had potential exposure.
It is important to screen the patient upon arrival implementing the same set of pre-screening questions, and if the patient is accompanied by another person, he/she should be screened as well. Follow guidelines on whether your office should consider taking the patient’s temperature when he/she arrives for an in-patient appointment. With respect to temperature checks, it is important to check your state website and the CDC for updated guidelines on the types of thermometers to use (forehead or oral). Make sure you have a process in place to properly disinfect in between patients.
All of these pre-screening and screening steps should be taken with both existing and new patients. Concerning new patients, you should review your new patient forms to determine if they need to be updated. Having all patients submit paperwork electronically when possible is strongly recommended. If actual paper forms are exchanged, staff should wear gloves or use hand sanitizer when handling.
Avoid Patient-to-Patient Contact. When possible, implement separate entrances, limit how many persons can be in the practice at a time, and request that patients do not enter the office until the time of their appointment. When able, consider asking patients to wait in their cars until the time of their appointment at which time they will be texted or otherwise informed.
Alter Payment Procedures. Avoid taking cash payments, when possible. When taking a credit/debit card payment, staff should wear gloves or use hand sanitizer when handling. Sanitize the card when returning to the patient.
Determine If Your Office Needs to be Rearranged. If you have a waiting room, determine if chairs will need to be rearranged to maintain safe distance. Remove any items such as magazines, books, or toys that can increase risk of spread. Again, if you have patients who are children and, as a result, have toys in your office, ensure they are able to be wiped down after each use. Additionally, talk with other colleagues about whether plexiglass partitions may be indicated in the check-in area.
Consider an Addendum to Informed Consent Document. Lawsuits related to the pandemic are already emerging. Consider implementing an addendum to your informed consent document that indicates the risk of transmission still remains, and the patient is choosing to accept that risk. Consult with your legal advisor when considering an assumption of risk document or an addendum to your informed consent document. When treating minors, ensure the person who is signing the document has the legal authority to do so.
Consider Telehealth When Possible. If your state allows Play Therapists to engage in telehealth, the service is compatible with telehealth, confidentiality can be protected, and the patient has access to a device to engage in telehealth and is skilled to interact with the device, this should be a consideration. Many states have relaxed regulations concerning telehealth. It is important to stay up-to-date on regulations as they may change when the emergency orders are lifted. There are times when telehealth may not be possible depending on the type of service; however, when able, consider use of telehealth versus in-person services.
Be Aware of Risks Associated with Technology. If engaging in telehealth, it is important to be aware of risks. During this time, the use of video-teleconferencing (VTC) platforms has surged. Many states implemented emergency orders improving access to telehealth, while at the same time, federal regulations, under HIPAA, have also been relaxed. New risks have emerged due to the increased use of these platforms. No matter which VTC platform you use, it is important to exercise due diligence in selecting a secure platform. Additionally, it is critical to have security systems in place to minimize security breaches.
Know Your Responsibilities Under the Americans with Disabilities Act (ADA). Be mindful your obligations and know if you need to make reasonable accommodations to communicate effectively by using auxiliary aids.
To ensure effective communication, you may need to use auxiliary aids to facilitate the communication. The ADA defines “auxiliary aids” and some examples include: Video Remote Interpreting (VRI) services, qualified interpreters, assistive listening devices, note takers, written materials, Braille materials, etc. Auxiliary aids should be accessible, timely, protect privacy, and independence. Given the current environment, you may not be able to access in-person interpreter services. Avoid using family members or friends accompanying the patient. Consider consulting with an attorney or risk management professional to determine permissible auxiliary services.
Know Reporting Obligations. You may not have seen your patient in person for an extended period of time. During the last few months, children may have been confined within their homes if they were in a state where there were stay at home orders. Children may have been in homes that were not safe and where they experienced or witnessed abuse. Children also may likely have been out of school and isolated from others. They may have been at increased risk due to additional stressors during this time including parental job loss, substance use, increased financial burdens, lack of social outlets, and limited in-person resources due to programs being closed due to social distancing rules. There may also have been challenges in your ability to assess for abuse or neglect or risk of harm given that the patient may only be seen on a screen (or an even more challenging observation via the phone) for a telehealth session. It is important, however, whether in person, on a screen, or on the phone, that you remain vigilant for signs that the patient may be experiencing abuse and neglect or risk of harm and report to relevant authorities, including the police, when indicated.
Each state has differing rules on mandated reporting of suspected abuse, what Play Therapists are required to report, and whether there are penalties for failing to report. It is important that you know the rules in your state and, if your patient lives in another state, what the rules are in that state.
Ensure Vendors Respect Your Office Practices. Should you have vendors or delivery persons, ensure they are adhering to relevant recommendations for social distancing and wearing protective equipment. Maintain open communication with those coming in and out of your office.
Review Your Contracts. You may have existing contracts with vendors. Your practice may change considerably, and cash flow may diminish. It is important to review your existing contracts and determine if you will need to renegotiate.
Stay Connected and Informed. Regulations and guidelines are changing all the time. Remain knowledgeable and up-to-date on applicable regulations pertinent to your practice. Be aware of guidance from the APT/your professional organization, the CDC, and federal and state regulations/guidelines. Consult with colleagues and seek advice should you have questions. Discuss your concerns, ask for guidance, and do not feel pressure to do something that could put you, your patients, and/or your family at risk.
Seek Professional Guidance. If you have questions, seek guidance from your local attorney or risk management professional.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
1 The Council of State Governments, “COVID-19 Resources for State Leaders,” https://web.csg.org/covid19/executive-orders/
3 CDC, “Guidelines for Opening Up America Again,” https://www.whitehouse.gov/openingamerica/
4 CDC, “Public Health Recommendations for Community-Related Exposure,” https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html
5 U.S. Dept. of Labor, U.S. Dept. of Health & Human Svcs., “Guidance on Preparing Workplaces for COVID-19,” OSHA 3990-03 2020, https://www.osha.gov/Publications/OSHA3990.pdf
6 U.S. Dept. of Labor, U.S. Dept. of Health & Human Svcs., “Guidance on Preparing Workplaces for COVID-19,” OSHA 3990-03 2020, https://www.osha.gov/Publications/OSHA3990.pdf, p. 7-8
7 U.S. Dept. of Labor, OSHA, “Ten Steps All Workplaces Can Take to Reduce Risk of Exposure to Coronavirus,” https://www.osha.gov/Publications/OSHA3994.pdf
8 U.S. EPA, “List N: Disinfectants for Use Against SARS-CoV-2,” https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
9 CDC, “Infection Control Recommendations, Care of Environment,” (Feb. 2017) IV.F. 4 https://www.cdc.gov/infectioncontrol/guidelines/isolation/recommendations.html [cleaning toys]; CDC, “Cleaning and Disinfecting Your Facility," https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html; CDC, “How to Clean and Disinfect Schools to Help Slow the Spread of Flu,” https://www.cdc.gov/flu/school/cleaning.htm
10 CDC, “Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19),” https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html
12 CDC, “Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States,” https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html; CDC, “Healthcare Professional Preparedness Checklist For Transport and Arrival of Patients With Confirmed or Possible COVID-19,” https://www.cdc.gov/coronavirus/2019-ncov/hcp/hcp-personnel-checklist.html
13 American Speech-Language-Hearing Association, “COVID-19: Tracking of State Laws and Regulations for Telepractice and Licensure Policy,” https://www.asha.org/uploadedFiles/State-Telepractice-Policy-COVID-Tracking.pdf, [last accessed updated April 27, 2020]
14 "The Council of State Governments, COVID-19 Resources for State Leaders,” https://web.csg.org/covid19/executive-orders/; U.S. Dept. of Health & Human Services, “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency,” https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
15 For more information on new risks associated with telehealth, see our Allied Healthcare Blog: “New Security Risks and Vulnerabilities: Engaging in Telehealth During the Coronavirus (COVID-19) Pandemic,” https://www.trustrms.com/Resources/Blog/new-security-risks-and-vulnerabilities-engaging-in-telehealth-during-the-coronavirus-covid-19-pandemic and additional resources found on our Allied Healthcare COVID-19 Resource Page: https://www.trustrms.com/Resources/COVID-19-Resources
16 National Network Information, Guidance, and Training on the Americans with Disabilities Act, “What is the Americans with Disabilities Act (ADA)?” https://adata.org/learn-about-ada
17 National Network Information, Guidance, and Training on the Americans with Disabilities Act, “What kinds of auxiliary aids and services are required by the ADA to ensure effective communication with individuals with hearing or vision impairments?” https://adata.org/faq/what-kinds-auxiliary-aids-and-services-are-required-ada-ensure-effective-communication
18 ADA Title III Regulation 28 CFR Part 36.03