Scope of Practice for the Speech-Language Pathology Assistant (SLPA)

Scope of Practice

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Ad Hoc Committee to Update the Scope of Practice for Speech-Language Pathology Assistants

Table of Contents

• About This Document
• Dedication
• Acknowledgements
• Executive Summary
• Introduction
• Statement of Purpose
• Minimum Requirements for an SLPA
  • Three Educational Options
  • Additional Requirements
• Expectations of an SLPA
• Responsibilities Within the Scope of Practice for SLPAs
• Service Delivery
• Culturally Responsive Practices
  • Responsibilities for SLPs and SLPAs
  • Responsibilities for Practitioners Who Use Multiple Languages
• Administrative Support
• Prevention and Advocacy
• Responsibilities Outside the Scope of Practice for Speech-Language Pathology Assistants
• Practice Settings
• Ethical Considerations
• Liability Issues
• Guidelines for SLP Supervision of SLPAs
  • Minimum Qualifications for a Supervising SLP
  • Expectations for the Supervising SLP
  • Supervision of SLPAs
  • SLP-to-SLPA Ratio
  • Requirements for the Frequency and Amount of Supervision
• Conclusion
• Definitions
• References

About This Document

This Scope of Practice for the Speech-Language Pathology Assistant (SLPA) was developed by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee to Update the Scope of Practice for Speech-Language Pathology Assistants (hereafter, “the Ad Hoc Committee”). In January 2021, the ASHA Board of Directors approved a resolution for the development of the ad hoc committee to complete this task. Members of the committee were Jerrold Jackson, MA, CCC-SLP (chair, Texas), Tyler T. Christopulos, PhD, CCC-SLP (Utah), Erin Judd, C-SLPA (Minnesota), Ashley Northam, CCC-SLP (Oregon), Katie Orzechowski, MS, CCC-SLP (Illinois), Jennifer Schultz, MA, CCC-SLP (South Dakota), Nancy Thul, MS, CCC-SLP (Minnesota), Nicole Wilson-Friend, C-SLPA (California), and Lemmietta McNeilly, PhD, CCC-SLP (ex officio). Linda I. Rosa-Lugo, EdD, CCC-SLP, Vice President for Speech-Language Pathology Practice, served as the Board liaison. The composition of the Ad Hoc committee included ASHA-certified speech-language pathologists (SLPs) and SLPAs with specific knowledge and experience working with/as support personnel in clinical practice in schools, health care, and/or private practice settings.

This document is intended to provide guidance for SLPAs and their SLP supervisors regarding ethical considerations related to the SLPA practice parameters. It addresses how services performed by SLPAs should be utilized and what specific responsibilities are within and outside their roles of clinical practice. This information was developed by analyzing current practice standards, certification requirements, methods of academic and clinical training (from academic program directors, clinical educators, etc.), and feedback from stakeholders in communication sciences and disorders. Given that standards, state credentialing (e.g., licensure, etc.), and practice issues vary from state to state, this document’s purpose is to provide information regarding ASHA’s guidelines for the use of SLPAs for the treatment of communication disorders across practice settings.

Dedication

In loving memory of Steve Ritch, whose dedication, commitment, and perseverance contributed to ensuring integrity and quality in addressing the topic of SLPAs within the ASHA structure.

Acknowledgements

We would like to acknowledge others who provided feedback and insights that aided in the development of this document. The Ad Hoc Committee would also like to acknowledge the expertise shared by Marianne Gellert-Jones, MA, CCC-SLP (Pennsylvania), Ianessa Humbert, PhD, CCC-SLP (Washington, D.C.), and Rosemary Montiel, C-SLPA (California).

Executive Summary

ASHA has identified critical shortages of speech-language pathologists (SLP) in all regions of the country, particularly in school settings. These shortages impede the ability of individuals with communication and related disorders to reach their full academic, social, and emotional potential. The use of speech-language pathologist assistants (SLPAs) is an essential element of aiding those professionals who provide services and individuals who rely on such services. It is the position of ASHA that the use of any support personnel be done with the explicit purpose of support for the SLP rather than used as an alternative.

This scope of practice presents minimum recommendations for the training, use, and supervision of speech-language pathology assistants. SLPAs perform tasks as prescribed, directed, and supervised by ASHA-certified and/or state-credentialed SLPs. Support personnel can be used to increase the availability, frequency, and efficiency of services.

Some tasks, procedures, or activities used to treat individuals with communication and related disorders can be successfully performed by individuals other than SLPs if the persons conducting the activity are properly trained and supervised by ASHA-certified and/or state-credentialed SLPs. The use of evidence as well as ethical and professional judgment should be at the heart of the selection, management, training, supervision, and use of SLPAs.

This scope of practice specifies the minimum qualifications and responsibilities for an SLPA and delineates the tasks that are the exclusive responsibilities of the SLP. In addition, the document provides guidance regarding ethical considerations when SLPAs provide clinical services and outlines the supervisory responsibilities of the supervising SLP.

Introduction

The Scope of Practice for the SLPA provides information regarding the training, use, and supervision of assistants in speech-language pathology – a designation that ASHA established to be applicable in a variety of work settings. Training for SLPAs should be based on the type of tasks specified in their scope of responsibility. Specific education and training may be necessary to prepare assistants for unique roles in various professional settings.

ASHA has addressed the topic of support personnel in speech-language pathology since the 1960s. In 1967, the ASHA Executive Board established the Committee on Supportive Personnel and, in 1969, the document ASHA Legislative Council (LC) approved the document Guidelines on the Role, Training and Supervision of the Communicative Aide. In the 1990s, several entities—including committees, a task force, and a consensus panel—were established and the LC approved a position statement, technical report, guidelines, and curriculum content for support personnel. In 2002, ASHA developed an approval process for SLPA programs, and in 2003 ASHA established a registration process for SLPAs. Both were discontinued by vote of the LC because of fiscal concerns. In 2004, the LC approved a position statement on the training, use, and supervision of support personnel in speech-language pathology. Since then, the number of SLPAs has increased primarily in schools and private practice settings. ASHA members in many states continue to request specific guidance from ASHA. In 2016, the ASHA Board of Directors (BOD) completed a feasibility study for the standardization of requirements for assistants; that study demonstrated strong support for certifying assistants, across all stakeholders. The ASHA BOD voted to approve the Assistants Certification program in 2017. In December 2020, the ASHA Assistants Certification Program launched; this program sets standards for the practices and operations for SLPAs as well as for audiology assistants.

This document does not supersede federal legislation and regulation requirements or any existing state credentialing laws, nor does it affect the interpretation or implementation of such laws. The document may serve, however, as a guide for the development of new laws or, at the appropriate time, for revising existing licensure laws.

Statement of Purpose

The purpose of this document is to define what is within and outside the scope of responsibilities for SLPAs who work under the supervision of properly credentialed SLPs. The following aspects are addressed:

• parameters for education and professional development for SLPAs
• SLPAs' responsibilities within and outside the scope of practice
• varied practice settings
• information for others (e.g., special educators, parents, consumers, health professionals, payers, regulators, members of the general public) regarding services that SLPAs perform
• information regarding the ethical and liability considerations for the supervising SLP and the SLPA
• supervisory requirements for the SLP and the SLPA.

Minimum Requirements for an SLPA

An SLPA must complete an approved course of academic study, complete a supervised clinical experience, successfully pass the ASHA Assistants Certification Exam, meet credentialing requirements for the state in which they practice, and receive orientation as well as on-the-job training of SLPA responsibilities specific to the setting.

The minimum educational, clinical, and examination requirements for all SLPAs are outlined in the subsections below:

Three Educational Options

An SLPA has three educational options:

1. Completion of an SLPA program from a regionally accredited institution (e.g., an associate degree, a technical training program, a certificate program).

OR

2. Receipt of a bachelor’s degree in communication sciences and disorders from a regionally accredited institution AND completion of ASHA education modules.

OR

3. Receipt of a bachelor’s degree in a field other than communication sciences and disorders AND completion of ASHA education modules AND successful completion of coursework from a regionally or nationally accredited institution in all of the following areas:

• • introductory or overview course in communication disorders
  • phonetics
  • speech sound disorders
  • language development
  • language disorders
  • anatomy and physiology of speech and hearing mechanisms

Additional Requirements

In addition to having satisfied one of the above three educational options, the SLPA must also meet all the following three requirements:

1. Completion of a supervised clinical experience that consists of a minimum of one hundred (100) hours under the direct supervision of an ASHA certified SLP. The supervising SLP must meet all ASHA certification and supervising requirements and state credentialing requirements.
2. Achieve a passing score on the ASHA Assistants Certification Exam.
3. Meet all state credentialing requirements.

Expectations of an SLPA

The following list details of the roles and performance expectations of an ASHA-certified SLPA:

• Adhere to all applicable state laws and rules regulating the practice of speech-language pathology.
• Adhere to the responsibilities for SLPAs specified in this scope of practice document and in state requirements.
• Avoid performing tasks or activities that are the exclusive responsibility of the SLP.
• Perform only those tasks approved by the supervising SLP.
• Work only in settings for which the SLPA has been trained and in which state regulations allow for SLPA employment.
• Deliver services only with an ASHA-certified and state licensed SLP providing direct and indirect supervision on a regular and systematic basis. Frequency and type of supervision should be based on the SLPA's competencies, and the caseload need, both of which are determined by the supervising SLP.
• Conduct oneself ethically within the ASHA Assistant’s Code of Conduct (ASHA, 2020b) and state ethical codes.
• Self-advocate for needed supervision and training and for adherence to this SLPA scope of practice and other requirements.
• Provide culturally responsive services while communicating and collaborating with students, patients, clients, the supervising SLP, colleagues, families, caregivers, and other stakeholders.
• Actively pursue continuing education and professional development activities.
• Obtain information regarding availability and need for liability insurance.

Responsibilities Within the Scope of Practice for SLPAs

The supervising SLP retains full legal and ethical responsibility for students, patients, and clients served but may delegate specific tasks to the SLPA. The SLPA may execute components of services as specified by the SLP in the plan of care. Services performed by the SLPA are only those within the scope of practice and are tasks that the SLPA has the training and skill to perform as verified by the supervising SLP. The SLP must provide appropriate and adequate direct and indirect supervision to ensure quality care for all persons served. The amount of supervision may vary depending on the case’s complexity and the SLPA’s experience. Under no circumstances should the use of an SLPA’s services (a) violate the ASHA Code of Ethics (2016a) or the ASHA Assistants Code of Conduct (2020b) or (b) negatively impact the quality of services. An SLPA’s services are designed to enhance the quality of care provided by the SLP.

Decisions regarding the tasks that are appropriate to assign to the SLPA should be made by the supervising SLP in collaboration with the SLPA. The SLPA is responsible for communicating their knowledge, experience, and self-assessment of competence with specific skills to the supervising SLP. It is the SLP’s responsibility to observe the SLPA performing specific tasks; to provide feedback regarding clinical performance; to recommend or provide education and training to develop skills to meet the needs of the students, patients, and clients served; and to validate the SLPA’s competence. The SLPA’s competence in practice areas can be determined by observations, collaboration between the supervising SLP and the SLPA, as well as other resources deemed significant by the supervisor/supervisee pair.

If the SLPA has demonstrated the necessary competencies and the supervising SLP provides the appropriate amount and type of supervision, the SLPA may engage in or assigned to perform the following tasks:

• service delivery
• culturally responsive practices
• responsibilities for all practitioners
• responsibilities for practitioners who use multiple languages
• administration and support
• prevention and advocacy.

Service Delivery

The SLPA should engage in the following activities when performing necessary tasks related to speech-language service provision:

• Self-identifying (e.g., verbally, in writing, signage, titles on name badges, etc.) as an SLPA to students, patients, clients, families, staff, and others.
• Exhibiting compliance with federal, state, and local regulations including: The Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA); reimbursement requirements; and state statutes and rules regarding SLPA education, training, and scope of practice.
• Administering and scoring screenings for clinical interpretation by the SLP.
• Assisting the SLP during assessment of students, patients, and clients (e.g., setting up the testing environment, gathering and prepping materials, taking notes as advised by the SLP, etc.).
• Administering and scoring assessment tools that (a) the SLPA meets the examiner requirements specified in the examiner’s manual and (b) the supervising SLP has verifed the SLPA’s competence in administration, exclusive of clinical interpretation.
• Administering and scoring progress monitoring tools exclusive of clinical interpretation if (a) the SLPA meets the examiner requirements specified in the examiner’s manual and (b) the supervisor has verified the SLPA’s competence in administration.
• Implementing documented care plans or protocols (e.g., individualized education plan [IEP], individualized family service plan [IFSP], treatment plan) developed and directed by the supervising SLP.
• Providing direct therapy services addressing treatment goals developed by the supervising SLP to meet the needs of the student, patient, client, and family.
• Adjusting and documenting the amount and type of support or scaffolding provided to the student, patient, or client in treatment to facilitate progress.
• Developing and implementing activities and materials for teaching and practice of skills to address the goals of the student, patient, client, and family per the plan of care developed by the supervising SLP.
• Providing treatment through a variety of service delivery models (e.g., individual, group, classroom-based, home-based, co-treatment with other disciplines) as directed by the supervising SLP.
• Providing services via telepractice to students, patients, and clients who are selected by the supervising SLP.
• Documenting student, patient, or client performance (e.g., collecting data and calculating percentages for the SLP to use; preparing charts, records, and graphs) and report this information to the supervising SLP in a timely manner.
• Providing caregiver coaching (e.g., model and teach communication strategies, provide feedback regarding caregiver-child interactions) for facilitation and carryover of skills.
• Sharing objective information (e.g., accuracy in speech and language skills addressed, participation in treatment, response to treatment) regarding student, patient, and client performance to students, patients, clients, caregivers, families and other service providers without interpretation or recommendations as directed by the SLP.
• Programming augmentative and alternative communication (AAC) devices.
• Providing training and technical assistance to students, patients, clients, and families in the use of AAC devices.
• Developing low-tech AAC materials for students, patients, and clients.
• Demonstrating strategies included in the feeding and swallowing plan developed by the SLP and share information with students, patients, clients, families, staff, and caregivers.
• Assisting students, patients, and clients with feeding and swallowing skills developed and directed by the SLP when consuming food textures and liquid consistencies.

Culturally Responsive Practices

Cultural responsiveness has been described as providing individuals “with a broader perspective from which to view our behaviors as they relate to our actions with individuals across a variety of cultures that are different from our own” (Hyter & Salas-Provance, 2019, p.7).

Engaging in culturally responsive practices refers to the “explicit use of culturally based care and health knowledge in sensitive, creative, and meaningful ways” (Leininger, 2002, p. 84). It is important to remember that cultural and linguistic backgrounds exist on a continuum and not all individuals will exhibit characteristics of one group at any given time. Practitioners must meet the student, patient, client, and their families or caregivers in a space of mutual understanding and respect.

Not only is the supervising SLP responsible for engaging in these practices, but they should also train and provide support for the SLPA to develop these skills

Responsibilities for SLPs and SLPAs

All practitioners have the following responsibilities related to cultural and linguistic supports:

• Adjust communication style and expectations to meet the needs of clients, patients, and students from different cultural groups and to provide services in a culturally responsive manner. For more information, see the ASHA Practice Portal on Cultural Responsiveness [ASHA, n.d.-b].
• Provide information to families and staff regarding the influence of first language on the development of communication and related skills in a second language (under the direction of the supervising SLP).
• Develop an understanding of the family dynamic from a cultural perspective to effectively engage in meetings surrounding intake, discussions of the therapy plan of care and other communication scenarios surrounding practices for addressing communication concerns
• Engage in continuing education and training opportunities focusing on the assessment and intervention process when working with individuals from culturally and linguistically diverse backgrounds.

Responsibilities for Practitioners Who Use Multiple Languages

Based on prior training and experiences in working with multilingual students, patients or clients and their families, the SLPA may engage in the following tasks:

• Assist the SLP with interpretation and translation in the student’s, patient’s, or client’s first language during screening and assessment activities exclusive of clinical interpretation of results. For more information, see Issues in Ethics: Cultural and Linguistic Competence (ASHA 2017) and the ASHA Practice Portal Page on Multilingual Service Delivery (ASHA, n.d.-a)
• Interpret for students, patients, clients, and families who communicate using a language other than English, when the provider has received specialized training with interpreting skills in the student’s, patient’s, or client’s first language. For more information, see Issues in Ethics: Cultural and Linguistic Competence (ASHA 2017) and the ASHA Practice Portal Page on Multilingual Service Delivery (ASHA, n.d.-a)
• Provide services in another language for individuals who communicate using a language other than English or for those who are developing English language skills. Such services are based on the provider's skills and knowledge of the language spoken by the student, patient, or client. For more information, see Issues in Ethics: Cultural and Linguistic Competence (ASHA 2017) and the ASHA Practice Portal Page on Multilingual Service Delivery (ASHA, n.d.-a).

Administrative Support

Depending on the setting, adequate training, and guidance from the supervising SLP, the SLPA may:

• assist with clerical duties and site operations (e.g., scheduling, recordkeeping, maintaining inventory of supplies and equipment);
• perform safety checks and maintenance of equipment, and
• prepare materials for screening, assessment, and treatment services.

Prevention and Advocacy

Depending on the setting, adequate training, and guidance from the supervising SLP, the SLPA may

• present primary prevention information to individuals and groups known to be at risk for communication and swallowing disorders;
• promote early identification and early intervention activities;
• advocate for individuals and families through community awareness, health literacy, education, and training programs to promote and facilitate access to full participation in communication—including addressing the social determinants of health and health disparities;
• provide information to emergency response agencies for individuals who have communication, swallowing, and/or related disorders;
• advocate at the local, state, and national levels for improved public policies affecting access to services and research funding;
• support the supervising SLP in research projects, in-service training, marketing, and public relations programs; and
• participate actively in professional organizations.

Responsibilities Outside the Scope of Practice for Speech-Language Pathology Assistants

There is potential for misuse of an SLPA’s services, particularly when responsibilities are delegated by other staff members (e.g., administrators, nursing staff, physical therapists, occupational therapists, psychologists, etc.) without the approval of the supervising SLP. It is highly recommended that this ASHA SLPA Scope of Practice as well as the ASHA Code of Ethics (ASHA, 2016a) and the ASHA Assistants Code of Conduct (ASHA, 2020b) be reviewed with all personnel involved when employing an SLPA. It should be emphasized that an individual’s communication and/or related disorders and/or other factors may preclude the use of services from anyone other than an ASHA-certified and/or licensed SLP. The SLPA should not perform any task without the approval of the supervising SLP. The student, patient, or client should be informed that they are receiving services from an SLPA under the supervision of an SLP.

The SLPA should NOT engage in any of the following activities:

• representing themselves as the SLP;
• interpreting assessment tools for the purpose of diagnosing disability, determining eligibility or qualification for services;
• administering or interpreting feeding and/or swallowing screenings, checklists, and assessments;
• diagnosing communication and feeding/swallowing disorders;
• developing or determining the feeding and/or swallowing strategies or precautions for students, patients, and clients;
• disclosing clinical or confidential information (e.g., diagnosis, services provided, response to treatment) either orally or in writing to individuals who have not been approved by the SLP to receive information unless mandated by law;
• writing, developing, or modifying a student's, patient's, or client's plan of care in any way;
• making referrals for additional services;
• assisting students, patients, and clients without following the individualized plan of care prepared by the ASHA certified SLP;
• assisting students, patients, and clients without access to supervision;
• selecting AAC systems or devices;
• treating medically fragile students, patients, and clients without 100% direct supervision;
• performing procedures that require specialized knowledge and training (e.g., vocal tract prosthesis shaping or fitting, vocal tract imaging);
• providing input in care conferences, case conferences, or any interdisciplinary team meeting without the presence or prior approval of the supervising SLP or other designated SLP;
• providing interpretative information to the student, patient, client, family, or others regarding the student’s, patient’s, or client’s status or service;
• signing or initialing any formal documents (e.g., plans of care, reimbursement forms, reports) without the supervising SLP’s co-signature;
• discharging a student, patient, or client from services.

Practice Settings

Under the specified guidance and supervision of an ASHA-certified and/or state-credentialed SLP, SLPAs may provide services in a wide variety of settings, which may include, but are not limited to, the following:

• public, private, and charter elementary and secondary schools
• early intervention settings (e.g., homes, preschools, daycare settings)
• hospitals (inpatient and outpatient)
• residential health care settings (e.g., long-term care and skilled nursing facilities)
• nonresidential health care settings (e.g., adult daycare, home health services, and clinics)
• private practice settings
• university/college clinics
• research facilities
• corporate and industrial settings
• student’s, patient’s, or client's residences

Ethical Considerations

ASHA strives to ensure that its members and certificate holders preserve the highest standards of integrity and ethical practice. ASHA maintains two separate documents that set forth the fundamentals of ethical conduct in the professions. The ASHA Code of Ethics (2016a) sets forth the fundamental principles and rules deemed essential for SLPs. This code applies to every individual who is (a) an ASHA member, whether certified or not, (b) a nonmember holding the ASHA Certificate of Clinical Competence, (c) an applicant for membership or certification, or (d) a Clinical Fellow seeking to fulfill standards for certification.

The ASHA Assistants Code of Conduct (2020b) sets forth the principles and fundamentals of ethical practice for SLPAs. The Assistants Code of Conduct applies to all ASHA-certified audiology and speech-language pathology assistants, as well as applicants for assistant certification. It defines the SLPA’s role in the provision of services under the SLP’s supervision and provides a framework to support decision-making related to the SLPA’s actions. The Assistants Code of Conduct holds assistants to the same level of ethical conduct as the supervising SLP with respect to responsibilities to people served professionally, the public, and other professionals; however, it does not address ethics in supervision and other duties that are outside the SLPA Scope of Practice.

It is imperative that the supervising SLP and the SLPA are knowledgeable about the provisions of both codes and that they behave in a manner consistent with the principles and rules outlined in the ASHA Code of Ethics and the ASHA Assistants Code of Conduct. Because the ethical responsibility for students, patients, and clients--or for subjects in research studies--cannot be delegated, the supervising SLP takes overall responsibility for the actions of any SLPA when that SLPA is performing their assigned duties. If the SLPA engages in activities that violate the Assistants Code of Conduct, then the supervising SLP may be found in violation of the Code of Ethics--if it is found that adequate oversight has not been provided.

The following principles and rules of the Code of Ethics specifically address issues that are pertinent when an SLP supervises SLPAs in the provision of services or when conducting research. Failure to comply with principles and rules related to supervisory activities in the Code of Ethics or failure to ensure that the SLPA complies with the Assistants Code of Conduct could result in a violation of the Code of Ethics by the supervisor.

Principle of Ethics I, Rule of Ethics A: Individuals shall provide all clinical services and scientific activities competently.

Guidance:

The supervising SLP must ensure that all services, including those provided directly by the SLPA, meet practice standards, and are administered competently. The supervising SLP is responsible for providing training as needed or requested by the SLPA, identifying the services that the SLPA is competent to perform, monitoring the provision of those services to ensure quality of care, and intervening to correct the actions of the SLPA as needed.

Principle of Ethics I, Rule of Ethics D: Individuals shall not misrepresent the credentials of aides, assistants, technicians, support personnel, students, research interns, Clinical Fellows, or any others under their supervision, and they shall inform those they serve professionally of the name, role, and professional credentials of persons providing services.

Guidance:

The supervising SLP must ensure that students, patients, clients, caregivers, and research subjects are informed of the title and qualifications of the SLPA. This is not a passive responsibility; that is, the supervisor must make this information easily available and understandable to the students, patients, clients, caregivers, and research subjects and not rely on the individual to inquire about or ask directly for this information.

Principle of Ethics I, Rule of Ethics E: Individuals who hold the Certificate of Clinical Competence may delegate tasks related to the provision of clinical services to aides, assistants, technicians, support personnel, or any other persons only if those persons are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.

Guidance:

The supervising SLP is responsible for providing appropriate and adequate direct and indirect supervision to ensure that the services provided are appropriate and meet practice standards. The SLP must consider student, patient, or client needs and the SLPA’s knowledge and skills to determine what constitutes appropriate supervision, which may be more than the minimum required in state regulations. The SLP must document supervisory activities and adjust the amount and type of supervision to ensure that the Code of Ethics and Assistants Code of Conduct are followed.

Principle of Ethics I, Rule of Ethics F: Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.

Guidance:

The supervising SLP is responsible for monitoring the professional activities performed by the SLPA and ensuring that they remain within the guidelines set forth in the ASHA SLPA Scope of Practice and applicable state and facility guidelines. In some cases, ASHA requirements may differ from state regulations. ASHA requirements do not supersede state licensure laws or affect the interpretation or implementation of such laws. The supervising SLP should ensure that the highest standards of ethical conduct are maintained.

Principle of Ethics II, Rule of Ethics A: Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

Guidance:

The supervising SLP is responsible for ensuring that they have the skills and competencies needed to provide appropriate supervision. This includes completion of required continuing education in supervision and may include seeking additional continuing education in supervision to remain current in this area.

Principle of Ethics II, Rule of Ethics E: Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member's certification status, competence, education, training, and experience.

Guidance:

The supervising SLP must ensure that the SLPA only performs those activities that are defined as appropriate for the level of training and experience and in accordance with applicable state regulations and facility guidelines. If the SLPA exceeds the practice role that has been defined for them, the SLP must intervene to correct the actions of the SLPA as needed.

Principle of Ethics III, Rule of Ethics D: Individuals shall not defraud through intent, ignorance, or negligence or engage in any scheme to defraud in connection with obtaining payment, reimbursement, or grants and contracts for services provided, research conducted, or products dispensed.

Guidance:

States and third-party payers (e.g., insurance, Medicaid) vary in their policies regarding recognition of SLPAs as approved service providers, rate of reimbursement for assistant-level services, and other policies. The supervising SLP and SLPA are jointly responsible for knowing and understanding federal and state regulations and individual payer policies, billing for services at the appropriate level, and providing the amount and type of supervision required by the payer when billing for SLPA services.

Principle of Ethics IV, Rule of Ethics I: Individuals shall not knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics.

Guidance:

Because the SLPA provides services as an extension of those provided by the certified SLP, the SLP is responsible for ensuring the SLPA adheres to the Assistants Code of Conduct and monitoring the performance of the SLPA.

Liability Issues

Individuals who engage in the delivery of services to persons with communication and swallowing disorders are potentially vulnerable to accusations of engaging in unprofessional practices. Therefore, ASHA recommends that SLPAs secure liability insurance as a protection for malpractice. SLPAs should consider the need for liability coverage. Some employers provide it for all employees. Other employers defer to the employee to independently acquire liability insurance. Some universities provide coverage for students involved in practicum and fieldwork. Obtaining or verifying liability insurance coverage is the SLPA’s responsibility and needs to be done prior to providing services.

Guidelines for SLP Supervision of SLPAs

For SLPAs to practice, a supervising SLP must be identified. The following indicates considerations for the supervising SLP:

• qualifications for the supervising SLP
• expectations of the supervising SLP
• considerations for the ratio of SLPs to SLPAs
• requirements for frequency and duration of supervision.

Minimum Qualifications for a Supervising SLP

The minimum qualifications for an SLP to supervise the SLPA include the following:

• Hold the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) from ASHA and/or possess the necessary state-credentials
• Completion of a minimum of 9 months of experience after being awarded ASHA certification (i.e., completion of the 9-month Clinical Fellowship followed by 9 months of experience)
• Completion of a minimum of 2 hours of professional development in clinical instruction/supervision
• Adherence to state guidelines for supervision of the SLPA
• It is recommended that the professional development course taken in clinical instruction or supervision include content related to the supervision of SLPAs

Expectations for the Supervising SLP

In addition to the minimum qualifications listed above, the following are additional roles and behavior that are expected of the supervising SLP:

• Adhere to the principles and rules of the ASHA Code of Ethics (ASHA, 2016a)
• Adhere to applicable licensure laws and rules regulating the practice of speech-language pathology
• Conduct ongoing competency evaluations of the SLPAs
• Provide and encourage ongoing education and training opportunities for the SLPA consistent with competency and skills required to meet the needs of the students, patients, and clients served
• Develop, review, and modify treatment plans for students, patients, and clients that the SLPA implements under the supervision of the SLP
• Make all case management decisions
• Adhere to the supervisory responsibilities for SLPs
• Retain legal and ethical responsibility for all students, patients, and clients served
• Maintain an active interest in collaborating with SLPAs

Supervision of SLPAs

The relationship between the supervising SLP and the SLPA is paramount to the welfare of the student, patient, or client. Because the clinical supervision process is a close, interpersonal experience, the supervising SLP should participate in the selection of the SLPA when possible. It is the SLP's responsibility to design and implement a supervision system that protects the students', patients', and clients' care and that maintains the highest possible standards of quality. The amount and type of supervision must meet (a) minimum requirements as specified in this document and (b) state requirements. Supervision must be based on (a) the needs, competencies, skills, expectations, philosophies, and experience of the SLPA and the supervisor; (b) the needs of students, patients, and clients served; (c) the service setting; (d) the tasks assigned; and (e) other factors. More intense supervision, for example, would be required in such instances as the orientation of a new SLPA; initiation of a new program, equipment, or task; or a change in student, patient, or client status (e.g., medical complications). Functional assessment of the SLPA's skills with assigned tasks should be an ongoing, regular, and integral element of supervision. SLPs and SLPAs should treat each other with respect and should interact in a manner that will provide the best possible outcomes for student, patient, and client care. It is also critical that the SLP and SLPA understand that their language, culture, and experiences will be different within the dyad and across the triad (SLP, SLPA, and patient, client, and student). It is expected that the practitioners stay grounded in cultural responsiveness and culturally responsive practices when engaged in all aspects of interactions.

As the SLP’s supervisory responsibility increases, overall responsibilities will change because the SLP is responsible for the students, patients, and clients as well as supervision of the SLPA. Therefore, adequate time for direct and indirect supervision of the SLPA(s) and caseload management must be allotted as a critical part of the SLP's workload. The purpose of the assistant level position is not to significantly increase the caseload size for SLPs. The specialized skills should be utilized to support the SLP with the care of individuals on the SLP's caseload. Under no circumstances should an assistant have their own caseload.

Diagnosis, treatment, and support of the students, patients, and clients served remains the legal and ethical responsibility of the supervisor. Therefore, the level of supervision required is considered the minimum level necessary for the supervisor to retain direct contact with the students, patients, and clients. The supervising SLP is responsible for designing and implementing a supervisory plan that protects consumer care, maintains the highest quality of practice, and documents the supervisory activities.

SLP-to-SLPA Ratio

The supervising SLP should determine the appropriate number of assistants whose practice can be supervised within their workload. Although more than one SLP may provide supervision of an SLPA, it is recommended that the SLP not supervise or be listed as a supervisor for more than three full-time equivalent (FTE) SLPAs in any setting. The number of SLPAs who can be appropriately supervised by a single SLP will depend on a variety of factors including caseload characteristics, SLPA experience, and SLP experience. The SLP is responsible for determining how many SLPAs can be supervised while maintaining the highest level of quality for services provided. When multiple SLPs supervise a single SLPA, it is critical that the supervisors coordinate and communicate with each other so that they collectively meet minimum supervisory requirements and ensure that they maintain the highest quality of services.

Requirements for the Frequency and Amount of Supervision

Supervision requirements may vary based on a variety of factors. The amount and type of supervision required must be consistent with (a) the SLPA’s skills and experience; the needs of the students, patients, and clients; (c) the service setting; (d) the tasks assigned; and (e) the laws and regulations that govern SLPAs. To ensure adequate and appropriate supervision, the supervising SLP should outline their expectations in collaboration with the SLPA. As the relationship continues to develop over time, the SLP/SLPA team can decide how and to what extent supervision is needed.

Before the SLPA begins to provide support independently, the supervising SLP must have first contact with all individuals on the caseload. “First contact” includes establishing rapport, gathering baseline data, and securing other necessary documentation to begin (or continue) the plan of care for the student, patient, or client. As the SLP/SLPA team dynamic continues to develop beyond the initial onboarding, minimum ongoing supervision must always include documentation of direct supervision provided by the SLP for each student, patient, or client at least every 30–60 days (depending on frequency of visits/sessions and setting).

The SLP can adjust the amount of supervision if they determine that the SLPA has met appropriate competencies and skill levels in treating students, patients, and clients who have a variety of communication disorders. Data on every student, patient, and client serviced by the SLPA should be reviewed by the supervisor in regular intervals and can be considered “indirect supervision.” Supervisors should arrange designated days and times of day (morning or afternoon) in such a way that all students, patients, and clients receive direct contact with the supervising SLP.

The supervising SLP must accurately document and regularly record all supervisory activities, both direct and indirect. Further, 100% direct supervision (synchronous or “live” telesupervision is acceptable) of SLPAs for medically fragile students, patients, or clients is required.

The supervising SLP is responsible for designing and implementing a supervisory plan, which ensures that the SLP maintains the highest standard of quality care for students, patients, and clients. A written supervisory plan is a tangible way to document progress and outline the practices of the supervising SLP and the SLPA. Care of the student, patient, or client remains the supervisor’s responsibility.

Direct supervision means in-view observation and guidance while the SLPA is performing a clinical activity. This can include the supervising SLP viewing and communicating with the SLPA via telecommunication technology as the SLPA provides clinical services, this scenario allows the SLP to provide ongoing immediate feedback. Direct supervision does not include reviewing an audio or video recorded session later.

Supervision feedback should provide information about the quality of the SLPA's performance of assigned tasks and should verify that clinical activity is limited to tasks specified in the list of an SLPA's ASHA-approved responsibilities. Information obtained during direct supervision may include, but is not limited to, data relative to (a) agreement (reliability) between the SLPA and the supervisor on correct or incorrect recording of target behavior, (b) accuracy implementing assigned treatment procedures, (c) accuracy recording data, and (d) ability to interact effectively with the student, patient, or client during presentation and implementation of assigned procedures or activities.

Indirect supervision does not require the SLP to be physically present or available via telecommunication while the SLPA is providing services. Indirect supervisory activities may include (a) reviewing demonstration videos; (b) reviewing student, client, or patient files; (c) reviewing and evaluating audio or video recorded sessions; and/or (d) conducting supervisory conferences either in person or via telephone and/or live, secure virtual meetings. The SLP will review each care plan as needed for timely implementation of modifications.

An SLPA may not perform tasks when a supervising SLP cannot be reached by personal contact, that is, phone, pager, or other immediate or electronic means. If, for any reason (i.e., maternity leave, illness, change of jobs) the supervisor is no longer available to provide the level of supervision stipulated, then the SLPA may not perform assigned tasks until an ASHA-certified and/or state-licensed SLP with experience and training in supervision has been designated as the new supervising SLP.

Any supervising SLP who will not be able to supervise an SLPA for more than 1 week will need to (a) inform the SLPA of the planned absence, (b) notify the employer or site administrator that other arrangements for the SLPA's supervision of services need to be made while the SLP is unavailable, and (c) inform the students, patients, or clients that their speech-language services will be rescheduled.

In some instances, multiple SLPs may supervise the SLPA. Those doing so must give special consideration to, and think carefully about, the impact that this supervisory arrangement may have on service providers. It is recommended that the SLPA not be supervised by more than three SLPs.

Conclusion

This document aims to provide guidance for the use of SLPAs in appropriate settings, thereby increasing access to timely and efficient speech-language services. The supervising SLP or SLPs are responsible for staying abreast of current guidelines (including state credentialing guidelines) and ensuring the quality of services rendered. Given that standards, state credentialing (e.g., licensure, etc.), and practice issues vary from state to state, this document’s purpose is to provide information regarding ASHA’s guidelines for the use of SLPAs for the treatment of communication disorders across practice settings.

Definitions

accountability—refers to being legally responsible and answerable for actions and inactions of self or others during the performance of a task by the SLPA.

aide/technician—individual who has completed on-the-job training, workshops, and other related tasks and who works under the direct supervision of an ASHA-certified SLP. See also speech-language pathology aide/technician.

assessment—procedures implemented by the SLP for the differential diagnosis of communication and swallowing disorders, which may include, per the ASHA Speech-Language Pathology Scope of Practice [PDF], “culturally and linguistically appropriate behavioral observation and standardized and/or criterion-referenced tools; use of instrumentation; review of records, case history, and prior test results; and interview of the individual and/or family to guide decision making” (ASHA, 2016b, p. 11). Assessments may also be referred to as evaluations, tests, and so forth.

cultural responsiveness—provides individuals with “a broader perspective from which to view our behaviors as they relate to our actions with individuals across a variety of cultures that are different from our own”. (Hyter and Salas-Provance, 2019, p. 7)

culturally responsive practices—Care that takes the client’s cultural perspectives, beliefs, and values into consideration in all aspects of education and/or service provision. Leininger (2002) defines this term as “the explicit use of culturally based care and health knowledge in sensitive, creative, and meaningful ways”.

direct supervision—in-view observation and guidance by an SLP while the SLPA performs an assigned activity. Direct supervision activities performed by the supervising SLP may include, but are not limited to, the following: observing a portion of the screening or treatment procedures performed by the SLPA, coaching the SLPA, and modeling for the SLPA. The supervising SLP must be present during all services provided to a medically fragile client by the SLPA (e.g., on-site or via synchronous telesupervision). The SLP can view and communicate with the student, patient, or client and SLPA via “real-time” telecommunication technology to supervise the SLPA, giving the SLP the opportunity to provide immediate feedback. This does not include reviewing a recorded session later.

indirect supervision—the monitoring or reviewing of an SLPA’s activities outside of observation and guidance during direct services provided to a student, patient, or client. Indirect supervision activities performed by the supervising SLP may include, but are not limited to, demonstration, records review, review and evaluation of audio or video recorded sessions, and interactive conferences that may be conducted by telephone, email, or other forms of telecommunication (e.g., virtual platforms).

interpretation—summarizing, integrating, and using of data for the purpose of clinical decision making, which may only be done by SLPs. SLPAs may summarize objective data from a session to the family or team members.

medically fragile—a term used to describe an individual who is acutely ill and in an unstable health condition. If an SLPA treats such an individual that treatment requires 100% direct supervision by an SLP.

plan of care—a written service plan developed and monitored by the supervising SLP to meet the needs of an individual student, patient, or client. The plan may address needs for screening, observation, monitoring, assessment, treatment, and other services. Examples of care plans include Individualized Education Plans (IEPs), Individualized Family Service Plans (IFSPs), rehabilitation services plans, and so forth.

progress monitoring—a process of collecting, graphing, and reviewing data on an individual's target skills to assess their response to treatment and then comparing their growth to a target trend line or goal to determine whether sufficient progress is being made. Definition adapted from Progress Monitoring webpage. (National Center on Intensive Intervention, n.d.)

screening—a pass-fail procedure to identify, without interpretation, students, patients, or clients who may require further assessment following specified screening protocols developed by and/or approved by the supervising SLP.

social determinants of health—the conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities-the unfair and avoidable differences in health status seen within and between countries. (World Health Organization, n.d.)

speech-language pathology aides/technician—an individual who has completed on-the-job training, workshops, and other related tasks and who works under the direct supervision of an ASHA-certified SLP; this is another type of support personnel that may not meet the requirements as an ASHA certified SLPA. See also aide/technician

speech-language pathology assistant—an individual who, following academic coursework, clinical practicum, and credentialing can perform tasks prescribed, directed, and supervised by ASHA-certified SLPs.

supervising speech-language pathologist—an SLP who holds a Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) from ASHA and/or a state licensure (where applicable), has an active interest and desire to collaborate with support personnel, has a minimum of 9 months of experience after being awarded ASHA certification, has completed the 2-hour supervision requirement per the ASHA Certification Standards (ASHA,2020a) and adheres to state credentialing guidelines for supervision of the SLPA, and who is licensed and/or credentialed by the state (where applicable).

supervision—the provision of direction and evaluation of the tasks assigned to an SLPA. Methods for providing supervision include direct supervision, indirect supervision, and telesupervision.

support personnel—these individuals perform speech-language tasks as prescribed, directed, and supervised by ASHA-certified SLPs. There are different levels of support personnel based on training and scope of responsibilities. The term support personnel includes SLPAs and speech-language pathology aides/technicians. ASHA is operationally defining these terms for ASHA resources. Some states use different terms and definitions for support personnel (e.g., assistant speech-language pathologist, speech-language pathologist paraprofessional, and SLP assistant, among others).

telepractice—applying telecommunications technology to the delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation (ASHA, n.d.).

telesupervision—the SLP can view and communicate with the patient and SLPA in real time via telecommunication software (e.g., virtual platforms), webcam, telephone, and similar devices and services to supervise the SLPA. This enables the SLP to give immediate feedback. Telesupervision does not include reviewing a recorded session later.

References

American Speech-Language-Hearing Association. (n.d.-a). Multilingual Service Delivery (Practice Portal). Retrieved February 4, 2022, from https://www.asha.org/practice-portal/professional-issues/multilingual-service-delivery/

American Speech-Language-Hearing Association. (n.d.-b). Cultural Responsiveness (Practice Portal). Retrieved February 4, 2022, from https://www.asha.org/practice-portal/professional-issues/cultural-responsiveness/

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. https://www.asha.org/policy/et2016-00342/

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. www.asha.org/policy

American Speech-Language-Hearing Association (2017). Issues in ethics: Cultural and linguistic competence. www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence

American Speech-Language-Hearing Association. (2020a). 2020 Standards and implementation procedures for the Certificate of Clinical Competence in Speech-Language Pathology. https://www.asha.org/certification/2020-slp-certification-standards/

American Speech-Language-Hearing Association. (2020b). Assistants code of conduct. https://www.asha.org/policy/assistants-code-of-conduct/

Hyter, Y. & Salas-Provance, M. (2019). Culturally Responsive Practices in Speech, Language, and Hearing Sciences. San Diego, CA: Plural Publishing.

Ladson Billings, G. (1994). The Dreamkeepers. San Francisco, CA: Josey Bass.

Leininger, M. (2002). Theory of culture care and the ethnonursing research method. In M. Leininger & M. R. McFarland (Eds.), Transcultural nursing: Concepts, theories, research and practice (pp. 71–98). New York, Ny: McGraw-Hill.

National Center on Intensive Intervention (n.d.). Progress Monitoring. https://intensiveintervention.org/data-based-individualization/progress-monitoring

Vose AK, Kesneck S, Sunday K, Plowman E, & Humbert I. (2018). A Survey of clinician decision making when identifying swallowing impairments and determining treatment. Journal of Speech Language Hearing Research, 61(11), 2735–2756.

World Health Organization (n.d.). Social determinants of health. www.who.int/health-topics/