SLPAHADB Audiology Aide Memo
While the regulatory process has been put in motion by the Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board (SLPAHADB) to develop and pass regulatory changes and proposed language that will address the tasks and supervision for Audiology Aides in California, Paul Sanchez, then Executive Officer of the SLPAHAD licensing board, agreed last fall that CAA may post the May 2022 Board memo regarding Audiology Aides to any party interested in the Board’s current perspective on this issue and the many factors involved.
Below are the links to the webcast on September 5, 2024 by the licensing board's Audiology Practice Committee that addresses this issue and board materials for that meeting:
Audiology Practice Committee Meeting - September 5, 2024
September 5, 2024 Meeting Materials
Background
Reports have reached the board that due to the perceived lack of clarity regarding appropriate clinical tasks and supervision requirements for Audiology Aides, this matter is being brought before the Audiology Practice Committee. Apparently, supervisors expressed concern that either Audiology Aides were being allowed to perform any and all clinical services normally provided by an Audiologist without the training or education of an Audiologist or supervision requirements were so strict that there was little point in utilizing an aide. In some cases, Audiology Aides have been reportedly trained to a level that a supervisor considers to be competent for a particular clinical task and then left to perform that task independently without supervision from a supervisor who is physically present. Reports of these types of misapplication of the regulations for Audiology Aides led to the Board discussing this issue at the October 10-11, 2019.
At the October 10-11, 2019 Board meeting, the Board discussed feedback received from audiology licensees who utilize Audiology Aides, who had complained of ambiguity regarding the regulatory requirements for the clinical tasks allowed to be performed by an Audiology Aide and the type of supervision required for Audiology Aides. The Board then directed the Audiology Practice Committee (Committee) to define the tasks an audiology aide can perform and the supervision necessary, and in addition, consider any legislative or regulatory changes needed to implement that.
At the February 20, 2020 Audiology Practice Committee (Committee) meeting, the Committee discussed language from the American Academy of Audiology (AAA) and the American Speech-Language-Hearing Association (ASHA) regarding the role of an audiology assistant, which was the national terminology for what Audiology Aides are in California. The language stated that audiology assistants should be trained to do specific tasks that support the Audiologist without being allowed to make diagnostic decisions.
The Committee discussed concerns regarding whether and when the supervising Audiologist must be physically present because the regulations are unclear. The Committee decided that reviewing the AAA and ASHA lists of tasks recommended or not recommended for audiology assistants would be a good starting point to engage stakeholders in the development of a regulatory package (Note: these lists and associated materials have been updated since 2020). Board Staff brought to the Committee’s attention that any regulatory package needed to explain why a particular task would be outside of the scope of responsibilities of an Audiology Aide and that it might be more effective to develop different levels of supervision requirements for Audiology Aides similar to the Speech-Language Pathology Assistant (SLPA) regulations. The Committee also discussed its concern that both AAA and ASHA recommend these individuals complete continuing education requirements, but understood that under current statute, that the Audiology Aide in California is a one-time registration with no renewal requirement or continuing education requirement, and that this issue would have to be addressed as part of the Sunset Review process.
At the February 2020 meeting, the Committee decided to work with staff to use the AAA and ASHA recommendations to help develop a list of tasks and supervision requirements for Audiology Aides for stakeholder consideration at a future meeting.
Due to the COVID-19 pandemic, Board Member vacancies, and limited staff resources in the interim, the Committee and Board Staff were not able to address this issue.
Statutory and Regulatory Provisions
The following statutory and regulatory language pertain to the functions and supervisory requirements for an audiology aide.
Business and Professions Code Section (BPC) Section 2530.2(m) defines an audiology aide as any person meeting the minimum requirements established by the board. An audiology aid may not perform any function that constitutes the practice of audiology unless he or she is under the supervision of an audiologist. The board may by regulation exempt certain functions performed by an industrial audiology aide from supervision provided that his or her employer has established a set of procedures or protocols that the aide shall follow in performing these functions.
Title 16, California Code of Regulations (CCR) sections 1399.154(b) states that an Audiology Aide means a person who (1) assists or facilitates while an audiologist is evaluating the hearing of individuals and/or is treating individuals with hearing disorders, and (2) is registered by the supervisor with the Board and the registration is approved by the Board.
Title 16 CCR section 1399.154.1 states the following:
Before allowing an aide to assist in the practice of speech-language pathology or audiology under his or her supervision, a supervisor shall register each aide with the Board on a form provided by the Board and pay the registration fee required in Section 1399.157. Regardless of their title or job classification, any support person who functions as a speech-language pathology or audiology aide and facilitates or assists a supervisor in evaluations or treatment shall be registered with the Board. In the application for registration, the supervisor shall provide to the Board, his or her proposed plan for supervising and training the speech-language pathology or audiology aide. The proposed plan for training shall be in accordance with Section 1399.154.4 and shall include the supervisor's training methods, the necessary minimum competency level of the aide, the manner in which the aide's competency will be assessed, the persons responsible for training, a summary of any past education, training and experience the aide may have already undertaken, and the length of the training program and assessment of the aide's competency level. The Board shall review the application for compliance with the requirements of this article and notify the supervisor of its disposition of the application for registration and whether further information is required in order to complete its review.
Title 16 CCR section 1399.154.2 states that an Audiology Aide’s supervisor shall do all of the following:
(a) Have legal responsibility for the health, safety and welfare of the patients.
(b) Have legal responsibility for the acts and services provided by the speech-language pathology or audiology aide, including compliance with the provisions of the Act and these regulations.
(c) Be physically present while the speech-language pathology or audiology aide is assisting with patients, unless an alternative plan of supervision has been approved by the Board. A supervisor of industrial audiology aides shall include a proposed plan for alternative supervision with the application form. An industrial audiology aide may only be authorized to conduct puretone air conduction threshold audiograms when performing outside the physical presence of a supervisor. The supervisor shall review the patient histories and the audiograms and make necessary referrals for evaluation and treatment.
(d) Evaluate, treat, manage and determine the future dispositions of patients.
(e) Appropriately train the speech-language pathology or audiology aide to perform duties to effectively assist in evaluation and/or treatment. A supervisor shall establish and complete a training program for a speech-language pathology or audiology aide in accordance with Section 1399.154.4 which is unique to the duties of the aide and the setting in which he or she will be assisting the supervisor.
(f) Define the services which may be provided by the speech-language pathology or audiology aide. Those services shall not exceed the competency of the aide as determined by his or her education, training and experience, and shall not include any treatment beyond the plan established by the supervisor for the patient.
Title 16 CCR section 1399.154.4 requires supervisors to ensure Audiology Aides complete appropriate training programs established by the supervisor and that the training program includes, but is not limited to:
(a) Instruction in the skills necessary to perform any acts or services which are the practice of speech-language pathology or audiology as defined in Section 2530.2 of the Code. The supervisor is not required to repeat any training which may have already been received by the aide because of any prior education, training and experience.
(b) A supervisor shall require a speech-language pathology or audiology aide to demonstrate his or her competence to perform any acts or provide any services which are the practice of speech-language pathology or audiology as defined in Section 2530.2 of the Code which may be assigned to the aide or which the aide may provide to patients. A supervisor shall allow a speech-language pathology or audiology aide only to perform those acts or to provide those services for which he or she has been provided training and has demonstrated competency.
(c) A supervisor shall instruct a speech-language pathology or audiology aide as to the limitations imposed upon his or her duties, acts or services by these regulations, by his or her training and skills, and by the evaluation and treatment plan for any patient.
(d) In addition to the requirements of this section, an industrial audiology aide shall be provided training in the use of an audiometer and in the necessary techniques for obtaining valid and reliable audiograms.
It is also important to note that BPC Section 2538.20 specifically states that, It is unlawful for an individual to engage in the practice of fitting or selling hearing aids, or to display a sign or in any other way to advertise or hold himself or herself out as being so engaged without having first obtained a license from the board under the provisions of this article.
Note: both the AAA Code of Ethics, AAA Standards of Practice, ASHA Code of Ethics, and ASHA Scope of Practice also provide information regarding supervision of audiology assistants, students, and support personnel (see attachments).
Issues for Consideration
BPC Section 2530.2(m) authorizes the Board to establish minimum requirements for the registration of an Audiology Aide and BPC Section 2530.6 authorizes the Board to designate requirements related to the extent, kind, and quality of services performed by the aide. Should the Board consider clarifying and enhancing the minimum requirements for registration, which include training, for Audiology Aides? For example, Title 16 CCR section 1399.154.4 requires the aide to complete a training program established by the supervisor prior to the aide being allowed to assist in the practice of audiology. Should the Board also consider clarifying requirements for the extent and kind of services an Audiology Aide is allowed to perform?
Some issues the Committee should consider regarding the development of regulations to detail tasks that can and cannot be performed by Audiology Aides are as follows:
Detailing Tasks an Audiology Aide Can Perform
- Historically, when a regulation details a list of multiple permissible tasks, the interpretation of that regulation can be that this is intended to be an exhaustive list and therefore only those tasks detailed in the regulation are permissible. Alternatively, supervisors may interpret the list to authorize other, similar tasks that are not listed as also permissible. As a result, the regulation may unnecessarily limit Audiology Aide activities or promote unlisted activities not identified in the regulation that would or would not be permitted or require similar education and training as those detailed in the regulation.
- If this option is pursued, the Committee should consider the following:
- oShould the Board identify appropriate Audiology Aide tasks or instead identify categories of appropriate tasks? For example:
- Audiology Aides are allowed to perform maintenance, preparation, and infection control procedures for testing equipment, testing materials, and treatment rooms.
- Audiology Aides with adequate training are allowed to perform and administer, without interpretation, standardized hearing tests and screenings.
- Audiology Aides with adequate training are allowed to perform, without interpretation, otoscopy, tympanometry, or the taking of earmold impressions.
- If the Board identifies appropriate tasks or categories of tasks, the Board should also detail appropriate levels of supervision for these tasks or instead define supervision levels that any task could fall under?
- oShould the Board identify appropriate Audiology Aide tasks or instead identify categories of appropriate tasks? For example:
Detailing Tasks an Audiology Aide Cannot Perform
- If the Committee goes in the direction of detailing which tasks or categories of tasks an Audiology Aide is prohibited from performing, the Committee should consider the following issues and evaluate potential alternatives to develop any potential associated rulemaking package:
- The risks to a patient if an Audiology Aide performs the task or category of tasks improperly and/or does not have the adequate education, training, or supervision and the severity of the potential risks.
- Whether or not adequate training and supervision or a higher level of supervision would mitigate this risk.
- Alternatively, is there a way to more broadly define prohibited tasks and levels of supervision that would meet the same need as identifying prohibited tasks? For example:
- Prohibiting categories of tasks prohibited by law, such as the fitting and sale of hearing aids;
- Prohibiting any task that requires interpretation of test results or involves the diagnosis of hearing disorders;
- Prohibiting the performance of therapies, counseling, or tasks that require specialized knowledge and professional competence;
- Prohibiting Audiology Aides from making any decisions related to the treatment, discharge or referral of patients for services; and/or
- Prohibiting Audiology Aides from supervising any hearing screening program.
The Board has the authority to define levels of supervision similar to how the SLPA supervision requirements are defined. For example, SLPAs have three broad levels of supervision that range from Immediate (physically present in the room), Direct (on-site), and Indirect (not on-site), and detail what duties require specified levels of supervision or when the duties require a higher level of supervision. SLPA supervision regulations can be found in Title 16 CCR sections 1399.170 and 1399.170.2 and activities, duties, and functions outside the scope of responsibilities of a SLPA are defined in Title 16 CCR section 1399.170.3.
Lastly, as part of the Board’s Sunset Review process, the creation of renewal and continuing education requirements are being considered by the Legislature. If the renewal and continuing education provisions are accepted and put into our Practice Act next year, would any regulatory changes the Committee is considering require changes after the law takes effect?
Action Requested
Staff recommends the Audiology Practice Committee discuss the above issues for consideration with stakeholders so that the Audiology Practice Committee can determine the best course of action in relation to a potential regulatory structure for Audiology Aides and provide guidance to staff so that they can begin preparing draft regulatory language to address the issues discussed at a future meeting.
Attachment A: American Academy of Audiology Code of Ethics
Attachment B: American Speech-Language-Hearing Association Code of Ethics
Attachment C: American Academy of Audiology Standards of Practice
Attachment D: American Speech-Language-Hearing Association Scope of Practice
Attachment E: American Academy of Audiology Position Paper Audiology Assistants
Attachment F: American Speech-Language-Hearing Association Audiology Assistants Overview
Attachment G: SLPA Regulations Related to SLPA Supervision and Scope of Responsibilities
Attachment H: Examples of Potential Audiology Aide Tasks