These FAQs provide answers to the questions that CMTO is receiving most often. We hope this information is helpful, and we will continue to provide updates.
Ces Foires Aux Questions fournissent des réponses aux questions sur les exigences pour reprendre l’exercice de la massothérapie sans incident.
Infection Prevention and Control/Personal Protective Equipment (PPE)
Infection Prevention and Control/Personal Protective Equipment (PPE)
What type of masks must RMTs wear while providing treatment and how often should they change them? [Updated – August 14, 2020]
RMTs must wear surgical/procedure masks approved for medical use while within two metres of clients, including while providing treatment. There are three classifications of surgical/procedure masks under American Society for Testing and Materials (ASTM) International Standards (Level 1, 2 and 3). Approved surgical/procedure masks of all levels and number of layers are acceptable for use by RMTs.
N95 respirators should not be used by RMTs as they are in short supply and should be reserved for front-line healthcare workers in higher risk environments. Additionally, N95 respirators must be correctly fit to the wearer to provide protection.
CMTO cannot approve specific masks or brands of masks. For more information about surgical/procedure masks, please refer to Government of Canada’s COVID-19 medical masks and respirators: Information for health professionals.
It is best practice for an RMT to change their mask after every client, and masks must be changed whenever wet, damaged or soiled. If an RMT is reusing the same mask between clients, they must ensure the mask is not wet, damaged or soiled. RMTs must wash their hands before and after touching, adjusting, putting on or removing their mask.
Are clients required to wear masks during treatment? What if they refuse? [Updated – August 14, 2020]
In accordance with the Ontario Ministry of Health’s requirement to wear masks whenever physical distancing is not possible within a healthcare setting, RMTs must instruct the client to come to the appointment wearing a clean disposable or reusable mask to be worn throughout the treatment. If the client arrives and is not wearing a mask, the RMT should provide the client with a new surgical/procedure mask to wear for the duration of the appointment.
The RMT may need to make practice modifications to accommodate and facilitate clients’ ability to safely and comfortably wear masks throughout treatment.
If a client cannot wear a mask (e.g. due to a health condition) or refuses to participate in any reasonable infection prevention measures that have been implemented, the RMT is entitled to use their professional judgement to assess the risk of providing treatment. If the RMT determines the risk of providing treatment outweighs the likely benefit (or the risk cannot be determined), the RMT can refuse to treat the client at that time. If the RMT decides to refuse to provide treatment, the RMT should have a discussion with the client about the risks and why they are not providing treatment. The RMT must clearly document the decision and discussion in the client health record.
What types of gloves are acceptable?
RMTs do not need to use gloves for most treatments. Glove use is never a substitute for proper hand washing. Hand washing is an extremely important measure in preventing the spread of COVID-19.
If gloves are used (for example, during treatments that pose a higher risk of transmission, such as intraoral treatments), the gloves should be single-use non-sterile nitrile or latex examination or medical gloves. These gloves may be an effective barrier for disease transmission, are durable enough for manual work, and provide a fit that allows for high dexterity.
Latex gloves should only be used with water-based topical products and when the client and RMT do not have a latex allergy or sensitivity.
Nitrile gloves can be used for all clients with oil or water-based topical products.
Vinyl gloves are not recommended because they may not be durable enough for manual work.
I can’t find the required PPE. Does that mean I cannot provide treatment to clients?
When an RMT encounters a situation in which specific PPE is necessary but not available, the RMT must not provide treatment to the client at that time. RMTs must explain the reasons for cancelling the appointment to the client and document those reasons into the client health record. See Standard of Practice #15 for more information.
RMTs are responsible for ordering appropriate PPE supplies specific to their own practice needs. Please see the Government of Ontario’s dedicated website for PPE for more information on obtaining PPE.
Does CMTO know where I can find PPE supplies to purchase?
Please see the Government of Ontario’s dedicated website for PPE for more information on obtaining PPE.
What type of cleaning and disinfecting agents/products should I be using?
RMTs must use products approved by Health Canada by cross-referencing the Drug Identification Number (DIN) on the product container with the list on the Health Canada website.
Public Health Ontario provides helpful guidance about cleaning detergents and disinfecting agents in Section 1.3 of the Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings document.
I need more information on cleaning and disinfecting my practice (e.g. using the “wipe twice” method). [New – August 28, 2020]
Public Health Ontario’s Environmental Cleaning Toolkit answers questions about how and why to do the “wipe twice” method (clean to remove visible soiling then disinfect to kill germs on the clean surface). Section 1.3 of the Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings provides information about whether a different cleanser should be used for the wipe to clean, versus the wipe to disinfect.
For disinfecting, RMTs must use products approved by Health Canada by cross-referencing the Drug Identification Number (DIN) on the product container with the list on the Health Canada website.
RMTs interested in learning more about principles of cleaning and disinfecting environmental surfaces in health care settings with a focus on the selection and appropriate use of cleaning agents, disinfectants and cleaning tools/equipment may want to review the Cleaning Products and Tools presentation within the Toolkit.
CMTO’s IPAC requirements are informed by Public Health Ontario’s expertise.
Do I need to clean and disinfect pillows after each use? Can I just change the pillowcase/cover?
To reduce the risks of contact and droplet transmission associated with COVID-19, RMTs must wash and dry all linens, blankets and pillows used in treatment in the highest heat possible after every client.
If the pillow is made of, or covered entirely by, a plastic or otherwise non-porous material, it must be cleaned and disinfected between clients using products approved by Health Canada.
If both the pillow and pillowcase/cover are made of porous materials (like cotton, polyester, rayon, viscose or linen), both the pillow and pillowcase/cover will need to be cleaned and disinfected after every client.
Items that cannot be cleaned and disinfected after every client should be removed from the treatment room.
What PPE and infection prevention and control training do I need to complete, and do I need to provide CMTO with proof of completion? Can CMTO help me with technical issues?
Before returning to practice, RMTs must, at minimum, complete the free online Public Health Ontario (PHO) training listed below. RMTs are not required to submit proof of completion to CMTO at this time, but should keep the completion certificates in their own records, in case they are asked to provide this information later.
- IPAC Core Competencies: Additional Precautions
- IPAC Core Competencies: Administrative Controls
- IPAC Core Competencies: Chain of Transmission and Risk Assessment
- IPAC Core Competencies: Control of the Environment
- IPAC Core Competencies: Health Care Provider Controls
- IPAC Core Competencies: Occupational Health and Safety
- IPAC Core Competencies: Personal Risk Assessment (select all modules appropriate to your practice setting)
Here are a few tips if you are having technical issues:
- The online learning platform is compatible with Internet Explorer and Chrome. Modules will not work properly in Firefox or Safari browsers.
- The PHO modules are to be completed in real time through their online learning platform. You cannot download the modules.
- The modules are media heavy. Clearing your browser cache before completing each course will help things run smoothly.
- Refer to PHO’s Online Learning Requirements to get your computer ready for the best learning experience.
- Refer to PHO’s Frequently Asked Questions (FAQs)and How Do I Guide for additional support
Can I treat all clients? CMTO’s guidance said to prioritize clients with essential care needs.
Prioritize means treating clients with more serious needs first. All clients can be treated at this time, however, RMTs must always use their professional judgement to ensure the anticipated benefit of treatment outweighs the risk (including the risk of COVID-19).
What screening questions do I need to ask a client before providing treatment? [Updated – August 14, 2020]
Please refer to the Ministry of Health’s COVID-19 Patient Screening Guidance document and COVID-19 Reference Document for Symptoms for screening questions. The client must be screened twice; once prior to arriving for treatment, and again immediately before treatment.
My client has a chronic or pre-existing health condition, and the symptoms of my client’s condition (e.g. headache, migraine, chronic muscle ache) are listed in the Ministry of Health (MOH)’s COVID-19 Patient Screening Guidance. Does this mean I can’t provide Massage Therapy treatment to my client? Won’t my client always screen positive for COVID-19? [New – September 3, 2020]
The MOH has developed the COVID-19 Patient Screening Guidance document to guide risk assessments for healthcare providers when providing care to clients. As the symptoms for COVID-19 are similar to other ailments, healthcare providers, including RMTs, are encouraged to further assess if any symptoms disclosed during the screening process are related to chronic or pre-existing conditions, or if they are new or worsening and may be attributed to COVID-19.
If a client responds “no” to every item on the patient screening guidance document, with the exception of responding “yes” to a symptom in Q4 (e.g. headache), the RMT needs to clarify with the client whether the symptom is related to a chronic or pre-existing health issue. If the client indicates the symptom is related to a chronic or pre-existing health issue, and the symptom is not new or worsening, the client is considered to screen negative for COVID-19 and the RMT can proceed with treatment.
If the symptom cannot be explained by a chronic or pre-existing health issue, or the symptom is new or worsening, the client is considered to screen positive for risk of COVID-19. The RMT should defer treatment and encourage the client to self-isolate at home and seek medical care such as from their primary care provider or by calling Telehealth Ontario at 1-866-797-0000, who may suggest they be tested.
All client screening must be documented in the client health record.
A client has shown up for their appointment and has screened as potentially having COVID-19. Should I provide treatment?
If a client screens as possibly being positive for COVID-19 when they arrive for their appointment or symptoms develop during treatment, the RMT must:
- establish and maintain a safe physical distance of two metres;
- have the client complete hand hygiene;
- if the client is not wearing a mask, provide the client with a new surgical/procedure mask;
- segregate the client from others in the clinic;
- explain the concern that they are symptomatic, discontinue treatment and reschedule the appointment;
- advise the client that they should self-isolate and complete the online self-assessment tool and should then call their primary care provider or Telehealth at 1-866-797-0000;
- clean and disinfect the practice area and anywhere the client is likely to have touched immediately; and,
- ensure a record is kept of all close contacts of the symptomatic patient/client and other visitors and staff in the clinic at the time of the visit. This information will be necessary for contact tracing if the patient/client later tests positive symptomatic for COVID-19.
All client screening and related decisions and actions must be documented in the client health record.
A client has tested as positive for COVID-19. Can I provide in-person treatment to this client? [New – September 3, 2020]
RMTs cannot provide treatment until the client has been cleared, or their case is considered resolved by a primary care provider, Telehealth Ontario, or Public Health Ontario (via their local public health unit). Clients can provide confirmation verbally or in written form.
When determining whether to proceed with treatment, RMTs must continue to follow the requirements set out in CMTO’s COVID-19 Pandemic – Practice Guidance for Massage Therapists; including:
- using the MOH’s COVID-19 Patient Screening Guidance Document to screen all clients (For Q3, RMTs should consider that fact that the client has been cleared or their case has been considered resolved i.e. they are no longer considered positive for COVID-19);
- evaluating the risks of proceeding with in-person treatment and comparing it to the intended benefits;
- implementing infection prevention and control measures; and,
- wearing required PPE.
RMTs must document the details of the clearance and screening into the client’s health record.
Someone who was in my practice environment is confirmed to have COVID-19, what should I do?
If there are any confirmed cases of COVID-19 in a provider, staff, client or visitor of the practice, the RMT should report it to their local public health unit and follow their directions.
Are there treatment techniques, skills or modalities that are higher risk?
Certain techniques or modalities may present a higher risk of transmission or exposure to COVID-19. The RMT must determine whether it is appropriate to use these techniques/modalities given the increased risk of COVID-19 transmission/exposure. Some potential areas of risk may include:
- Techniques requiring direct contact with areas close to the client’s mouth, nose, eyes or ears.
- Techniques that cause prolonged vibration, such as tapotement, as this may loosen phlegm or mucus leading to increased risk of coughing.
- Intraoral massage which increases exposure to respiratory droplets and requires contact interaction with the client’s mucus membranes. This may also increase risk of coughing.
- Hydrotherapy, due to the use of equipment and/or the increased risk of exposure to fluids that may be contaminated.
The RMT may only provide treatment if the benefit to the client outweighs the potential harm that could be done to the client (e.g. contracting COVID-19 and/or spreading it within their community). If these treatment modalities/techniques must be used, additional PPE may be required.
To determine if additional PPE is warranted (e.g. face shields, goggles), RMTs should conduct a risk assessment as outlined in Public Health Ontario’s Routine Practices and Additional Precautions in All Health Care Settings (Appendix B) on pages 57-58 and use their professional judgment.
Do I still need to sign my receipts? Can I provide them electronically?
RMTs are required to sign receipts according to the CMTO Policy for Receipts. RMTs can choose to apply their signature in hand-written or electronic form. Clean and disinfect any equipment used during this process (e.g. pens, tablets).
Do I still need to obtain written consent from a client to treat sensitive areas?
RMTs must obtain written consent from clients to treat sensitive areas. During the pandemic, RMTs should consider additional precautions to safely obtain written consent when appropriate, including preparing any equipment used (e.g. pens and tablet devices) before and after treatment by cleaning and disinfecting.
Are there any additional considerations for record keeping? [Updated – August 14, 2020]
In addition to the routine requirements for record keeping, RMTs must record all new procedures related to the client in the client health record, including but not limited to:
- a general infection prevention and control record/log for the practice,
- a notation of COVID-19 infection precautions taken for each client in the client health record, including
- screening dates, outcomes and related decisions;
- PPE used during treatment;
- modifications to treatment; and
- details of infection prevention and control measures used to prepare for, during, and after each treatment
- a roster of all people entering the space for contact tracing purposes.
Documentation should be kept for 10 years.
Are there additional consent requirements or considerations during the COVID-19 pandemic? [Updated – August 14, 2020]
Disclosing risk is always a crucial part of obtaining informed consent. In that sense, there are no new consent requirements. Disclosing risks specific to COVID-19 will be an important part of providing information required to obtain informed consent. To obtain consent, RMTs explain and document the measures taken to lessen risk of transmission of COVID-19, while highlighting that the risk is still present.
As a reminder, informed consent includes the client understanding all of the following:
- nature of the treatment;
- expected benefits of the treatment;
- material risks of the treatment;
- material side effects of the treatment;
- alternative courses of action; and
- likely consequence(s) of not having the treatment.
Can Massage Therapists offer Massage Therapy through a remote platform via telecommunications (“telepractice”) during the pandemic?
Offering Massage Therapy through a remote platform via telecommunications technology has a number of complexities that will need to be considered and should only be used in very few and unique situations.
RMTs will need to consider whether the proposed telepractice treatment is within the scope of practice of Massage Therapy in Ontario:
“The practice of Massage Therapy is the assessment of the soft tissue and joints of the body and the treatment and prevention of physical dysfunction and pain of the soft tissues and joints by manipulation to develop, maintain, rehabilitate or augment physical function, or relieve pain.”
Some examples of these rare situations in which telepractice may be within the scope of practice may include:
- When an RMT must provide guidance for client self-care; or
- When an RMT would like to complete an intake process for a new client who will be receiving treatment when the RMT returns to practice (e.g. the RMT might receive health history information electronically and conduct an intake interview virtually).
If telepractice treatment is within the scope of practice, the RMT must be transparent in all documentation, including billing invoices, that the services were provided remotely and whether only a partial assessment/treatment was performed (i.e. it does not constitute a full session of Massage Therapy and cannot be billed as such). RMTs must advise their clients that telepractice may not be covered by their insurance provider as Massage Therapy.
Prior to using any platform, the RMT must ensure the platform is confidential and secure and meets the requirements of the Personal Health Information Protection Act, 2014; and the RMT must obtain the consent required under the Health Care Consent Act, 1996 and CMTO’s written consent requirements for treating (or viewing) sensitive areas (if applicable). In addition, all applicable legislative and CMTO requirements would still need to be adhered to, such as maintaining client health records.
What should I do if an employer/facility operator is pressuring me to provide Massage Therapy in a way that contradicts government or CMTO guidance? [Updated – August 14, 2020]
CMTO expects RMTs to comply with government and public health directives to prevent and control the spread of COVID-19. RMTs who are found to be practicing contrary to guidance may face serious consequences, including suspension or revocation of their Certificate of Registration, penalties under the Health Protection and Promotion Act, the Occupational Health and Safety Act, as well as civil liability in court.
If an employer or facility operator attempts to encourage an RMT to practice in violation of government orders, or if you have concerns about health and safety that your employer is not addressing, you can file a complaint with the Health and Safety Contact Centre at 1-877-202-0008.
RMTs must follow directions provided by:
RMTs should not return to practice if they cannot meet the requirements set out in these documents.
What about my income? What financial relief is available to me?
CMTO suggests RMTs continue to follow the ongoing updates from the provincial and federal government regarding support for individuals and businesses financially impacted by the pandemic. Information about economic relief is available at: Canada’s COVID-19 Economic Response Plan.
The Registered Massage Therapists’ Association of Ontario (RMTAO) is also providing updates for RMTs on economic relief.