Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs. That act defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

This bill would authorize a licensed physical therapist to be registered with the Veterinary Medical Board as an authorized a registered animal physical therapist and to provide animal physical rehabilitation, as defined, to an animal if specified requirements are met, including that the authorized registered animal physical therapist performs all delegated animal rehabilitation tasks under the supervision of a veterinarian who has an established veterinarian-client-patient-relationship with the animal. The bill would authorize an animal physical rehabilitation assistant, as defined, to assist with delegated animal rehabilitation tasks subject to specified conditions, including requiring that the tasks to be are performed under the direct supervision of an authorized a registered animal physical therapist. The bill would require the owner or operator of an animal physical rehabilitation facility, as defined, to be registered with submit a registration application to the Veterinary Medical Board. Board and pay a registration fee, as prescribed.

This bill would require the Veterinary Medical Board and the Physical Therapy Board of California to determine qualifications to receive an authorization in necessary for a physical therapist to register with the board to provide animal physical rehabilitation, rehabilitation and would require the Veterinary Medical Board to create the registration form and determine the registration process. The bill would authorize the Veterinary Medical Board to discipline an authorized a registered animal physical therapist, as specified, and would require the Veterinary Medical Board to report disciplinary actions against a registered physical therapist to the Physical Therapy Board of California.

This bill would make a violation of the provisions by a licensee of the Physical Therapy Practice Act unprofessional conduct. The bill would establish fees for the issuance and renewal of an authorization a registration in animal physical rehabilitation and initial and annual renewal fees for registration of an animal physical rehabilitation facility, which would be deposited in the Veterinary Medical Board Contingent Fund.

Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs. That act defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs. That act defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

This bill would state the intent of the Legislature to enact subsequent legislation to authorize a veterinarian to refer an animal to a licensed physical therapist holding an advanced certification to provide animal physical rehabilitation under the supervision of the veterinarian.

ASSEMBLY THIRD READING

ATR Bill Id:AB 814

Author:(Lowenthal)

As Amended Ver:April 27, 2023

Majority vote

SUMMARY

Authorizes a licensed physical therapist (PT), who meets requirements determined by the Veterinary Medical Board (VMB), to provide animal physical rehabilitation (APR) to an animal patient if certain requirements are met, including that the APR is performed on premises registered with the VMB and that the PT works under the supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship with the animal, among other requirements.

Major Provisions

1. Authorizes a licensed PT and a PT assistant, as specified, to perform APR.
2. Makes a violation of this bill by a PT unprofessional conduct with the PTBC.
3. Makes a report of a final disciplinary action against PT by the VMB under this bill conclusive evidence of unprofessional conduct.
4. Establishes various definitions, including:
   1. "Indirect supervision" means both of the following:
      1. The supervising veterinarian is not physically present at the location where delegated APR tasks are to be performed, but has given an order for treatment to an registered animal PT to provide treatment to an animal patient.
      2. The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated APR task.
   2. "Supervising veterinarian" means a veterinarian who is responsible for all of the following:
      1. Examining the animal patient before giving an order for treatment to an registered animal PT or APR assistant to perform a delegated APR task. The examination of the animal patient shall establish a veterinary-patient-client-relationship and shall be conducted within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task, including specific consideration of the animal patient’s condition.
      2. Making all decisions relating to the diagnosis, treatment, management, and future disposition of the animal patient.
      3. Determining the appropriate degree of supervision of an registered animal PTor an APR assistant necessary for the performance of the particular delegated animal physical rehabilitation task, consistent with standards of good veterinary medical practice.
5. Authorizes an registered animal PT to provide APR to an animal if all of the following requirements are met:
   1. The registered animal PT performs all delegated APR tasks under the supervision of a veterinarian who has an established veterinary-patient-client-relationship with the animal. This veterinary-patient-client-relationship need not be established on the same premises where the delegated APR tasks are performed.
   2. The degree of supervision is consistent with standards of good veterinary medical practice and the particular delegated APR task, as determined by the supervising veterinarian.
   3. The delegated APR task is performed on a veterinary premise registered with the VMB, in an APR facility registered with the VMB, or in a mobile or range setting.
   4. The registered animal PT has registered to practice APR with the VMB and has paid the required fee.
6. Prohibits, except as specified, a registered animal PT or APR assistant from performing any activity that represents the practice of veterinary medicine or requires the knowledge, skill, and training of a licensed veterinarian or RVT.
7. Requires an APR facility to be registered with the VMB and pay the registration fee.
8. Authorizes the VMB to inspect an animal rehabilitation facility for safety and compliance with this bill.
9. Requires the VMB to determine the qualifications necessary for a PT to register with the VMB and receive authorization in APR and requires, when making this determination, the VMB and PTBC to ensure that the qualifications provide for safe and efficacious treatment of an animal and are consistent with the VMB’s Animal Rehabilitation Task Force findings and approved motions.
10. Requires the VMB to create the registration form and determine the registration process for authorization.
11. Specifies that an authorization expires two years after the date of issuance and may be renewed in a manner approved by the VMB.
12. Specifies that a registered animal PT shall be solely liable for any delegated animal rehabilitation tasks that they perform. The veterinarian who issues an order for treatment for APR shall not be liable for any animal physical rehabilitation provided by the registered animal PT or the APR assistant.
13. Authorizes the VMB to discipline a registered animal PT, including, but not limited to, revocation of the PT’s authorization to perform APR.
14. Specifies that failure to comply with the supervision requirements under this bill shall be deemed unprofessional conduct and shall subject a registered animal PT to revocation of the authorization issued by the VMB.
15. Requires the VMB to report final disciplinary actions against a registered PT to the PTBC.
16. Specifies that the fee for the issuance and renewal of authorization in APR shall be set by the VMB in an amount not to exceed the reasonable regulatory costs to the VMB.
17. Specifies that the initial and annual renewal fees for registration of an APR facility shall be set by the VMB in an amount not to exceed the reasonable regulatory costs to the VMB
18. Makes the bill operative on January 1, 2025.
19. Sunsets the bill January 1, 2026.

COMMENTS

Background. In California, only licensed veterinarians may provide veterinary medicine to an animal for a wound, fracture, or bodily injury, which includes all treatment, including physical therapy, except that RVTs and unlicensed veterinary assistants may treat animals under a veterinarian’s supervision.

Like other licensing requirements, practice restrictions on veterinary medicine serve to protect consumers of professional services and the public from practices that present a high risk of harm when performed by unqualified practitioners. As a result, those who wish to practice a licensed profession must demonstrate a minimum level of competency that reduces the risk of harm to an acceptable level. Licensing requirements vary by profession but usually include specific education, examination, and experience. Specific training and education may also be supplemented with or substituted for additional supervision by a licensee with the proper level of training.

Currently, a licensed PT who wants to perform physical therapy on an animal must pursue additional licensure as a veterinarian, pursue registration as RVT, or work under the direct supervision of a licensed veterinarian as a veterinary assistant. Direct supervision means the supervising veterinarian is on-site, is readily available, and performs necessary examinations on the animal patient.

RVTs work under the indirect supervision of a licensed veterinarian, which means the licensed veterinarian is not on-site but has provided written or oral instructions, has established a VCPR with the animal patient, and performs examinations as necessary under the veterinary standard of care. This bill seeks to also authorize PTs who are certified in APR, as determined by the VMB and PTBC, to work under the indirect supervision of a licensed veterinarian.

Veterinary Medicine Education. Applicants for licensure as a veterinarian must graduate with a Doctor of Veterinary Medicine (DVM) degree from a four-year program at an accredited college of veterinary medicine or its equivalent, as determined by the VMB. Graduates must take and pass the North American Veterinary Licensing Exam and a California-specific law and ethics examination. The national exam covers all aspects of veterinary medicine and contains visual materials designed to test diagnostic skills.

Licensed veterinarians may also seek board certification by completing a 3-to-4-year residency program. The residency program provides intensive training in one of the 39 specialties recognized by the American Veterinary Medical Association (AVMA). The specialties include internal medicine, oncology, pathology, dentistry, nutrition, radiology, surgery, dermatology, anesthesiology, neurology, cardiology, ophthalmology, preventive medicine, and exotic-small-animal medicine.

Applicants for registration as an RVT must be at least 18 years of age, complete a two-year minimum veterinary technology program at a VMB-approved college or postsecondary institution or the equivalent, as determined by the VMB. The VMB may also consider a combination of education and clinical experience of the RVT as equivalent of the graduation requirement. The RVT must also pass a national examination and state-specific examination.

Veterinary assistants are not required to meet any specific requirements for education or examination. RVTs and veterinary assistants may perform animal health care services and tasks as prescribed by law or regulation under the supervision of a veterinarian. However, RVTs may perform animal health care services on impounded animals pursuant to direct, written, or telephonic order of a veterinarian and may directly purchase sodium pentobarbital for performance of euthanasia without the supervision or authorization of a veterinarian.

Physical Therapy Education. Applicants for licensure as a PT must complete a post- baccalaureate (master's) degree in physical therapy from an accredited postsecondary institution or an institution approved by the PTBC. The educational requirements must include instruction in the subjects prescribed by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association or Physiotherapy Education Accreditation Canada and must include a combination of didactic and clinical experiences.

Generally, PT programs cover basic science courses, including biology, chemistry, and physics as well as specialized courses in biomechanics, neuroanatomy, human growth and development, manifestations of disease, examination techniques, and therapeutic procedures. In addition to classroom and laboratory instruction, students must complete at least 18 weeks of full-time clinical experience with a variety of patients.

Graduates must also take and pass the National Physical Therapy Examination (NPTE) and a California- specific law and ethics examination. The NPTE PT exam consists of 250 multiple choice questions that are designed to assess basic entry-level competence after graduation from an accredited program or from an equivalent non-accredited program.

Animal Physical Rehabilitation Task Force. During the VMB's 2016 Sunset Review hearing, the staff background paper noted that the VMB was becoming increasingly concerned about the welfare of the animals being treated by unlicensed personnel and found evidence of animal harm. As a result, the staff recommendation was for the VMB to "create a task force comprised of stakeholders including veterinarians, RVTs, animal rehabilitation and related animal industry professionals, consumers, and representatives from the legislature to further examine the issue and present a recommendation to the [VMB] by January 1, 2017."

The specific recommendations approved at each meeting are as follows:

First meeting on June 20, 2016:

1. Animal Physical Rehabilitation is defined as the treatment of injury or illness to address pain and improve function by means of physical corrective treatment.
2. Animal Physical Rehabilitation does not include relaxation, recreational or wellness modalities, including but not limited to, massage, athletic training or exercise.
3. Any proposed changes to existing law and regulations are not an attempt to restrict or amend section 2038 of the California Code of Regulations regarding the provision of Musculoskeletal Manipulation modalities.
4. Prior to performing or authorizing Animal Physical Rehabilitation, a veterinarian shall establish a valid veterinarian-client-patient relationship as defined in sections 2032.1 or 2032.15 of the California Code of Regulations.

Second meeting on October 4, 2016:

1. Veterinarians have sufficient education and training to provide Animal Physical Rehabilitation.
2. Registered Veterinary Technicians (RVTs) may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian unless in a range setting in which case the veterinarian may provide the appropriate level of supervision.
3. Veterinary Assistants may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian or an RVT.

Third and final meeting on February 2, 2017:

California licensed physical therapists with advanced certification in Animal Physical Rehabilitation (with such certification to be defined by the Veterinary Medical Board and Physical Therapy Board working cooperatively) may provide animal physical rehabilitation under the degree of supervision to be determined by the veterinarian who has established a veterinarian-client-patient relationship, on a veterinary premises or an Animal Physical Rehabilitation premises (as defined in regulation by the Veterinary Medical Board and the Physical Therapy Board working cooperatively), or a range setting.

However, at the VMB's April 19, 2017, board meeting, the VMB approved a motion to modify the task force's final recommendation to specify that a PT may offer APR under direct supervision, rather than the degree of supervision to be determined by the supervising veterinarian. This bill seeks to codify the task force’s original recommendations.

According to the Author

"California is facing a shortage of veterinarians that has resulted in challenges to accessing veterinary care for animal owners, including physical rehabilitation. [This bill] will help ease the burden on veterinarians by providing them with an additional option for physical rehabilitation care by authorizing a licensed veterinarian, after establishing a veterinary-patient-client-relationship, to refer an animal to an authorized animal physical therapist for treatment. Additionally, the bill authorizes the referring veterinarian to determine the appropriate degree of supervision for an authorized animal physical therapist to provide rehabilitation services on an animal. As the state and veterinary community continue to explore options to address the veterinary shortage and issues with access to care, [this bill] represents a piece of the puzzle that will help balance workload for overburdened veterinary practices and expand options and access to care for animal owners."

Arguments in Support

The Animal Physical Therapy Coalition (sponsor) writes in support:

We are acutely aware of the veterinary access to care issues that plague California. It is very difficult to get the physical rehabilitative care for our animals and passage of this bill will make a profound difference so more animals can get the care they need.

1. Veterinarians have been asking for the ability to authorize/refer to a qualified animal physical therapist (licensed PT with additional training specifically on animals) to assess and treat their animal patients under their supervision (whether that be direct or indirect) at a premise that meets health and safety standards. Once a veterinarian has diagnosed, examined, and determined that physical rehabilitation is the best choice for an animal patient, the veterinarian should be allowed to refer to a qualified animal PT at a facility that is registered with the California Veterinary Medical Board (CVMB).
2. Consumers want and need more access to and choice of animal rehabilitative services.
3. The CVMB wants the ability to inspect facilities where animal rehabilitation services are provided. For this reason, under this measure, a qualified animal PT will be allowed to carry the newly created Animal Physical Rehabilitation Facility permit. This limited premise permit will give the CVMB the authority to inspect these animal rehabilitation facilities as an additional layer of consumer protection.
4. The CVMB wants to ensure liability would not fall on the referring veterinarian. Sharing this concern, [this bill] makes clear that liability would appropriately be placed on the treating licensed professional. This is standard and customary for any licensed professional in California but was explicitly defined in this measure to directly address CVMB concerns.
5. Qualified animal PTs want to be able to provide physical rehabilitative services at their own facility registered with the CVMB under veterinary indirect supervision after a veterinarian has made a diagnosis and determined that their animal patient could benefit from such services.

This bill will not only greatly increase safe access to animal rehab care, but it will also improve interprofessional collaboration between DVMs and PTs which will elevate patient care for animals.

Arguments in Opposition

The California Veterinary Medical Association (CVMA), the Southern California Veterinary Medical Association (SCVMA), the Sacramento Valley Veterinary Medical Association (SVVMA), and the American Veterinary Medical Association (AVMA), write in opposition:

1. Animal Physical Rehabilitation (APR) is the Practice of Veterinary Medicine and Should be Performed by or Under the Direct Supervision of Veterinarians, as Stated in Current Law

After over a decade of dialogue about animal physical rehabilitation and how it should be performed, the California Veterinary Medical Board (VMB) promulgated CCR Title 16, section 2038.5 in 2022. This regulation is now in effect and defines APR as "the treatment of an injury or an illness to address pain and improve function by means of physical corrective treatment," which places it squarely within the practice of veterinary medicine per California Business and Professions Code section 4826(c).

The rulemaking process pursuant to which Section 2038.5 was promulgated was open and fair and welcomed all stakeholders to present information to help the VMB craft a regulation that best serves the interests of animals and consumers alike. The resulting regulation allows a registered veterinary technician (RVT), veterinary assistant, or even a human physical therapist (the subject of AB 814) to perform APR on an animal, but only if specific supervisory parameters are in place to guarantee the safety of the treatment. The model for these 2022 regulations were based on California’s twenty-year old regulations allowing chiropractors to work on animals under the direct supervision of a veterinarian, which have been viewed as successful and workable by veterinarians and chiropractors alike.

1. [This bill] Would Allow Physical Therapists to Practice on Animals Without Veterinary Supervision

California’s Veterinary Medicine Practice Act—specifically, 16 CCR section 2034—defines two types of veterinary supervision: "Direct" or "indirect." "Direct" supervision means that the veterinarian has established a Veterinarian-Client-Patient Relationship (VCPR) through examination of the animal and communication with the client, and is present on the premises while veterinary staff perform a treatment. "Indirect" supervision means that the same VCPR is established, but the veterinarian is not present on the premises while veterinary staff perform a treatment under direct veterinarian treatment orders. For example, under "indirect supervision," an RVT could be instructed by a veterinarian to give a pill to an animal every 4 hours if the veterinarian had to be offsite during that time.

The "supervision" contemplated with [this bill] falls under neither of these rubrics. Indeed, and in stark contrast to the two types of supervision resident in the practice act, [this bill] would allow a human physical therapist to "hang out their own shingle" and perform work on an animal without any veterinarian present on the property whatsoever. Because of the misleading characterization of the term "supervision" both in the bill itself and in the sponsors’ publications concerning same, an unsuspecting consumer will wrongly assume that all protections will be in place at the animal rehab facility to provide for the safety and proper veterinary medical care of the animal. Such will not be the case.

1. Physical Therapists Have No Animal-Related Training in Their Licensing Curriculum

Allowing physical therapists to work without veterinary supervision poses a threat to both animal welfare and consumer protection for the following reasons:

• 1. Physical therapists learn only about human beings in their core education. Vast anatomic, physiologic, and behavioral differences exist between human beings and animals. For that matter, significant differences exist between animal species. In addition, animals obviously cannot speak, and will instinctively hide signs of pain. Animal-specific education is absent in a physical therapist’s education, and training in human anatomy and physiology does not translate sufficiently to safely permit physical therapists to practice on animals without veterinary supervision.
  2. Physical Therapists have no formal training or aptitude testing to address emergency conditions in animals. Currently, if a human suffers a health emergency on a physical therapy premises, the physical therapist can call 911 and have paramedics promptly arrive. Because there is no 911 or 911 equivalent for animals, animals experiencing a health crisis will not receive emergency care if being treated at a facility that does not have veterinary licensees present. In that regard, veterinary practices are required by law to be equipped with emergency medical equipment and drugs to treat emergencies that could arise as a result of procedures being performed on the premises.

Furthermore, allowing physical therapists to arbitrarily insert the word "animals" into the California Physical Therapy Practice Act is unacceptable since they have no formal training to justify them working on animals.

1. Certification is Inadequate to Permit Unsupervised Veterinary Practice

Currently, the two certification programs in the United States that offer animal-centric training to physical therapists do so via online self-study and/or a few weekend classes. Because the core education of physical therapists is focused on a very specific facet of human medicine, the certifications offered in APR do not give them the necessary education or experience needed to safely manage animal patients without veterinary supervision. Specifically, these certifications include:

• • 1. No standardization and institutional oversight of curricula
    2. No uniform time, clinical practice, or course work requirements
    3. No practice restriction for those who perform poorly in the course
    4. No standardized aptitude testing
    5. No continuing education requirement
    6. No obligation to meet ongoing minimum standards of care

1. The Veterinary Profession Has Adequate Training in APR and Provides Services at Hundreds of Veterinary Hospitals Throughout California

As demonstrated through analysis of standardized veterinary school curricula and previously presented to both the VMB and the California legislature, veterinary school curricula incorporate elements of APR throughout a veterinary student’s education. Veterinarians who graduate from accredited schools and obtain licensure are well-versed in rehabilitative therapy and commonly incorporate such practices into their case management. There are currently 13,082 licensed veterinarians in California—all of whom have knowledge, skill, ability, and experience in rehabilitating sick or injured animals.

FISCAL COMMENTS

According to the Assembly Appropriations Committee:

1. The VMB estimates costs of $843,000 in 2024-25, $315,000 in 2025-26 and $161,000 in 2026-27 and ongoing to support the increased workload associated with this bill (VMB Contingent Fund). These funds would support one limited term government program analyst and one program technician to process regulations, create new applications, provide outreach, process applications, and take calls related to the new registration requirements.

If an examination is required to determine minimum qualifications for licensure, VMB would need to conduct an occupational analysis, a one-time cost of $175,000, as well as conduct annual exam workshops, which would cost approximately $50,000 annually. Additionally, VMB would need to modify existing office space to accommodate for the additional staff which is projected to be up to $196,000 in one-time costs. Costs to update the BreEZe licensing system, including a new license type, approximately 20 new enforcement codes, and a new modifier are also included in the above cost estimate. The VMB would receive generated revenue, however the amount is unknown at this time.

1. The Physical Therapy Board (PTB) projects this bill would create approximately 15 enforcement complaints annually, which would equate to approximately 180 hours of staff time. The total fiscal impact to the Board in staff time would be $13,000 annually. Additionally, PTB would need to establish and update regulations. PTB assumes a total of four regulatory packages at 80 hours to complete one package. The total fiscal impact to PTB would be $27,000. The total workload for PTB is considered absorbable at this time.

VOTES

ASM BUSINESS AND PROFESSIONS: 14-1-3

YES: Berman, Flora, Alvarez, Bonta, Gipson, Grayson, Irwin, Jackson, Lee, Lowenthal, McKinnor, Stephanie Nguyen, Joe Patterson, Ting

NO: Dixon

ABS, ABST OR NV: Alanis, Chen, McCarty

ASM APPROPRIATIONS: 12-3-1

YES: Holden, Bryan, Calderon, Wendy Carrillo, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Weber, Ortega

NO: Megan Dahle, Dixon, Sanchez

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: April 27, 2023

CONSULTANT: Vincent Chee / B. & P. / (916) 319-3301 FN: 0000538

Date of Hearing: May 17, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 814

Author:(Lowenthal) – As Amended Ver:April 27, 2023

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill creates a new registration for a licensed physical therapist (PT) under the Veterinary Medical Board (VMB) and, under specified conditions, to provide animal physical rehabilitation (APR) to an animal patient. This bill also authorizes an APR assistant, as defined, to assist with delegated APR tasks, under the direct supervision of a registered animal physical therapist, among other requirements. The bill requires the owner or operator of an APR facility to register with the VMB. This bill requires the VMB to determine requirements for a PT to register with the VMB to provide APR.

FISCAL EFFECT:

1. The VMB estimates costs of $843,000 in 2024-25, $315,000 in 2025-26 and $161,000 in 2026-27 and ongoing to support the increased workload associated with this bill (VMB Contingent Fund). These funds would support one limited term government program analyst and one program technician to process regulations, create new applications, provide outreach, process applications, and take calls related to the new registration requirements.
   
   If an examination is required to determine minimum qualifications for licensure, VMB would need to conduct an occupational analysis, a one-time cost of $175,000, as well as conduct annual exam workshops, which would cost approximately $50,000 annually. Additionally, VMB would need to modify existing office space to accommodate for the additional staff which is projected to be up to $196,000 in one-time costs. Costs to update the BreEZe licensing system, including a new license type, approximately 20 new enforcement codes, and a new modifier are also included in the above cost estimate. The VMB would receive generated revenue, however the amount is unknown at this time.
   
2. The Physical Therapy Board (PTB) projects this bill would create approximately 15 enforcement complaints annually, which would equate to approximately 180 hours of staff time. The total fiscal impact to the Board in staff time would be $13,000 annually. Additionally, PTB would need to establish and update regulations. PTB assumes a total of four regulatory packages at 80 hours to complete one package. The total fiscal impact to PTB would be $27,000. The total workload for PTB is considered absorbable at this time.

COMMENTS:

1. Purpose. The Animal Physical Therapy Coalition (APTC), which describes itself as a grassroots coalition of physical therapists, veterinarians, registered veterinary technicians, and consumers, is the sponsor of this bill. The author states:

California is facing a shortage of veterinarians that has resulted in challenges to accessing veterinary care for animal owners, including physical rehabilitation. AB 814 will help ease the burden on veterinarians by providing them with an additional option for physical rehabilitation care by authorizing a licensed veterinarian, after establishing a veterinary-patient-client-relationship, to refer an animal to an authorized animal physical therapist for treatment. Additionally, the bill authorizes the referring veterinarian to determine the appropriate degree of supervision for an authorized animal physical therapist to provide rehabilitation services on an animal. As the state and veterinary community continue to explore options to address the veterinary shortage and issues with access to care, AB 814 represents a piece of the puzzle that will help balance workload for overburdened veterinary practices and expand options and access to care for animal owners.

1. Background. In California, only licensed veterinarians may provide veterinary medicine to an animal for a wound, fracture, or bodily injury, which includes all treatment, including physical therapy, except that registered veterinary technicians (RVTs) and unlicensed veterinary assistants may treat animals under a veterinarian’s supervision. A licensed PT who wants to perform physical therapy on an animal must pursue additional licensure as a veterinarian, pursue registration as an RVT, or work under the direct supervision of a licensed veterinarian as a veterinary assistant. Direct supervision means the supervising veterinarian is on-site, is readily available, and performs necessary examinations on the animal patient.
   
   Animal Physical Rehabilitation Task Force. Due to the VMB’s increasing concern about the welfare of the animals being treated by unlicensed personnel and evidence of animal harm, the VMB created a task force comprised of stakeholders including veterinarians, RVTs, animal rehabilitation and related professionals, among others, to examine the issue and make a recommendation to the VMB. At its third and final meeting, the task force recommended California licensed PTs with advanced certification in APR (to be defined by the VMB and PTB working cooperatively) may provide animal physical rehabilitation under the degree of supervision to be determined by the veterinarian who has established a veterinarian-client-patient relationship, on a veterinary premises or an animal physical rehabilitation premises (to be defined in regulation by the VMB and the Physical Therapy Board working cooperatively), or a range setting. However, the VMB subsequently approved a motion to modify the task force's recommendation to specify that a PT may offer APR under direct supervision, rather than the degree of supervision to be determined by the supervising veterinarian. This bill seeks to codify the task force’s original recommendation.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 814

Author:(Lowenthal) – As Amended Ver:March 23, 2023

SUBJECT: Veterinary medicine: animal physical rehabilitation.

SUMMARY: Authorizes a licensed physical therapist (PT), who meets requirements determined by the Veterinary Medical Board (VMB) in collaboration with the Physical Therapy Board of California (PTBC), to provide animal physical rehabilitation (APR) to an animal patient if certain requirements are met, including that the APR is performed on premises registered with the VMB and that the PT works under the supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship with the animal, among other requirements.

EXISTING LAW:

1. Provides for the regulation of veterinary medicine under the Veterinary Medicine Practice Act, and prohibits the unlicensed practice of veterinary medicine. (Business and Professions Code (BPC) §§ 4800-4917)
2. Establishes the VMB within the Department of Consumer Affairs (DCA) to implement and enforce the Act, including licensing and regulating veterinarians, registered veterinary technicians (RVTs), unlicensed veterinary assistants, and veterinary premises. (BPC § 4800-4811)
3. Defines the practice of "veterinary medicine, surgery, and dentistry, and the various branches thereof" as the following:
   1. Representing engagement in the practice of veterinary medicine, veterinary surgery, or veterinary dentistry in any of its branches. (BPC § 4826(a))
   2. Diagnosing or prescribing a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of animals. (BPC § 4826(b))
   3. Administering a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of animals, as specified. (BPC § 4826(c))
   4. Performing a surgical or dental operation upon an animal. (BPC § 4826(d))
   5. Performing any manual procedure for the diagnosis of pregnancy, sterility, or infertility upon livestock or Equidae. (BPC § 4826(e))
   6. Using words, letters, or titles that may induce the belief that the person using them is engaged in the practice of veterinary medicine, veterinary surgery, or veterinary dentistry, as specified. (BPC § 4826(f))
4. Makes it unprofessional conduct for a veterinarian to administer, prescribe, dispense or furnish a drug, medicine, appliance, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture or bodily injury or disease of an animal without having first established a veterinarian-client-patient relationship (VCPR) with the animal patient or patients and the client, except where the patient is a wild animal or the owner is unknown. (California Code of Regulations (CCR), Title 16, § 2032.1)
5. Specifies that a VCPR must be established through all three of the following:
   1. The client has authorized the veterinarian to assume responsibility for making medical judgments regarding the health of the animal, including the need for medical treatment. (CCR, tit. 16, § 2032.1(b)(1))
   2. The veterinarian has sufficient knowledge of the animal to initiate at least a general or preliminary diagnosis of the medical condition of the animal. This means that the veterinarian is personally acquainted with the care of the animal by virtue of an examination of the animal or by medically appropriate and timely visits to the premises where the animals are kept. (CCR, tit. 16, § 2032.1(b)(2))
   3. The veterinarian has assumed responsibility for making medical judgments regarding the health of the animal and has communicated with the client a course of treatment appropriate to the circumstance. (CCR, tit. 16, § 2032.1(b) (3))
6. Authorizes RVTs and veterinary assistants to perform specified animal health care services under the supervision of a veterinarian licensed or authorized to practice in this state. (BPC § 4840)
7. Requires the VMB to adopt regulations establishing animal health care tasks and an appropriate degree of supervision required for those tasks that may be performed only by an RVT or a licensed veterinarian; authorizes the VMB to adopt regulations for veterinary assistants; requires the VMB to establish an appropriate degree of supervision by an RVTs or a licensed veterinarian over a veterinary assistant for any tasks established; and requires the degree of supervision for any of those tasks to be higher than, or equal to, the degree of supervision required when an RVT performs the task. (BPC § 4836)
8. Defines “direct supervision” to mean: (1) the supervisor is physically present at the location where animal health care job tasks are to be performed and is quickly and easily available and (2) the animal has been examined by a veterinarian at such time as good veterinary medical practice requires consistent with the particular delegated animal health care job task. (CCR, tit. 16, § 2034(e))
9. Defines “indirect supervision” to mean: (1) that the supervisor is not physically present at the location where animal health care job tasks are to be performed, but has given either written or oral instructions (“direct orders”) for treatment of the animal patient; and (2) the animal has been examined by a veterinarian at such times as good veterinary medical practice requires, consistent with the particular delegated animal health care task and the animal is not anesthetized, as defined. (CCR, tit. 16, § 2034(f))
10. Lists specific animal health care tasks an RVT may or may not perform and the required level of supervision, provides that an RVT may perform health care tasks not listed under the direct or indirect supervision of a licensed veterinarian, and requires the degree of supervision by the licensed veterinarian over the RVT to be consistent with standards of good veterinary medical practices. (CCR, tit. 16, § 2036)
11. Authorizes licensed chiropractors to perform musculoskeletal manipulation (MSM) under direct supervision by a veterinarian, as specified. (CCR, tit. 16, § 2038)
12. Provides for the licensure and regulation of physical therapy under the Physical Therapy Practice Act. (BPC §§2600-2696)
13. Establishes the PTBC within the DCA to administer and enforce the Physical Therapy Practice Act, including licensing PTs, physical therapist assistants, and physical therapy aides and technicians. (BPC § 2602)
14. Defines "physical therapy" as "the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise," which includes "physical therapy evaluation, treatment planning, instruction and consultative services" and "the promotion and maintenance of physical fitness to enhance the bodily movement related health and wellness of individuals through the use of physical therapy interventions," but excludes "use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes, and the use of electricity for surgical purposes, including cauterization," and "the diagnosis of disease." (BPC § 2620)
15. Provides that a PT is not authorized to practice medicine, surgery, or any other form of healing except as described under the definition of "physical therapy." (BPC § 2621)
16. Authorizes the PTBC to take action against a PT license for unprofessional conduct through citation, discipline, denial of a license, or issuance of a probationary license. (BPC § 2660)
17. Specifies that unprofessional conduct includes, among other things:
    1. Practicing or offering to practice beyond the scope of practice of physical therapy. (BPC § 2660(d))
    2. Failure to maintain adequate and accurate records relating to the provision of services to his or her patients. (BPC § 2660(g))
    3. Gross negligence or repeated acts of negligence in practice or in the delivery of physical therapy care. (BPC § 2660(h))
    4. Aiding or abetting any person to engage in the unlawful practice of physical therapy. (BPC § 2660(i))
    5. The commission of any fraudulent, dishonest, or corrupt act that is substantially related to the qualifications, functions, or duties of a PT or physical therapist assistant. (BPC § 2660(j))
    6. Permitting a physical therapist assistant or physical therapy aide under a PT's supervision or control to perform, or permitting the physical therapist assistant or physical therapy aide to advertise competence to perform, professional services beyond the level of education, training, and experience of the physical therapist assistant or aide. (BPC § 2660(n))
18. The revocation, suspension, or other discipline, restriction, or limitation imposed by another state upon a license or certificate to practice physical therapy issued by that state, or the revocation, suspension, or restriction of the authority to practice physical therapy by any agency of the federal government. (BPC § 2660(o))

THIS BILL:

1. Authorizes a licensed PT to perform APR.
2. Makes a violation of this bill by a PT unprofessional conduct with the PTBC.
3. Makes a report of a final disciplinary action against PT by the VMB under this bill conclusive evidence of unprofessional conduct.
4. Defines, for purposes of this bill:
   1. “Animal physical rehabilitation” (APR) as the treatment of injury or illness to address pain and improve function using physical or corrective treatment, consistent with the VMB’s regulations, but excludes relaxation, recreational, or wellness modalities, including massage, athletic training, or exercise.
   2. “Animal physical rehabilitation assistant” as an unlicensed person who is not a licensed veterinarian, registered veterinarian technician, or authorized animal PT, and who assists an authorized animal PT with delegated animal rehabilitation tasks.
   3. “Animal physical rehabilitation facility” as a facility registered with the VMB where an authorized animal PT performs delegated animal rehabilitation tasks on an animal patient.
   4. “Authorized animal physical therapist” as a PT who is registered with the VMB, and who performs APR under a supervising veterinarian.
   5. “Delegated animal rehabilitation task” as APR treatments, functional assessment, or services delegated to an authorized animal PT or APR assistant by a supervising veterinarian providing an order for treatment.
   6. “Direct supervision” as both of the following:
      1. The supervising veterinarian is physically present at the location where delegated APR tasks are to be performed and is quickly and easily available.
      2. The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated APR task.
   7. “Indirect supervision” as both of the following:
      1. The supervising veterinarian is not physically present at the location where delegated APR tasks are to be performed, but has given an order for treatment to an authorized animal PT to provide treatment to an animal patient.
      2. The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated APR task.
   8. “Order for treatment” as oral or written instruction from a supervising veterinarian authorizing APR of an animal patient, including, but not limited to, communication and safety protocols or procedures specific to the animal patient, consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task.
   9. “Supervising veterinarian” means a veterinarian who is responsible for all of the following:
      1. Examining the animal patient before giving an order for treatment to an authorized animal PT or APR assistant to perform a delegated APR task. The examination of the animal patient shall establish a veterinary-patient-client-relationship and shall be conducted within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task.
      2. Making all decisions relating to the diagnosis, treatment, management, and future disposition of the animal patient.
      3. Determining the appropriate degree of supervision of an authorized animal PTor an APR assistant necessary for the performance of the particular delegated animal physical rehabilitation task, consistent with standards of good veterinary medical practice.
   10. “Supervision” or “degree of supervision” as veterinary oversight of the treatment plan performed by the authorized animal physical therapist and may be either direct supervision or indirect supervision.
5. Authorizes an authorized animal PT to provide APR to an animal if all of the following requirements are met:
   1. The authorized animal PT performs all delegated APR tasks under the supervision of a veterinarian who has an established veterinary-patient-client-relationship with the animal. This veterinary-patient-client-relationship need not be established on the same premises where the delegated APR tasks are performed.
   2. The degree of supervision is consistent with standards of good veterinary medical practice and the particular delegated APR task, as determined by the supervising veterinarian.
   3. The delegated APR task is performed on a veterinary premise registered with the VMB, in an APR facility registered with the VMB, or in a mobile or range setting.
   4. The authorized animal PT has registered to practice APR with the VMB and has paid the required fee.
6. An APR assistant may assist with delegated APR tasks if both of the following requirements are met:
   1. The APR assistant performs the delegated APR tasks under the direct supervision of an authorized animal PT.
   2. The APR assistant is working under the degree of supervision consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task, as determined by the authorized animal physical therapist’s supervising veterinarian.
7. Prohibits, except as specified, an authorized animal PT or APR assistant from performing any activity that represents the practice of veterinary medicine or requires the knowledge, skill, and training of a licensed veterinarian or RVT, including the following:
   1. Surgery.
   2. Diagnosis and prognosis of animal diseases.
   3. Prescription of drugs, medicines, or appliances.
   4. Anesthesia.
   5. Application of casts or splints, except temporary cast molding for purposes of fitting custom or prefabricated orthotics or prosthetics if ordered by a supervising veterinarian.
   6. Dental extraction.
   7. Suture.
   8. Administration of controlled substances.
   9. Any other veterinary medicine function, tasks, or activities not specifically authorized by a supervising veterinarian as a delegated APR task.
8. Requires an APR facility to be registered with the VMB and pay the registration fee.
9. Authorizes the VMB to inspect an animal rehabilitation facility for safety and compliance with this bill.
10. Requires the VMB and the PTBC, in cooperation, to determine the qualifications necessary for a PT to register with the VMB and receive authorization in APR and requires, when making this determination, the VMB and PTBC to ensure that the qualifications provide for safe and efficacious treatment of an animal and are consistent with the VMB’s Animal Rehabilitation Task Force findings and approved motions.
11. Requires the VMB to create the registration form and determine the registration process for authorization.
12. Specifies that an authorization expires two years after the date of issuance and may be renewed in a manner approved by the VMB.
13. Specifies that an authorized animal PT shall be solely liable for any delegated animal rehabilitation tasks that they perform. The veterinarian who issues an order for treatment for APR shall not be liable for any animal physical rehabilitation provided by the authorized animal PT or the APR assistant.
14. Authorizes the VMB to discipline an authorized animal PT, including, but not limited to, revocation of the PT’s authorization to perform APR.
15. Specifies that failure to comply with the supervision requirements under this bill shall be deemed unprofessional conduct and shall subject an authorized animal PT to revocation of the authorization issued by the VMB.
16. Requires the VMB to report final disciplinary actions against an authorized PT to the PTBC.
17. Specifies that the fee for the issuance and renewal of authorization in APR shall be set by the VMB in an amount not to exceed the reasonable regulatory costs to the VMB.
18. Specifies that the initial and annual renewal fees for registration of an APR facility shall be set by the VMB in an amount not to exceed the reasonable regulatory costs to the VMB.

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the Animal Physical Therapy Coalition. According to the author, “California is facing a shortage of veterinarians that has resulted in challenges to accessing veterinary care for animal owners, including physical rehabilitation. [This bill] will help ease the burden on veterinarians by providing them with an additional option for physical rehabilitation care by authorizing a licensed veterinarian, after establishing a veterinary-patient-client-relationship, to refer an animal to an authorized animal physical therapist for treatment. Additionally, the bill authorizes the referring veterinarian to determine the appropriate degree of supervision for an authorized animal physical therapist to provide rehabilitation services on an animal. As the state and veterinary community continue to explore options to address the veterinary shortage and issues with access to care, [this bill] represents a piece of the puzzle that will help balance workload for overburdened veterinary practices and expand options and access to care for animal owners.”

Background. In California, only licensed veterinarians may provide veterinary medicine to an animal for a wound, fracture, or bodily injury, which includes all treatment, including physical therapy, except that RVTs and unlicensed veterinary assistants may treat animals under a veterinarian’s supervision.

Like other licensing requirements, practice restrictions on veterinary medicine serve to protect consumers of professional services and the public from practices that present a high risk of harm when performed by unqualified practitioners. As a result, those who wish to practice a licensed profession must demonstrate a minimum level of competency that reduces the risk of harm to an acceptable level. Licensing requirements vary by profession but usually include specific education, examination, and experience. Specific training and education may also be supplemented with or substituted for additional supervision by a licensee with the proper level of training.

Currently, a licensed PT who wants to perform physical therapy on an animal must pursue additional licensure as a veterinarian, pursue registration as RVT, or work under the direct supervision of a licensed veterinarian as a veterinary assistant. Direct supervision means the supervising veterinarian is on-site, is readily available, and performs necessary examinations on the animal patient.

RVTs work under the indirect supervision of a licensed veterinarian, which means the licensed veterinarian is not on-site but has provided written or oral instructions, has established a VCPR with the animal patient, and performs examinations as necessary under the veterinary standard of care. This bill seeks to also authorize PTs who are certified in APR, as determined by the VMB and PTBC, to work under the indirect supervision of a licensed veterinarian.

Veterinary Medicine Education. Applicants for licensure as a veterinarian must graduate with a Doctor of Veterinary Medicine (DVM) degree from a four-year program at an accredited college of veterinary medicine or its equivalent, as determined by the VMB. Graduates must take and pass the North American Veterinary Licensing Exam and a California-specific law and ethics examination. The national exam covers all aspects of veterinary medicine and contains visual materials designed to test diagnostic skills.

Licensed veterinarians may also seek board certification by completing a 3-to-4-year residency program. The residency program provides intensive training in one of the 39 specialties recognized by the American Veterinary Medical Association (AVMA). The specialties include internal medicine, oncology, pathology, dentistry, nutrition, radiology, surgery, dermatology, anesthesiology, neurology, cardiology, ophthalmology, preventive medicine, and exotic-small-animal medicine.

Applicants for registration as an RVT must be at least 18 years of age, complete a two-year minimum veterinary technology program at a VMB-approved college or postsecondary institution or the equivalent, as determined by the VMB. The VMB may also consider a combination of education and clinical experience of the RVT as equivalent of the graduation requirement. The RVT must also pass a national examination and state-specific examination.

Veterinary assistants are not required to meet any specific requirements for education or examination. RVTs and veterinary assistants may perform animal health care services and tasks as prescribed by law or regulation under the supervision of a veterinarian. However, RVTs may perform animal health care services on impounded animals pursuant to direct, written, or telephonic order of a veterinarian and may directly purchase sodium pentobarbital for performance of euthanasia without the supervision or authorization of a veterinarian.

Physical Therapy Education. Applicants for licensure as a PT must complete a post- baccalaureate (master's) degree in physical therapy from an accredited postsecondary institution or an institution approved by the PTBC. The educational requirements must include instruction in the subjects prescribed by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association or Physiotherapy Education Accreditation Canada and must include a combination of didactic and clinical experiences.

Generally, PT programs cover basic science courses, including biology, chemistry, and physics as well as specialized courses in biomechanics, neuroanatomy, human growth and development, manifestations of disease, examination techniques, and therapeutic procedures. In addition to classroom and laboratory instruction, students must complete at least 18 weeks of full-time clinical experience with a variety of patients.

Graduates must also take and pass the National Physical Therapy Examination (NPTE) and a California- specific law and ethics examination. The NPTE PT exam consists of 250 multiple choice questions that are designed to assess basic entry-level competence after graduation from an accredited program or from an equivalent non-accredited program.

Animal Physical Rehabilitation Task Force. During the VMB's 2016 Sunset Review hearing, the staff background paper noted that the VMB was becoming increasingly concerned about the welfare of the animals being treated by unlicensed personnel and found evidence of animal harm. As a result, the staff recommendation was for the VMB to "create a task force comprised of stakeholders including veterinarians, RVTs, animal rehabilitation and related animal industry professionals, consumers, and representatives from the legislature to further examine the issue and present a recommendation to the [VMB] by January 1, 2017."

The specific recommendations approved at each meeting are as follows:

First meeting on June 20, 2016:

1. Animal Physical Rehabilitation is defined as the treatment of injury or illness to address pain and improve function by means of physical corrective treatment.
2. Animal Physical Rehabilitation does not include relaxation, recreational or wellness modalities, including but not limited to, massage, athletic training or exercise.
3. Any proposed changes to existing law and regulations are not an attempt to restrict or amend section 2038 of the California Code of Regulations regarding the provision of Musculoskeletal Manipulation modalities.
4. Prior to performing or authorizing Animal Physical Rehabilitation, a veterinarian shall establish a valid veterinarian-client-patient relationship as defined in sections 2032.1 or 2032.15 of the California Code of Regulations.

Second meeting on October 4, 2016:

1. Veterinarians have sufficient education and training to provide Animal Physical Rehabilitation.
2. Registered Veterinary Technicians (RVTs) may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian unless in a range setting in which case the veterinarian may provide the appropriate level of supervision.
3. Veterinary Assistants may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian or an RVT.

Third and final meeting on February 2, 2017:

California licensed physical therapists with advanced certification in Animal Physical Rehabilitation (with such certification to be defined by the Veterinary Medical Board and Physical Therapy Board working cooperatively) may provide animal physical rehabilitation under the degree of supervision to be determined by the veterinarian who has established a veterinarian-client-patient relationship, on a veterinary premises or an Animal Physical Rehabilitation premises (as defined in regulation by the Veterinary Medical Board and the Physical Therapy Board working cooperatively), or a range setting.

However, at the VMB's April 19, 2017, board meeting, the VMB approved a motion to modify the task force's final recommendation to specify that a PT may offer APR under direct supervision, rather than the degree of supervision to be determined by the supervising veterinarian. This bill seeks to codify the task force’s original recommendations.

Other States. According to the American Veterinary Medical Association, thirty states are silent regarding APR. Thirteen states specifically include APR in their practice acts, with some allowing direct supervision of PTs: Florida, Georgia, Illinois, Iowa, Maine, Mississippi, Tennessee, Indiana, Louisiana, New Mexico, Oklahoma, Pennsylvania, and South Carolina.

Seven states allow for an indirect model similar to this bill: Oregon, Colorado, Nebraska, Utah, Virginia, Nevada, and New Hampshire. Oregon has authorized PTs to practice APR since 1975.

Prior Related Legislation. AB 3013 (Chu) of 2018 would have authorized a licensed PT with a certificate in APR, as determined by the VMB in collaboration with the PTBC, to provide APR to an animal patient if certain requirements are met, including that the APR is performed on specified premises registered with the VMB and that the PT works under the indirect supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship with the animal, among other things.

ARGUMENTS IN SUPPORT:

The Animal Physical Therapy Coalition (sponsor) writes in support:

We are acutely aware of the veterinary access to care issues that plague California. It is very difficult to get the physical rehabilitative care for our animals and passage of this bill will make a profound difference so more animals can get the care they need.

• Veterinarians have been asking for the ability to authorize/refer to a qualified animal physical therapist (licensed PT with additional training specifically on animals) to assess and treat their animal patients under their supervision (whether that be direct or indirect) at a premise that meets health and safety standards. Once a veterinarian has diagnosed, examined, and determined that physical rehabilitation is the best choice for an animal patient, the veterinarian should be allowed to refer to a qualified animal PT at a facility that is registered with the California Veterinary Medical Board (CVMB).
• Consumers want and need more access to and choice of animal rehabilitative services.
• The CVMB wants the ability to inspect facilities where animal rehabilitation services are provided. For this reason, under this measure, a qualified animal PT will be allowed to carry the newly created Animal Physical Rehabilitation Facility permit. This limited premise permit will give the CVMB the authority to inspect these animal rehabilitation facilities as an additional layer of consumer protection.
• The CVMB wants to ensure liability would not fall on the referring veterinarian. Sharing this concern, [this bill] makes clear that liability would appropriately be placed on the treating licensed professional. This is standard and customary for any licensed professional in California but was explicitly defined in this measure to directly address CVMB concerns.
• Qualified animal PTs want to be able to provide physical rehabilitative services at their own facility registered with the CVMB under veterinary indirect supervision after a veterinarian has made a diagnosis and determined that their animal patient could benefit from such services.

This bill will not only greatly increase safe access to animal rehab care, but it will also improve interprofessional collaboration between DVMs and PTs which will elevate patient care for animals.y

ARGUMENTS IN OPPOSITION:

The California Veterinary Medical Association (CVMA), the Southern California Veterinary Medical Association (SCVMA), the Sacramento Valley Veterinary Medical Association (SVVMA), and the American Veterinary Medical Association (AVMA), write in opposition:

A. Animal Physical Rehabilitation (APR) is the Practice of Veterinary Medicine and Should be Performed by or Under the Direct Supervision of Veterinarians, as Stated in Current Law

After over a decade of dialogue about animal physical rehabilitation and how it should be performed, the California Veterinary Medical Board (VMB) promulgated CCR Title 16, section 2038.5 in 2022. This regulation is now in effect and defines APR as “the treatment of an injury or an illness to address pain and improve function by means of physical corrective treatment,” which places it squarely within the practice of veterinary medicine per California Business and Professions Code section 4826(c).

The rulemaking process pursuant to which Section 2038.5 was promulgated was open and fair and welcomed all stakeholders to present information to help the VMB craft a regulation that best serves the interests of animals and consumers alike. The resulting regulation allows a registered veterinary technician (RVT), veterinary assistant, or even a human physical therapist (the subject of AB 814) to perform APR on an animal, but only if specific supervisory parameters are in place to guarantee the safety of the treatment. The model for these 2022 regulations were based on California’s twenty-year old regulations allowing chiropractors to work on animals under the direct supervision of a veterinarian, which have been viewed as successful and workable by veterinarians and chiropractors alike.

B. [This bill] Would Allow Physical Therapists to Practice on Animals Without Veterinary Supervision

California’s Veterinary Medicine Practice Act—specifically, 16 CCR section 2034—defines two types of veterinary supervision: “Direct” or “indirect.” “Direct” supervision means that the veterinarian has established a Veterinarian-Client-Patient Relationship (VCPR) through examination of the animal and communication with the client, and is present on the premises while veterinary staff perform a treatment. “Indirect” supervision means that the same VCPR is established, but the veterinarian is not present on the premises while veterinary staff perform a treatment under direct veterinarian treatment orders. For example, under “indirect supervision,” an RVT could be instructed by a veterinarian to give a pill to an animal every 4 hours if the veterinarian had to be offsite during that time.

The “supervision” contemplated with [this bill] falls under neither of these rubrics. Indeed, and in stark contrast to the two types of supervision resident in the practice act, [this bill] would allow a human physical therapist to “hang out their own shingle” and perform work on an animal without any veterinarian present on the property whatsoever. Because of the misleading characterization of the term “supervision” both in the bill itself and in the sponsors’ publications concerning same, an unsuspecting consumer will wrongly assume that all protections will be in place at the animal rehab facility to provide for the safety and proper veterinary medical care of the animal. Such will not be the case.

C. Physical Therapists Have No Animal-Related Training in Their Licensing Curriculum

Allowing physical therapists to work without veterinary supervision poses a threat to both animal welfare and consumer protection for the following reasons:

1) Physical therapists learn only about human beings in their core education. Vast anatomic, physiologic, and behavioral differences exist between human beings and animals. For that matter, significant differences exist between animal species. In addition, animals obviously cannot speak, and will instinctively hide signs of pain. Animal-specific education is absent in a physical therapist’s education, and training in human anatomy and physiology does not translate sufficiently to safely permit physical therapists to practice on animals without veterinary supervision.

2) Physical Therapists have no formal training or aptitude testing to address emergency conditions in animals. Currently, if a human suffers a health emergency on a physical therapy premises, the physical therapist can call 911 and have paramedics promptly arrive. Because there is no 911 or 911 equivalent for animals, animals experiencing a health crisis will not receive emergency care if being treated at a facility that does not have veterinary licensees present. In that regard, veterinary practices are required by law to be equipped with emergency medical equipment and drugs to treat emergencies that could arise as a result of procedures being performed on the premises.

Furthermore, allowing physical therapists to arbitrarily insert the word “animals” into the California Physical Therapy Practice Act is unacceptable since they have no formal training to justify them working on animals.

D. Certification is Inadequate to Permit Unsupervised Veterinary Practice

Currently, the two certification programs in the United States that offer animal-centric training to physical therapists do so via online self-study and/or a few weekend classes. Because the core education of physical therapists is focused on a very specific facet of human medicine, the certifications offered in APR do not give them the necessary education or experience needed to safely manage animal patients without veterinary supervision. Specifically, these certifications include:

• No standardization and institutional oversight of curricula

• No uniform time, clinical practice, or course work requirements

• No practice restriction for those who perform poorly in the course

• No standardized aptitude testing

• No continuing education requirement

• No obligation to meet ongoing minimum standards of care

E. The Veterinary Profession Has Adequate Training in APR and Provides Services at Hundreds of Veterinary Hospitals Throughout California

As demonstrated through analysis of standardized veterinary school curricula and previously presented to both the VMB and the California legislature, veterinary school curricula incorporate elements of APR throughout a veterinary student’s education. Veterinarians who graduate from accredited schools and obtain licensure are well-versed in rehabilitative therapy and commonly incorporate such practices into their case management. There are currently 13,082 licensed veterinarians in California—all of whom have knowledge, skill, ability, and experience in rehabilitating sick or injured animals.

POLICY ISSUES FOR CONSIDERATION:

Consent. One point of disagreement among proponents and opponents is whether clients can safely consent to APR on behalf of animal patients, even if a veterinarian performs a pre-examination due to the possibility of latent conditions or other difficult-to-observe risks. In human healthcare, a patient or guardian can in most circumstances provide well-informed consent and assume the risk of healthcare procedures. However, in veterinary healthcare, a veterinarian's duties extend to both the client and the animal patient. Because concepts like risk and recovery outcomes cannot be effectively communicated to an animal patient, it is often up to the client to decide whether the risk to an animal patient is acceptable. However, if the provider is unable to explain or the client does not fully understand the risks, then neither the animal patient nor human client can consent.

AMENDMENTS:

1. To incorporate VMB staff recommendations made on April 19, 2023, amend the bill to:
   1. Rename authorization to registration.
   2. Establish premises expiration and reporting requirements.
   3. Remove cross-references to existing APR requirements.
   4. Strike the veterinary medicine activity list, including surgery, that an authorized animal PT or APR assistant shall not perform “unless specifically authorized.”
   5. Delay implementation by 1 year.
2. To further clarify the role of veterinarians in the referral process, amend the bill to:
   1. Require the veterinarian order to additionally include directions, reporting, and limitations.
   2. Require the veterinarian pre-exam to account for the animal’s specific condition.
3. Because the PTBC is not involved in veterinary medicine education, amend the bill to remove the PTBC from the education development process.
4. To provide an opportunity to review the safety of the new supervision model under this bill, amend the bill to add a sunset date aligned with the VMB sunset date.

On page 3 of the bill, after line 15:

4828.5. (a) For purposes of this section, the following definitions apply:

(1) “Animal physical rehabilitation” means the treatment of injury or illness to address pain and improve function by means of physical or corrective treatment, as defined under Section 2038.5 of Title 16 of the California Code of Regulations. treatment. Animal physical rehabilitation does not include relaxation, recreational, or wellness modalities, including, but not limited to, massage, athletic training, or exercise.

(2) “Animal physical rehabilitation assistant” means an unlicensed person who is not a licensed veterinarian, registered veterinarian technician, or authorized registered animal physical therapist, and who assists an authorized a registered animal physical therapist with delegated animal rehabilitation tasks pursuant to this section.

(3) “Animal physical rehabilitation facility” means a facility registered with the board where an authorized a registered animal physical therapist performs delegated animal rehabilitation tasks on an animal patient.

(4) “Authorized “Registered animal physical therapist” means a physical therapist licensed under the Physical Therapy Practice Act (Chapter 5.7 (commencing with Section 2600)), who is registered with the board, and who performs animal physical rehabilitation under a supervising veterinarian pursuant to this section.

(5) “Delegated animal rehabilitation task” means animal physical rehabilitation treatments, functional assessment, or services delegated to an authorized a registered animal physical therapist or animal physical rehabilitation assistant by a supervising veterinarian providing an order for treatment.

(6) “Direct supervision” means both of the following:

(A) The supervising veterinarian is physically present at the location where delegated animal rehabilitation tasks are to be performed and is quickly and easily available.

(B) The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task.

(7) “Indirect supervision” means both of the following:

(A) The supervising veterinarian is not physically present at the location where delegated animal rehabilitation tasks are to be performed, but has given an order for treatment to an authorized a registered physical therapist to provide treatment to an animal patient.

(B) The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(8) “Order for treatment” means oral or written instruction from a supervising veterinarian authorizing physical rehabilitation of an animal patient, including, but not limited to, communication directions, communication, reporting, limitations, and safety protocols or procedures specific to the animal patient, consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task.

(9) “Supervising veterinarian” means a veterinarian licensed pursuant to this chapter who is responsible for all of the following:

(A) Examining the animal patient before giving an order for treatment an authorized a registered physical therapist or animal physical rehabilitation assistant to perform a delegated animal physical rehabilitation task. The examination of the animal patient shall establish a veterinary-patient-client-relationship and shall be conducted within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task. task, including specific consideration of the animal patient’s condition.

(B) Making all decisions relating to the diagnosis, treatment, management, and future disposition of the animal patient.

(C) Determining the appropriate degree of supervision of an authorized a registered animal physical therapist or an animal physical rehabilitation assistant necessary for the performance of the particular delegated animal physical rehabilitation task, consistent with standards of good veterinary medical practice.

(10) “Supervision” or “degree of supervision” means veterinary oversight of the treatment plan performed by the authorized registered physical therapist and may be either direct supervision or indirect supervision.

(b) Notwithstanding any other law, an authorized a registered physical therapist may provide animal physical rehabilitation to an animal if all of the following requirements are met:

(1) The an authorized a registered animal physical therapist performs all delegated animal rehabilitation tasks under the supervision of a veterinarian who has an established veterinary-patient-client-relationship with the animal. This veterinary-patient-client-relationship need not be established on the same premises where the delegated animal rehabilitation tasks are performed.

(2) The degree of supervision is consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task, as determined by the supervising veterinarian.

(3) The delegated animal rehabilitation task is performed on a veterinary premise registered with the board, in an animal physical rehabilitation facility registered with the board, or in a mobile or range setting.

(4) The authorized registered physical therapist has registered to practice animal physical rehabilitation with the board and has paid the fee as described in Section 4905.

(c) An animal physical rehabilitation assistant may assist with delegated animal rehabilitation tasks if both of the following requirements are met:

(1) The animal physical rehabilitation assistant performs the delegated animal rehabilitation tasks under the direct supervision of an authorized a registered physical therapist in compliance with subdivision (b).

(2) The animal physical rehabilitation assistant is working under the degree of supervision consistent with standards of good veterinary medical practice and the particular delegated animal rehabilitation task, as determined by the authorized registered physical therapist’s supervising veterinarian.

(d) Unless specifically authorized by this section, an authorized a registered physical therapist or animal physical rehabilitation assistant shall not perform any activity that represents the practice of veterinary medicine or requires the knowledge, skill, and training of a licensed veterinarian or registered veterinary technician, including the following: technician.

(1) Surgery.

(2) Diagnosis and prognosis of animal diseases.

(3) Prescription of drugs, medicines, or appliances.

(4) Anesthesia.

(5) Application of casts or splints, except temporary cast molding for purposes of fitting custom or prefabricated orthotics or prosthetics if ordered by a supervising veterinarian.

(6) Dental extraction.

(7) Suture.

(8) Administration of controlled substances.

(9) Any other veterinary medicine function, tasks, or activities not specifically authorized by a supervising veterinarian as a delegated animal rehabilitation task.

(e) (1) An The owner or operator of an animal physical rehabilitation facility shall be registered with the board, on a form approved by the board, submit a registration application to the board and pay the registration fee described in Section 4905.

(2) The application shall include the name of each owner or operator of the premises, including the type of corporate entity, if applicable, the name of the premises, and the name of the responsible licensee or registered physical therapist manager who is to act for and on behalf of the registered premises.

(3) The board may inspect an animal rehabilitation facility for safety and compliance with this chapter. and require reporting of adverse events, client complaints, or other safe and compliance information.

(4) The registration shall expire two years after the date of registration and may be renewed in a manner approved by the board and consistent with Article 5 (commencing with Section 4900).

(f) (1) The board and the Physical Therapy Board of California, in cooperation, shall determine the qualifications necessary for a physical therapist licensed under Chapter 5.7 (commencing with Section 2600) to register with the board and receive an authorization in to provide animal physical rehabilitation. When making this determination, the board and the Physical Therapy Board of California shall ensure that the qualifications provide for safe and efficacious treatment of an animal and are consistent with the Veterinary Medical Board’s Animal Rehabilitation Task Force findings and approved motions.

(2) The board shall create the registration form and determine the registration process for the authorization. process.

(g) An authorization A registration shall expire two years after the date of issuance registration and may be renewed in a manner approved by the board and consistent with Article 5 (commencing with Section 4900).

(h) An authorized A registered animal physical therapist shall be solely liable for any delegated animal rehabilitation tasks that they perform. The veterinarian who issues an order for treatment for animal physical rehabilitation shall not be liable for any animal physical rehabilitation provided by the authorized registered physical therapist or the animal physical rehabilitation assistant.

(i) Consistent with this chapter, the board may discipline an authorized a registered physical therapist, including, but not limited to, revocation of the physical therapist’s authorization to perform animal physical rehabilitation.

(j) Failure to comply with the supervision requirements in this section shall be deemed unprofessional conduct and shall subject an authorized a registered physical therapist to revocation of the authorization issued by the board.

(k) The board shall report final disciplinary actions against an authorized physical therapist pursuant to subdivision (i) to the Physical Therapy Board of California.

(l) This section shall become operative on January 1, 2025, and shall remain in effect only until January 1, 2026, and as of that date is repealed.

REGISTERED SUPPORT:

Animal Physical Therapy Coalition (sponsor)

Best Friends Animal Society

A Well-Adjusted Pet

Veterinary Medical and Surgical Group

Advanced Veterinary Specialists

Jurney Veterinary Neurology

Wilder Animal Hospital

Santa Barbara Veterinary Integrative Services

Scout’s House—A Rehab Center for Animals

Roadogs Rescue

The Whole Pet Vet Hospital and Wellness Center

Adobe Pet Hospital

Canine Rehabilitation Institute, Inc.

Law Enforcement Canine Handlers

Search and Rescue Canine Handlers

FitPaws

SpectraVet Therapeutic Lasers

Paw Prosper

Hero Canine Orthotics

Doggon’ Wheels

The Street Dog Coalition

Santa Barbara Flyers Dog Sports

FourLeg Rehab, Inc.

Beach Animal Rehabilitation Center (BARC)

Atlas Rehabilitation for Canines

Shorty’s Rescue

Chrissie’s Fund

K9 PT Academy

A Heart Performance Horses

Return to Freedom Wild Horse Conservation

Academy of Orthopaedic Physical Therapy—Animal Physical Therapy SIG

Dermatology and Allergy Clinic for Animals

Santa Ynez Valley Humane Society/Dog Adoption and Welfare Group

Happy Hounds Massage and Fitness

Moe Love Myofascial Release

Medipaw

Help ‘Em Up Harness

ResQcats

Respond Systems Therapeutic Lasers

Animal Rehab Division of the Canadian Physiotherapy Association

Muffin’s Halo—Guide for Blind Dogs

Registry of Allied Animal Health Practitioners of Canada

Wiggleless—Canine Spine Supportive Device

California Physical Therapy Association

Office of The Sheriff, Santa Barbara County

Santa Barbara County Sheriff's Search and Rescue Team

Numerous individuals

REGISTERED OPPOSITION:

American College of Veterinary Sports Medicine and Rehabilitation

American Veterinary Medical Association

California Veterinary Medical Association

Sacramento Valley Medical Association

Southern California Veterinary Medical Association

Numerous individuals

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301