Controlled Acts and Delegation

The College is committed to supporting Ontario occupational therapists (OTs) to ensure they are competent, ethical and accountable when providing service to the public. This document is intended to help OTs interpret and apply the legislation related to controlled acts within the context of their practice.

Under Ontario law, the Regulated Health Professions Act, 1991 (RHPA) certain acts, referred to as “controlled acts,” may only be performed by certain authorized health care professionals. Authorization to perform controlled acts is granted in legislation that is specific to each profession. For occupational therapy, the authorization for controlled acts and the professional scope of practice are provided for in the Occupational Therapy Act, 1991. Under appropriate circumstances, performance of controlled acts may also be delegated from a professional, who is authorized to perform a controlled act, to another professional who is competent to perform that same act. 

Controlled Acts are procedures or activities which may pose a risk to the public if not performed by a qualified practitioner.

Controlled acts specified in the RHPA, section 27(2):

Who Can Perform Controlled Acts?

Controlled acts can only be performed by a regulated health professional authorized to perform the act under his or her profession-specific legislation or where the controlled act has been appropriately delegated by an authorizer to another professional who has the knowledge, skill and judgement to safely perform the act. 

Depending on the controlled act, some professions may have complete authorization to perform the entire act while other professions may only have partial authorization to perform a specific part of the act. For example, physiotherapists (PTs) have partial authorization for the controlled act of putting an instrument, hand or finger into a body opening that permits performance of tracheal suctioning and assessment/treatment of pelvic musculature but PTs cannot perform any other parts of the act without delegation. 

OTs have complete authorization to perform the controlled act of psychotherapy. OTs are also able to perform acupuncture without delegation (see Exemption).

Occupational Therapy Scope of Practice

Central to the discussion of controlled acts and delegation is the scope of practice for occupational therapy defined in the Occupational Therapy Act, 1991 as follows:

The practice of occupational therapy is the assessment of function and adaptive behaviour and the treatment and prevention of disorders which affect function or adaptive behaviour to develop, maintain, rehabilitate or augment function or adaptive behaviour in the areas of self-care, productivity and leisure. 1991, c. 33, s. 3. 

An OT must consider whether performance of a delegated controlled act falls within the occupational therapy scope of practice prior to accepting delegation.

Psychotherapy

OTs are authorized to perform the controlled act of psychotherapy under section 27 of the RHPA. OTs are permitted to use the protected title ‘Psychotherapist’ when they identify themselves as an OT as set out in the section 33.1 (1) of the RHPA. OTs performing psychotherapy and using the title Psychotherapist are expected to practice according to the College Standards for Psychotherapy.

In specific circumstances, the RHPA permits health professionals to perform controlled acts without having direct statutory authorization. OTs may be permitted to perform controlled acts in the following three ways: 

• Exemptions (Acupuncture) 
• Exceptions
• Delegation (Order or Medical Directive) 

Regardless of the mechanism under which OTs are permitted to perform a controlled act, OTs are expected to obtain the necessary competencies to perform the act safely and to work within the scope of the occupational therapy profession.

Exemptions are modifications to the legislation that grant direct authority for a specific task that falls within the parameters of a controlled act to a profession that is not otherwise authorized to perform the controlled act.

Acupuncture is the one exemption that applies to occupational therapy.

Acupuncture

Acupuncture is a procedure performed on tissue below the dermis, which is a controlled act. Through a legislative exemption under the RHPA, (Ontario Regulation 107/96, Controlled Acts, s. 8(2)), OTs are permitted to perform acupuncture on their own authority, without delegation. The acupuncture exemption applies to OTs performing the activity of acupuncture within the occupational therapy scope of practice.

OTs performing acupuncture are expected to adhere to the Standards for Acupuncture. OTs are not permitted to delegate acupuncture to anyone.

The RHPA, section 29(1) describes five circumstances in which OTs are permitted to perform a controlled act without authority or delegation:

1. Rendering first aid or temporary assistance in an emergency.
   
   OTs can provide emergency assistance that involves a controlled act without receiving delegation. For example, an OT can administer an epinephrine injection, such as an EpiPen, for a client to prevent anaphylactic shock (the controlled act of administering a substance by injection). An OT can splint a fracture (the controlled act of setting a fracture) or apply a defibrillator (the controlled act of applying a form of energy) during an emergency situation.
2. Fulfilling the requirements to become a registrant of a health profession and the act is within the scope of practice of the profession and is done under the supervision or direction of a registrant of the profession.
   
   Student OTs may be included in the delivery of controlled acts as part of fulfilling the requirement to become a registrant of the profession. OTs have direct access to the controlled act of psychotherapy and access to acupuncture by exemption. Delegation of psychotherapy is not required for Student OTs to be included in the delivery of this controlled act. Student OTs are not permitted to perform acupuncture.
   
   When a student is learning to perform controlled acts delegated to OTs, the supervising OT should: obtain delegation for their own involvement; provide the appropriate level of supervision to the student; and seek permission from the authorizer to involve the student in the performance of the controlled act.
3. Treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment.
   
   This exception does not apply to OT.
4. Treating a member of the person’s household. The controlled acts allowed under this exception are communicating a diagnosis, administering a substance by injection or inhalation and putting an instrument, hand or finger into a body opening.
   
   This means that an OT, in his or her personal capacity of caregiver, can perform these acts for his or her own family members without delegation within the role of caregiver.
5. Assisting a person with his or her routine activities of living. The controlled acts allowed under this exception are administering a substance by injection or inhalation and putting an instrument, hand or finger into a body opening.
   
   This exception is an important one for OTs. It gives OTs the authority to assist clients with managing routine activities such as changing a catheter, inserting a tampon, assisting with toileting, administering or titrating oxygen and administering insulin injections provided the OT is competent to assist. For example, increasing the oxygen level as prescribed when engaging the client in activity is considered a routine activity of living if the client’s condition is stable, oxygen therapy has been well-established for a period of time, and such oxygen titration changes are routine for the client within his or her home or community environment.
   
   The interpretation of a routine activity of living may not always be clear. To make the distinction between a routine activity of living and the performance of controlled act requiring delegation, the OT needs to use his/her clinical judgement and consider the following questions:
   • Is this activity one that is routinely taught to clients and caregivers so they can perform it in the absence of a health care provider? If it is, then it is likely a routine activity of living.
   • Is the client’s condition stable? If the client has a stable, ongoing condition that requires regular management, it could likely be a routine activity of living. If client’s condition is in an early, acute or changing state, the client’s condition may not be stable and as a result the activity might not yet be routine. Communicate with the authorizer to determine if the activity is appropriate to perform.
   • Am I competent to perform the controlled act under the circumstances and am I prepared to manage any risks or outcomes associated with the performance of the act?

Delegation is the legislative framework that allows the transfer of legal authority to perform a controlled act from a health professional authorized to perform the controlled act (the authorizer) to another health provider who is not authorized to perform the controlled act. In circumstances where an OT does not have authority to perform a controlled act under the legislation, an OT can accept delegation from an authorizer if the authorizer and the OT both have the competence (knowledge, skill and ability) to safely perform the act.

A controlled act can be delegated for a specific client at a point in time (for example, doctor’s order) or for a client population or group of clients over an unspecified period of time (for example, medical directive).

In every instance of delegation, the client’s best interest must be considered. In deciding to receive delegation of a controlled act, the OT should consider how to achieve an appropriate balance between client need, quality and access. Controlled acts must not be delegated solely for monetary or convenience reasons and quality patient care must not be compromised by the delegation.

Delegation and Assignment

To ensure clear and accurate communication, it is important for OTs to understand the difference between the terms delegation and assignment. Assignment is the process whereby an OT assigns components of occupational therapy service (such as range of motion exercises, ADL retraining, functional mobility, community integration, work simulation activities) that are not restricted acts, to a support person or other care provider. In these circumstances, OTs are not delegating, they are assigning the activity to the occupational therapist assistant (OTA).

For additional information regarding the process of assignment refer to the Standards for the Supervision of Occupational Therapist Assistants and the Standards for Psychotherapy. 

Sub-delegation

It is considered sub-delegation when an individual who has acquired the authority to perform a controlled act through delegation, then delegates it to another provider. OTs are not permitted to subdelegate to other health care professionals or OTAs.

When supervising a student, the student can perform a controlled act under the supervision or direction of the OT provided the OT: 

• has appropriately received delegation (directly from a health professional who has the authority to perform the controlled act);
• is competent to perform the procedure; and,
• is confident the student is competent to safely perform the procedure.

It would be prudent for the OT to seek delegation for the student when the student is learning to perform the act. It is recommended that the OT communicate with the authorizer that a student will be working with the OT and involved in performing the procedure. In addition, it is expected that the OT will practise in accordance with the Standards for the Supervision of Students.

Orders and Medical Directives

Direction provided by an authorizer can take two forms:

1. An order: The criteria and conditions necessary to perform a specific controlled act for a specific client.
2. A medical directive: The authorization to perform a specific controlled act for multiple clients under specific conditions.

It is prudent for the OT to obtain the specific instructions provided by the authorizer in writing. If the directive is incomplete or unclear, it is the OT’s responsibility to seek clarification.

Suggested Content of a Directive for Delegation of a Controlled Act

A directive is intended to provide guidance or parameters related to decision-making when performing a controlled act. Each directive related to a controlled act needs to be context – or situation – specific. Ideally, directives are jointly developed by the regulated health professional with the authority for the controlled act and the OT to whom the act is being delegated. 

A directive may contain:

1. a description of the controlled act being delegated;
2. specific client conditions and circumstances which must be met before the act can be implemented, including differentiating between acts that:
   1. require a client-specific directive/order, meaning, the directive can be implemented only on delegation of the act for a specified patient or,
   2. may be implemented when the OT has identified that client conditions and circumstances have been met (for example, the OT may perform the controlled act on all patients referred to the team, providing the therapist identifies that conditions set out in the directive are met);
3. any contraindications for implementing the controlled act;
4. identification of who may implement the controlled act, including specified educational requirements for the implementers;
5. identification of a feedback mechanism to enable the OT(s) implementing the directive to contact the authorizer to seek for clarification if needed;
6. identification of resources available if the possible outcomes of treatment are not within the OT’s competence or scope of practice;
7. documentation requirements;
8. the date and signature of the administrative authority approving the directive; and
9. any additional information.

When accepting delegation, OTs must ensure they have the knowledge, skill and judgement to perform the activity safely and effectively and are competent to manage all aspects of the act, including environmental factors and potentially adverse reactions. The type and combination of training undertaken by the OT must be sufficient to attain the required competencies prior to performing any controlled acts. Training may include formal courses, workshops, on-the-job supervised practice, observation, rounds and/or review of current evidence in the literature.

The College has considered the factors related to the safe, effective performance of controlled acts. The following section outlines the acts for which the College considers it appropriate for OTs to accept delegation and the acts for which the College does not recommend OTs accept delegation.

Performance of some controlled acts fall outside the scope of practice for occupational therapy or require knowledge, skills and experience not typically addressed in occupational therapy education. For these reasons, the College recommends that OTs do not pursue or accept delegation for certain controlled acts.

For each of the 14 controlled acts, the following section outlines:

1. When it is not recommended for OTs to accept delegation for the act;
2. Activities associated with the controlled act that OTs are permitted to perform within the scope of practice of the profession; and,
3. When delegation of the controlled act to OTs may be appropriate.

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his personal representative will rely on the diagnosis.

While occupational therapists are not permitted to communicate a diagnosis, they do play an important role in collecting and interpreting data that contributes to a diagnosis.

Communicating Assessment Findings

Occupational therapists do regularly communicate their assessment findings to clients and substitute decision maker (SDM). It is essential that the OT provide the client/SDM with an explanation of the nature of the problem, including labeling or naming the identified dysfunction, for example, ataxic gait, left neglect, fine motor delay. The College considers this to be communicating symptoms and does not require delegation.

If the dysfunction suggests the presence of a disease or disorder that a diagnosing practitioner has not identified, the OT, after obtaining appropriate consent from the client/SDM should communicate the findings to this practitioner. When appropriate, Occupational Therapists may be asked to comment on expected functional progress and outcomes within the scope of occupational therapy competency.

Explanation of the Diagnosis

In the process of assessment and intervention, occupational therapists must often explain how the client’s diagnosis may be impacting their occupational performance. In addition, clients/SDM may ask occupational therapists to provide them with information about functional abilities regarding the disease/disorder/injury. This is acceptable if the diagnosis has already been communicated to the client/SDM by the diagnosing practitioner.

Determining a Provisional Diagnosis

Occupational therapists in the course of their assessment and treatment may be alerted to signs and symptoms which are indicative of a disease/disorder/injury of which the client/SDM is unaware. In some instances, occupational therapists are uniquely qualified to assess signs or symptoms and provide clinical information that is essential for the diagnosing practitioner to arrive at a definitive diagnosis. In this case it is the occupational therapist’s professional responsibility to make the client/SDM aware of the significance of the signs or symptoms and to suggest the appropriate action.

Discussions with the client/SDM should occur in a manner that will not result in the client/SDM relying upon the information as a definitive diagnosis and thus, is not considered the controlled act of “communicating a diagnosis which identifies a disease or disorder.” During discussions occupational therapists can refer to a cluster of symptoms but may not relay a suspected diagnosis for example;

An occupational therapist may NOT say: “It seems like you have generalized anxiety disorder”

An occupational therapist may say: “most of the time you feel restless and can’t stop your worry, and that you are afraid something awful might happen…. I think it would be a good idea to make anappointment with your family doctor so they can assess these symptoms.”

Accepting Delegation

As occupational therapy roles evolve, there may be circumstances where occupational therapists have developed the required competency to receive delegation to perform the controlled act of communicating a diagnosis within a specific area of practice. If the authorizer determines that the occupational therapist is competent to accept the delegation and procedures are in place to ensure safe performance of the act, it may be appropriate for an occupational therapist to accept delegation for this controlled act. For example, an occupational therapist with training and experience in arthritis care may have the required competencies to safely accept delegation to communicate a diagnosis of osteoarthritis of the thumb to the client.

2. Performing a procedure below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.

OTs may assess and provide care for superficial wounds, pressure ulcers and burns without delegation if the stage of the wounds does not require the OT to work below the dermis.

For example, debridement of a wound may be performed by an OT when the wound is at the epidermis or dermis level. Once a wound is considered below the dermis, the OT is required to seek delegation to perform the procedure.

3. Setting or casting a fracture of a bone or a dislocation of a joint.

Interventions that do not involve a fracture or dislocation, such as carpal tunnel syndrome, arthritis and post-surgical tendon repair, do not require delegation when an orthotic is required.

While orthotics are not specified in this controlled act, applying them to an unstable fracture carries a risk similar to applying a cast. Depending on the nature of the fracture and its healing stage, this treatment may require delegation.

4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.

 The College recommends OTs not accept delegation of this act.

5. Administering a substance by injection or inhalation.

OTs are often delegated procedures within this controlled act when helping clients engage in daily activities. If the activities are routine activities of living, they do not require delegation as they fall under an exception.

However, when administering a substance by injection or inhalation is not a routine activity, delegation is required. The procedure may no longer be routine if the client’s health status has changed (become unstable), the client’s need for the procedure has changed or the client’s response to the procedure has changed.

For example, a client with a history of Chronic Obstructive Pulmonary Disease (COPD) has been admitted to hospital following a heart attack. The client experiences shortness of breath and dizziness with minimal physical exertion, requires assistance to transfer, and has extremely low activity tolerance. This is a significant change from the client’s pre-hospital admission status. Before proceeding with the controlled act of oxygen titration during a therapy session, the OT must use their clinical judgement to determine if the procedure requires delegation or falls under the routine activities of living exception.

6. Inserting an instrument, hand or finger into a body opening.

Any or all parts of this controlled act can be delegated to an OT. For example, an OT could receive delegation to provide suctioning beyond the larynx or through a tracheotomy. An OT may also receive delegation for assessment and treatment of pelvic health conditions impacting daily function.

As previously noted, routine activities of daily living are excepted from the requirement for delegation. Once established activities are well-established for the client, assisting a client with inserting a nasalgastric tube, tampon, urinary catheter or birth control device may not require delegation.

7. Applying or ordering the application of a form of energy prescribed by the regulations under the RHPA.

The forms of energy referred to in Ontario Regulation 107/96 include:

1.  electricity (for aversive conditioning, cardiac pacemaker therapy, cardioversion, defibrillation, electrocoagulation, electroconvulsive shock therapy, electromyography, fulguration, nerve conduction studies, transcutaneous cardiac pacing);
2. electromagnetism for magnetic resonance imaging; and
3. sound waves for diagnostic ultrasound or lithotripsy.

This controlled act is specific only to the procedures listed above. This means that while diagnostic ultrasound is a controlled act, the use of ultrasound as a treatment modality is not. Likewise, while using lasers to dissolve kidney stones is a controlled act, using lasers to treat a musculoskeletal condition, as would apply to occupational therapy practice, is not. Other procedures that involve forms of energy but are not controlled acts include:

• applying heat;
• using transcutaneous electrical nerve stimulation (TENS), other than to the heart;
• attaching electrodes that do not pierce the dermis to receive biofeedback; and,
• electrical muscle stimulation.

The ordering of x-rays is also not a controlled act. Instead it falls under the Healing Arts Radiation Protection Act, 1990 (HARP) that does not permit OTs to order x-rays. While OTs are often interested in ordering x-rays to support their practice, it must be recognized that it is the HARP and not the controlled act that limits access to OTs.

8. Prescribing, dispensing, selling or compounding a drug as defined in subsection 1(1) of the Drug and Pharmacies Regulation Act 1990, or supervising the part of a pharmacy where such drugs are kept.

This controlled act is specific to the procedures of prescribing, dispensing, selling or compounding a drug and does not include administration.

The College recommends OTs not accept delegation of this act.

Administration refers to everything that happens after the drug is dispensed. An OT does not require delegation to administer a medication unless it involves the controlled act of administering a substance by injection or inhalation, or the controlled act of inserting an instrument, hand or finger into a body opening. Inserting a rectal or vaginal suppository involves the controlled act of inserting an instrument, hand or finger into a body opening.

Administration includes preparing a dose of a drug from the client’s labeled supply and providing it to the client when it is due. Similarly, administering pro re nata (PRN) medication as required does not require delegation if the medication has been dispensed to the client, is taken from his or her own medication supply and does not involve a controlled act to administer. OTs may also repackage properly dispensed medications into mechanical aids, such as a dosette, to facilitate selfadministration, or administration by a family member or unregulated care provider. When administering medication, OTs must take necessary precautions to ensure accuracy and compliance with the prescribed medication.

9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eyeglasses other than simple magnifiers.

The College recommends OTs not accept delegation of this act.

Page magnifiers and non-prescription reading glasses are considered simple magnifiers. Therefore, recommending or providing magnifiers is not a controlled act and OTs do not need delegation to use these assistive devices with clients.

10. Prescribing a hearing aid for a hearing impaired person.

The College recommends OTs not accept delegation of this act.

An FM system that transmits sound waves from one person (for example, a teacher) to another person (for example, a student with a hearing or attention impairment) is not considered a hearing aid. Consequently, recommending or providing such a system is not considered a controlled act and an OT does not require delegation.

11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.

The College recommends OTs not accept delegation of this act.

Recommending a mouth guard to protect the teeth from external blows or falls does not involve a controlled act so delegation is not required.

12. Managing labour or conducting the delivery of a baby.

The College recommends OTs not accept delegation of this act.

13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.

The College recommends OTs not accept delegation of this act.

14. Treating by means of psychotherapy technique.

OTs who are competent to perform psychotherapy are authorized to perform the controlled act and use the title Psychotherapist in compliance with the requirements set out in the RHPA. Delegation is not required. All OTs performing psychotherapy are expected to adhere to the Standards for Psychotherapy.

Informed Consent

As with all interventions, informed consent must be obtained before the OT may perform all or part of a controlled act. The client must be advised if the act has been delegated and be given an opportunity to ask questions and receive answers about the procedure. For additional information regarding informed consent refer to the Standards for Consent. 15

Harm Clause

Section 30 of the RHPA includes a harm clause that prohibits any person from treating or advising a person about his/her health in circumstances in which it is reasonably foreseeable that serious physical harm may result. This clause regulates dangerous activities that may not be specifically listed as controlled acts. It is primarily meant to capture conduct by unregistered practitioners.

There are exceptions to the harm clause including:

• Registered practitioners acting within the scope of their profession;
• Those acting under the direction or in collaboration with a registered practitioner acting withinthe scope of his or her profession; and
• Persons acting pursuant to a properly given delegation

Informing Employers and Other Stakeholders

As a regulated health professional, an OT is accountable for adhering to legislation and professional standards in all situations. If an OT is asked to perform a controlled act outside his or her competence, it poses a risk to the client. The OT is obliged under Ontario Regulation 95/07: Professional Misconduct to inform the authorizer and/or employer that he or she is unable to perform the activity.

The OT may use such a situation to inform stakeholders about controlled act legislation and the harm clause. Employers and other stakeholders need to recognize it is an offence to aid and abet a person to perform aspects of health care that the individual is prohibited from doing.

Documenting Delegation and Performance of Controlled Acts

As with any intervention, documenting the process is important. The Standards for Record Keeping (2016), state “The occupational therapist will ensure that information is documented on all delegated controlled acts that he or she performs for a client.” Documentation should contain:

• the controlled act that has been delegated;
• any specific instructions related to the delegation;
• acceptance of the delegation; and
• the name, date, and designation of the person delegating the controlled act. For example,referencing a medical directive or order may be appropriate.

OTs, in a variety of practice settings and areas of practice are in a position to consider accepting delegation. OTs are accountable for their actions and responsible for demonstrating competency, seeking guidance and refraining from practice beyond the OT’s competence or scope of practice.

OTs are accountable for the practice they provide to the public. Guides are issued by the College to assist the professional. They represent guidance from the College on how OTs should practice in order to comply with legislation. Guides are intended to support, not replace, an OT’s application of clinical reasoning and professional judgment in the context of their practice setting.

Regulated Health Professions Act, 1991.
https://www.ontario.ca/laws/statute/91r18

Occupational Therapy Act, 1991.
https://www.ontario.ca/laws/statute/91o33

College of Occupational Therapists of Ontario (2000). Guideline on the Controlled Acts and Delegation. Toronto, ON.

College of Occupational Therapists of Ontario (2012). PREP Module: Controlled Acts and Scope of Practice. Toronto, ON.

Federation of Health Regulatory College of Ontario (2012). Controlled Acts Chart (Including acts authorized by profession). Retrieved from July 2 , 2015.
http://ipc.fhrco.org/files/Controlled_Acts_Chart_Updated_2015_02_06.pdf

Healing Arts Radiation Protection Act, 1990 (HARP)
https://www.ontario.ca/laws/statute/90h02

College of Occupational Therapists of Ontario (2009). Standards for Acupuncture. Toronto, ON.
https://www.coto.org/resources/standard-for-acupuncture-2023/

College of Occupational Therapists of Ontario (2017). Standards for Consent. Toronto, ON.
https://www.coto.org/resources/standard-for-consent-2023/

College of Occupational Therapists of Ontario (2010). Standards for Psychotherapy. Toronto, ON.
https://www.coto.org/resources/standard-for-psychotherapy-2023/

College of Occupational Therapists of Ontario (2011). Standards for the Supervision of Students. Toronto, ON.
https://www.coto.org/resources/standard-for-the-supervision-of-students-and-occupational-therapy-assistants-2023/

College of Occupational Therapists of Ontario (2011). Standards for the Supervision of Support Personnel. Toronto, ON.

College of Occupational Therapists of Ontario (2016). Standards for Record Keeping. Toronto, ON
https://www.coto.org/resources/standard-for-record-keeping-2023/