CMTO’s Inquiries, Complaints and Reports Committee (ICRC) is the screening committee for investigations of complaints and reports about Massage Therapy care. The ICRC can refer a matter to the Discipline Committee, order a corrective measure or take no action. The following is a case study demonstrating how the ICRC addressed a complaint at CMTO.

CMTO received a report raising concerns about a Massage Therapist’s billing and record-keeping practices. In response, CMTO’s ICRC appointed an investigator to look into this case.

Case Study Summary

During a visit to the Massage Therapist’s clinic, the investigator found pre-signed receipts in an unlocked cabinet near the reception desk. The Massage Therapist said she was busy in between treating clients and pre-signing receipts allowed reception staff to issue receipts to clients.

Upon further review of the Massage Therapist’s record keeping practices, several concerns were identified:

• The Massage Therapist kept client records in an unlocked, unattended filing cabinet.
• The Massage Therapist didn’t have appointment records. The clinic owner’s practice was to discard appointment records after payment was received.
• Health history forms were blank or incomplete and the Massage Therapist acknowledged not always reviewing these forms.
• Treatment notes lacked detail and would sometimes only refer to ‘upper body’ or ‘lower body’.
• Most client records did not contain a treatment plan. The Massage Therapist didn’t think clients followed these plans often enough to make it worthwhile to complete them.
• Consent was not always documented in the health record.

ICRC’s Perspective: Decision Process and Outcome

The ICRC reviewed the investigation report and identified several areas of concern that called for remediation:

• Pre-signing and leaving receipts at reception leaves a Massage Therapist’s information open to misuse. A Massage Therapist must take steps to protect their registration information from misuse.
• The Massage Therapist must store their health records in a secure space that is always monitored or locked to protect client privacy and confidentiality.
• The Massage Therapist must keep appointment records, as set out in sections 8 and 11 of Ontario Regulation 544/94 under the Massage Therapy Act, 1991.
• The Massage Therapist must collect and review health history information from clients to provide client-centred care, and to accurately assess the risks and benefits to treatment.
• Treatment notes that only reference treating the upper or lower body are inadequate and must include particulars (i.e., what muscles were treated).
• The Massage Therapist must create a treatment plan for each client and include a copy of any/all treatment plans in the client health record.
• The Massage Therapist must obtain consent before every treatment, assessment, reassessment, and if there is a change in the treatment plan. Consent must be documented within 24 hours of the assessment/treatment.

The ICRC ordered the Massage Therapist to complete courses in ethics, professionalism and record-keeping, followed by a CMTO practice inspection, to ensure the Massage Therapist adheres to CMTO’s Standards of Practice and the Massage Therapy Act regulations in the future.