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Ethical Dilemmas in Audiology & Speech-Language Pathology:
It’s Complicated!
Iowa Speech-Language-Hearing Association Convention
Des Moines, Iowa
October 17, 2019
Theresa H. Rodgers, MA, CCC-SLP, ASHA-F, L-SLP, EdS (LD)
Disclosures
Financial
Honorarium from ISHA
Travel expenses reimbursed by ASHA
Nonfinancial
• 2017 Chair, ASHA Board of Ethics/2018 Ethics Education Subcommittee
• Former member and chair of the Louisiana licensure board
No portion of this presentation may be reproduced without permission (2019).
Acknowledgements!
Special thanks to the following individuals who contributed significantly in the development of this presentation:
• Shelly Chabon, PhD, CCC-SLP
• Glenn Waguespack, MS, CCC-A
Retrieved September 18, 2019 from https://idph.iowa.gov/Licensure/Iowa-Board-of-Speech-Pathology-and-Audiology/Laws-and-Rules
Retrieved September 19, 2019, from http://www.asha.org/uploadedFiles/ET2016-00342.pdf(included in handouts)
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ASHA Code of Ethics – 2016 Revisions
New Terminology Section
Updated Preamble and Edited Principles III and IV
15 New Rules and Edits to Already-Existing Rules to address:
Interprofessional Collaboration
Supervision
Informed Consent
Technology
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ASHA Code of Ethics – 2016 Revisions
New Rules and Edits to Already-Existing Rules to address: Impaired PractitionerPatient/Client AbandonmentResearch ConductAdministrative/Supervisory RolesConflict of InterestDisclosuresReporting Members of Other ProfessionsSelf-Reporting
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The Current Practice Environment: Considerations and Constraints?
Productivity Demands (e.g., SLPs in SNF required to clock out for paperwork, expectation that clients will be maintained on caseload [at same level of service] even when no longer warranted, etc.)
Pressure to bill on-going assessment provided within therapy sessions as “evaluation”
Billing for services which do not match CPT code(s)
The Current Practice Environment: Considerations and Constraints?
Patient/client abandonment
Currency of practice techniques/service delivery models (lack of release time for quality continuing education); practitioner burn-out and work-life balance issues
Provision of services without adequate training in that area of practice
The Current Practice Environment: Considerations and Constraints?
Paperwork burden and its effect on service provision to clients/students, as well as quality
of record-keeping (potential billing errors, inadequate documentation of services, etc.)
Pressure to “sign-off” on Medicaid billing when proper supervision has
not been delivered (lack of caseload/workload relief to allow
for adequate supervision time)
Inadequate/improper supervision of assistants, interns, Clinical Fellows
The Current Practice Environment: Considerations and Constraints?
• Inappropriate delegation of tasks to graduate students (and/or assistants)
• Inadequate documentation of supervision
• Conflict of interest (e.g., solicitation of cases for part-time private practice from practitioner’s full-time employment entity)
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The Current Practice Environment: Considerations and Constraints?
Questions concerning cultural competence in the administration and
interpretation of diagnostic materials
Cultural competence issues in interacting
with families and those whom we serve
Law
EthicsMorals
Ethics and the Law
Legal Moral
Illegal Immoral
Slocum, J.M. Ethics, law and regulatory affairs: Comparisons and contrasts. Retrieved August 12, 2018 from http://slocumboddie.com/wpmain/wp-content/uploads/2014/02/T71-Ethics-v-Law.pdf
Codes of Ethics, Disciplinary Powers, and Processes Differences/ Similarities
▪ Professional Organizations –American Speech-Language-Hearing Association; American Academy of Audiology
▪ Regulatory Agencies – Iowa Board of Speech Pathology and Audiology
How Is the ASHA Code Organized?
• The fundamentals of ethical conduct are described by Principles of Ethics and by Rules of Ethics.
• Principles of Ethics form the underlying philosophical basis for the Code of Ethics.
• Rules of Ethics are specific statements of minimally acceptable as well as unacceptable professional conduct.
Bupp, H. & Rodgers, T. (2016, July). It’s hot, hot, hot! Applying the 2016 ASHA Code of Ethics in speech-language pathology practice. Seminar presented at the ASHA Connect conference, Minneapolis, Minnesota.
Principles within Code of Ethics
• Responsibility to persons served professionally and to research participants
Principle I
• Responsibility for one’s professional competencePrinciple II
• Responsibility to the publicPrinciple III
• Responsibility for professional relationshipsPrinciple IV
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Common Themes of Ethics Inquiries (ASHA)
• Documentation lapses
• Billing and coding
• Conflicts of interest
• Employer demands
• Supervision issues
• Sexual misconduct
• Client abandonment
• Confidentiality
1500 annually
Euben, D. & Rodgers, T. (2019, July). Navigating ethical dilemmas in schools. Seminar presented at ASHA’s Connect conferences, Chicago, Illinois.
Board of Ethics (BOE) Jurisdiction
ASHA Board of Ethics only has jurisdiction over:
Members of ASHA – Certified and Noncertified
Nonmembers holding the CCC
Applicants for membership and/or certification
BOEJurisdiction
Ethics Complaints & BOE Powers
ASHA BOE has no “investigative” resources/authority.
ASHA BOE has no subpoena power.
Cases are heard and decided based on information provided by complainants,
respondents, and, in limited cases, licensing boards, courts, public records,
or the media.
No anonymous complaints
Iowa Board of Speech Pathology and Audiology
Complaints must be in writing.
Investigative authority (may utilize an investigator, a board member [who shall be recused] or a peer review committee)
Subpoena power
SANCTIONS – ASHA Board of Ethics
PUBLICPublished in The ASHA Leader
and on ASHAwireCensure
Withholding – for Applicants or Dropped Members
Suspension– For months or years
Revocation – For months, years, or life
(PRIVATE) Reprimand
Between Complainant and Respondent
If found in violation of the ASHA Code of Ethics, one of the following sanctions will be applied:
Cease & desist orders, which can be public or private, can also be issued.
• Censure (essentially a public reprimand)
• Suspension (individual remains member/certified, paying dues/keeping up with certification requirements, shorter duration of time than revocation, e.g., 6-12 months, no requirement to petition the BOE for reinstatement)
• Revocation (individual’s membership/certification revoked; to rejoin, individual must petition the BOE for reinstatement which can be rejected; must then meet any new certification standards/requirements)
• Withholding (like revocation, but for applicants and former members/certified individuals)
PUBLIC SANCTIONS – ASHA Board of Ethics
Euben, D. & Rodgers, T. (2019). Navigating ethical dilemmas faced by SLPs practicing in schools. Seminar presented at ASHA Connect conferences, Chicago, Illinois.
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Potential Sanctions of the Board of Ethics
• Revocation (individual’s membership/certification revoked; to rejoin, individual must petition the BOE for reinstatement which can be rejected; must then meet any new certification standards/requirements)
• Withholding (like revocation, but for applicants and former members/certified individuals)
• Cease and Desist (letter to immediately stop conduct that violates Code of Ethics)
Iowa Board of Speech Pathology and AudiologySANCTIONS
▪ Issue a citation and warning
▪ Require additional education or training
▪ Require reexamination
▪ Probation
▪ Civil penalties not to exceed $1000
▪ Order a physical or mental evaluation, or order alcohol
and drug screening within a tie specified by the board
Iowa Administrative Code 645-304.3(272C)
Iowa Board of Speech Pathology and AudiologySANCTIONS
▪ Prohibit permanently, until further order of the board, or for a
specific period the licensee’s engaging in specified procedures,
methods, or acts
▪ Suspension (until further order of the board, or for a specific
period)
▪ Revocation
▪ Such other sanctions allowed by law as may be appropriate
Iowa Administrative Code 645-304.3(272C)
Sanctions and Factors to be
Considered by Iowa Board
• Relative serious nature of the violation as it relates to assuring the citizens of this state a high standard of professional care
• The facts of the particular violation
• Any extenuating facts
• The number of prior violations or complaints
• Whether remedial action has been taken
• Such other factors as may reflect upon the competency, ethical standards, and professional conduct of the licensee.
IAC 645-13.2(272C)
Public Disclosure of Sanctions: Online
www.asha.org/practice/ethics
Retrieved June 24, 2019 https://www.asha.org/practice/ethics/
Public Sanctions – ASHA Board of Ethics
In 2017, the Board imposed Censure on a school-based SLP with 16 years’ experience who was already publicly-disciplined by the XXXXX licensing board, because she failed to properly document and provide services based on students’ IEPs; failed to accurately document therapy sessions; and falsely documented sessions that were not conducted.
Code of Ethics (2010r): I, I-A, I-M, II, III, III-D, IV, IV-EThe ASHA Leader, April 2017, 22(11), 63. doi.org/10.1044/leader.AN7.22112017.63
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Public Sanctions – ASHA Board of Ethics
In 2018, the Board imposed Suspension of membership for 12 months on an SLP who falsified records, submitted billing for services not provided, and forged a patient’s signature; and failed to report her Settlement Agreement with the XXXXX licensure board to ASHA Standards and Ethics.
Code of Ethics (2016): I, I-Q, III, III-D, IV, IV-D, IV-E, IV-TThe ASHA Leader, November 2018, 23(11), 59. https://leader.pubs.asha.org/doi/full/10.1044/leader.AN4.23112018.59
Public Sanctions – ASHA Board of Ethics
In 2018, the Board imposed Suspension of membership for 6 months on an audiologist who attested to completing required continuing education on his license renewal application, failed to provide documentation supporting completion of required continuing education as required by XXX state licensure board, failed to respond to the board’s audit requiring evidence of continuing education, failed to pay the board’s imposed fine, and failed to self-report the professional discipline he received from the board to ASHA Standards and Ethics..
Code of Ethics (2016): II, II-D, IV, IV-E, IV-R, IV-TThe ASHA Leader, November 2018, 23(11), 59. https://leader.pubs.asha.org/doi/full/10.1044/leader.AN4.23112018.59
Public Sanctions – ASHA Board of Ethics
In 2017, the Board imposed Withholding of Membership and Certification for 8 years as well as a Cease-and-Desist Order on a school-based SLP with 10 years’ experience who pled guilty in X State criminal court to two felonies of sex/sexual battery with adolescent students from the high school where she was employed.
Code of Ethics (2016): I, III, III-B, IV, IV-D, IV-E, IV-G, IV-RThe ASHA Leader, March 2017, 22(3), 60. https://leader.pubs.asha.org/doi/full/10.1044/leader.AN2.22032017.60
Retrieved September 18, 2019 from https://idph.iowa.gov/Licensure/Iowa-Board-of-Speech-Pathology-and-Audiology/Discipline-and-Public-Actions
Iowa Board of Speech Pathology and AudiologyDiscipline and Public Action
Case No. 18-0184 - Speech-Language Pathologist
January 15, 2019 Combined Statement of Charges, Settlement Agreement, and Final Order
• Charged with billing for services which were not rendered
• Licensee self-reported billing for speech-language therapy serviceswhich were never provided.
• Sanction - Probation
Iowa Board of Speech Pathology and AudiologyDiscipline and Public Action
• One year of monitored practice before being released from probation (monitoring plan, weekly face-to-face meeting during probation period with monitor to review clinical and billing records; quarterly reports to the Board)
• Complete minimum of 16 continuing education hours including atleast 8 ethics hours and 8 billing or recordkeeping hours (in addition to those required for license renewal)
• Licensee shall notify all employers and prospective employers that require SLP licensure of the Order.
Retrieved September 18, 2019 from https://idph.iowa.gov/Licensure/Iowa-Board-of-Speech-Pathology-and-Audiology/Discipline-and-Public-Actions
The intent is to protect the public, improve the quality of health care and deter fraud and abuse in the health care system by providing information about past adverse actions of practitioners, providers, or suppliers to authorized health care entities and agencies.
National Practitioner Data Bank (NPDB)
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Who must report and what must be reported to the National Practitioner Data Bank (NPDB)?
• Federal and State Government Agencies including Licensure Actions (result of formal proceeding)
• (Also, medical malpractice judgments and settlements, Medicaid & Medicare exclusions, health-care related criminal convictions and civil judgments, DEA actions, etc.)
Illich, D. and Hua, J. (2017). Reporting Adverse Actions to the NPDB. Licensure, Summer 2017.
Report Type Audiologists SLPs Total
Clinical Privileges/Panel
Membership Action
1 2 3
Government Administrative
Action
5 7 12
Health Plan Action 8 2 10
Judgment or Conviction 13 66 79
Malpractice Payment 56 20 76
State Licensure Actions 295 1476 1771
Total NPDB Reports 378 1573 1951
Number of NPDB Reports by Practitioner Type 09/01/1990-12/31/2016
Report Trends 1990 - 2017
o428 reports for audiologists
o1667 reports for SLPs
West, W. (2018). NPDB Update. Presentation at the annual convention of the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology, Vienna, VA.
This Photo by Unknown Author is licensed under CC BY
A code of ethics does not make a person ethical nor is it the mechanism by which we solve ethical problems.
English, 2001 in Chabon, S. & Rodgers, T. (2012). Resolving ethical dilemmas. Presentation at Spring Conference of the Council of State Association Presidents. Anchorage, Alaska.
Ethical Decision-Making
This Photo by Unknown Author is licensed under CC BY-SA-NC
Am Ifacing an
ethicaldilemma
here?
What are therelevant facts,
values & beliefs?
Who are the keypeople involved?
Chabon, S. and Dunham, Chapter 7, in Chabon, S., Denton, D.R., Lansing, C.R., Scudder, R.R. and Shinn, R. (2007) Ethics education. ASHA Publication.
Ethical Decision-Making Model
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State thedilemma clearly
Analysis
Chabon, S. & Morris, J. (2005). Raising ethical awareness in the practice of speech-language pathology and audiology: A 24/7 endeavor. California Speech-Language-Hearing Association Magazine, 35 (1) 6-8.
Ethical Decision-Making Model
What are thepossible courses
of actionone could take?
What are theconflicts
that arise fromeach action?
PROPOSEDCOURSE OF
ACTION
Chabon, S. & Morris, J. (2005). Raising ethical awareness in the practice of speech-language pathology and audiology: A 24/7 endeavor. California Speech-Language-Hearing Association Magazine, 35 (1) 6-8.
Ethical Decision-Making Model
Evaluate:
1) Ethical Principles2) Code of Ethics3) Cultural Heritage/Values4) Social Roles5) Self-Interests 6) Laws
Does your proposed
course of actionlead to
CONSENSUS?If YES –
then proceed …
Chabon, S. & Morris, J. (2005). Raising ethical awareness in the practice of speech-language pathology and audiology: A 24/7 endeavor. California Speech-Language-Hearing Association Magazine, 35 (1) 6-8.
Ethical Decision-Making ModelAm I
facing anETHICALdilemma
here?
If NO
What are therelevant facts,
values & beliefs?
Who are the keypeople involved?
State thedilemma clearly
Analysis
What are thepossible courses
of actionone could take?
What are theconflicts
that arise fromeach action?
PROPOSEDCOURSE OF
ACTION
Does your proposedcourse of action
lead toCONSENSUS?
If YES –then proceed …
Evaluate:1) Ethical Principles2) Code of Ethics3) Cultural Heritage/Values4) Social Roles5) Self-Interests 6) Laws
(Chabon & Morris, 2005)
Ethical Decision-Making Model
Ethical Scenarios
Scenarios will be presented which represent a potential violation of the Iowa Rules, ASHA Code of Ethics, or a dilemma with which an individual may be confronted. Participants will determine if any violation has occurred and, if so, which principle(s) and/or rule(s) has/have been violated. Situations will be analyzed relative to ethical violations and potential resolution of the issue.
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This Photo by Unknown Author is licensed under CC BY-SA-NC
1. What is the major ethical issue or disagreement in this case?
2. Is this a violation of the ASHA Code of Ethics? If so, which principle(s) and/or rules(s) does it violate?
3. Is this a violation of the Iowa Administrative Code?
4. Assuming that a disciplinary hearing is held, what would be an appropriate sanction?
Discussion Questions
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Ethical Use of Social Media
Consider…➢ Breach of Confidentiality
➢ Misrepresentation of services, products, level of expertise, credentials, etc.
➢ Defamation
https://www.asha.org/Practice/ethics/Ethical-Use-of-Social-Media/
This Photo by Unknown Author is licensed under CC BY
Defamation
• Defamation laws vary from state to state.
• Defamation laws are generally intended to protect individuals and organizations from false factual statements that could harm their reputations.
• The term defamation can include verbal and written statements that are factually false.
Elements that establish defamation
• A false factual statement about the aggrieved party
• Uttered or published by a defendant
• Heard or read by a third party
• Causing economic injury to one’s reputation (e.g., significant loss of income, sponsorship, etc.)
Euben, D. & Rodgers, T. (2019). Navigating ethical dilemmas faced by SLPs practicing in schools. Seminar presented at ASHA Connect, Chicago, Illinois.
Retrieved June 5, 2019 from https://www.asha.org/About/Civility/
Retrieved June 24, 2019 from https://hsc.unm.edu/ipe/resources/ipec-2016-core-competencies.pdf
Core Competency Statements for IPP:
Values/Ethics
Competency 1. Work with individuals of other professions to maintain
a climate of mutual respect and shared values.
(Values/Ethics for Interprofessional Practice)
Specific Values/Ethics Competencies:
VE1. Place interests of patients and populations at center of
interprofessional health care delivery and population health programs and
policies, with the goal of promoting health and health equity across the life
span.
VE2. Respect the dignity and privacy of patients while maintaining
confidentiality in the delivery of team-based care.
VE3. Embrace the cultural diversity and individual differences that
characterize patients, populations, and the health team.
VE4. Respect the unique cultures, values, roles/responsibilities, and
expertise of other health professions and the impact these factors can have
on health outcomes.
VE5. Work in cooperation with those who receive care, those who
provide care, and others who contribute to or support the delivery of
prevention and health services and programs.
VE6. Develop a trusting relationship with patients, families, and other
team members (CIHC, 2010).
VE7. Demonstrate high standards of ethical conduct and quality of
care in contributions to team-based care.
VE8. Manage ethical dilemmas specific to interprofessional patient/
population centered care situations.
VE9. Act with honesty and integrity in relationships with patients,
families, communities, and other team members.
VE10. Maintain competence in one’s own profession appropriate to
scope of practice.
Core Competency Statements for IPP:
Values/Ethics
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Retrieved April 1, 2019 from http://www.asha.org/practice/ethics/
ASHA Resources
ASHA Ethics Resources: Issues in Ethics Statements
Retrieved April 1, 2019 https://www.asha.org/practice/ethics/ethics_issues_index/
2020 CERTIFICATION STANDARDS
Effective: January 1, 2020
• Who? All individuals who hold the CCC-A and/or CCC-SLP
• What? Out of 30 required professional development hour for certification maintenance, at least 1 hour must be in the area of ethics.
• When? Beginning with certificate holders in the January 1, 2020-December 31, 2022 certification maintenance interval.
• How often? Each 3-year maintenance interval.
ASHA National Office Staff
Donna Euben, Esq.
Director of Ethics and Legal Counsel to the Board of Ethics
This Photo by Unknown Author is licensed under CC BY-SA
Iowa Board of Speech Pathology and AudiologyBureau of Professional LicensureIowa Department of Public HealthLucas State Office Bldg., 5th Floor321 East 12th StreetDes Moines, IA 50319-0075Phone (515) 281-0254FAX (515) 281-3121
Twitter: @theresahrodgers
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